Worst Shift Ever

[Pinner Doc]

We just "went live" on a computer charting/ordering system (previously used paper) yesterday, with the lab communication system down AND being down one physician. It was the worst shift I have EVER worked, hands down.

Anyone else been through a transition to computerized ordering/charting? How did that go for you?

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[docB]

I have.

We started an EMR system years ago that we struggled with for 18 months and had to abandon it.

We have been a Cerner based system for over a year now. It was a tough transition. We started with charting and then later added ordering.

I work for the hospital company going to other hospitals to teach where the system is going live. I've done about 11 of these so far. They're always hard.

The biggest fib that EMR vendors give before go live is that the system will save you time. It won't. I've never seen an EMR that was faster than paper. You may pick up other benefits, more billing capture, better documentation, faster administrative tasks (i.e. data gathering), easier record access and so on, but it will never be faster on a per patient basis.

Order entry (aka in government speak CPOE - Computer Physician Order Entry) is always a quagmire. There are several reasons. Most have to do with instituting fail safes and electronic checking. It seems easy on the surface but once you really dig into it it is an incredibly complex issue.

Good luck. There is a big learning curve and it usually gets better after about 60 days.

 

[beanbean]

I have as a resident and it was awful. Physician paper charting and computer order entry/nursing charting on Sunrise transitioned everything over to Allscripts. First few shifts were a nightmare but it settled out fairly quickly.

We just moved from IBEX to McKesson for nurse charting and order entry about 6 weeks ago. I figured this would be similar to my previous experience; I was wrong. It never got better. We have had major patient safety issues!
Medication errors (order for 2G Mag results in order to the nurse for 20G)
Wrong orders (order foot X-ray and see lumbar puncture ordered)
Delays in registration
Delays in triage
System crashes multiple times in a shift
Order for NPO results in order that reads "ED diet: Quantity 1 Stat" (surgery loves that!)

Fortunately our hospital administration took quick action and we are going back to IBEX. The change to McKesson was based on trying to meEt CPOE "meaningful use". Our version of IBEX does not communicate with the other hospital EMRs. The solution of transitioning the entire hospital to McKesson should have been given us a more efficient and cohesive system. What we got was delays, risk to patients, frustration to staff, and a big headache!

Good luck to you!

 

[nlax30]

Over the last 2 months we just made the transition to full EMR on the inpatient side, first with electronic documentation and most recently with our CPOE rollout. Our ED had already been live with CPOE for a good while before the inpatient side so they were basically up to speed already.

As a resident I sat on our hospitals physician panel overseeing the transition and it was interesting the whole process and everything involved. Also made me realize my whole generation is going to adopt and embrace this whole "EMR transition" a lot differently than the current generation and older physicians from just listening to the complaints, concerns from others.

My first year we still all inpatient notes and orders on paper so I got to see both ways. I definitely see the arguments established physicians bring up, but really for my generation I can't see any scenario where we would want to stick to paper.

 

[gro2001]

Over the last 2 months we just made the transition to full EMR on the inpatient side, first with electronic documentation and most recently with our CPOE rollout. Our ED had already been live with CPOE for a good while before the inpatient side so they were basically up to speed already.

As a resident I sat on our hospitals physician panel overseeing the transition and it was interesting the whole process and everything involved. Also made me realize my whole generation is going to adopt and embrace this whole "EMR transition" a lot differently than the current generation and older physicians from just listening to the complaints, concerns from others.

My first year we still all inpatient notes and orders on paper so I got to see both ways. I definitely see the arguments established physicians bring up, but really for my generation I can't see any scenario where we would want to stick to paper.

Agree. I caught the tail end of paper charting as a med student. As a resident had to go back a couple of times during disaster situations to paper charting. Definitely faster than electronic charting, but still wouldn't ever willingly go back to paper full time because of all the secondary benefits (availability/legibility of previous records, improved billing, improved medicolegal protection, etc).

 

[SoCuteMD]

We just "went live" on a computer charting/ordering system (previously used paper) yesterday, with the lab communication system down AND being down one physician. It was the worst shift I have EVER worked, hands down.

Anyone else been through a transition to computerized ordering/charting? How did that go for you?

I've been through transition to EMR twice and both times it was pretty painful/anxiety-filled/etc. Both places (90,000 and 60,000 visits/yr) staffed up by 16-24 physician hours daily, and I truly think that was a saving grace. This took a LOT of advance planning - people were told they would not be allowed vacation and only the most urgent of schedule requests would be accommodated. There was an extra physician on a special "backup" shift in case the ED got overwhelmed. Everyone worked about 1/4 more shifts than usual (the hospital, not the department, paid for this which I understand is fairly unique).

I think it would be almost impossible to have a successful transition at a time when you are staffed DOWN from your usual. Congrats on surviving.

 

[deleted547339]

We went the other way for a night shift recently and I experienced "downtime" when our EMR, cpoe and labs were all on paper. That was a cluster.....

 

[Spinach Dip]

Wrong orders (order foot X-ray and see lumbar puncture ordered)

How does that even happen?

 

[la gringa]

We went the other way for a night shift recently and I experienced "downtime" when our EMR, cpoe and labs were all on paper. That was a cluster.....

unplanned downtime makes me horribly stressed... where is what patient? what orders went through vs didn't? where are the paper orders again? who needs what? why isn't the downtime system working? ugh ugh ughhhhh....

 

[RustedFox]

The EMR transition happened 1 month into my new gig. Goddamned mess. It now takes me thirteen distinct and separate actions to sign a midlevel's chart. It used to take me a hot second to glace it thru and scribble on the line. Now, its: click.... wait... click.... wait.... scroll.... wait.... click.... doubleclick... PIN... click... wait... scroll... click.... wait... verify.... sign.

Thirteen actions. Thirteen. Freaking. Actions. That doesn't count "wait for a hot minute while the laggy, cache-overburdened PC catches up". Add to that the fact that every nurse and midlevel takes this time to interrupt you, because they see you sitting there and well... "you're not doing anything right now." Thirteen actions quickly becomes seventeen when you add "tell RN staff three separate times to come back in 90 seconds", then "tell RN staff again that you can't put in that order for a foley right phucking now because you'd have to interrupt your present stream of clicks and start it all over again. "

What "management" needs to learn is that while EMR is legible and easy to transfer... it takes... wait for it....


t... i...m...e...

 

[Birdstrike]

The EMR transition happened 1 month into my new gig. Goddamned mess. It now takes me thirteen distinct and separate actions to sign a midlevel's chart. It used to take me a hot second to glace it thru and scribble on the line. Now, its: click.... wait... click.... wait.... scroll.... wait.... click.... doubleclick... PIN... click... wait... scroll... click.... wait... verify.... sign.

Thirteen actions. Thirteen. Freaking. Actions. That doesn't count "wait for a hot minute while the laggy, cache-overburdened PC catches up". Add to that the fact that every nurse and midlevel takes this time to interrupt you, because they see you sitting there and well... "you're not doing anything right now." Thirteen actions quickly becomes seventeen when you add "tell RN staff three separate times to come back in 90 seconds", then "tell RN staff again that you can't put in that order for a foley right phucking now because you'd have to interrupt your present stream of clicks and start it all over again. "

What "management" needs to learn is that while EMR is legible and easy to transfer... it takes... wait for it....


t... i...m...e...

...because "time" is money? Yeah, they know that. But Obamacare mandates fines if you're not on an EMR, which amounts to a bigger loss, than the loss of your productivity. They're smart. They know the money. They've already run calculations as to what minimizes their losses, or maximizes their gains. EMR is a long term win for managememt.

 

[RustedFox]

...because "time" is money? Yeah, they know that. But Obamacare mandates fines if you're not on an EMR, which amounts to a bigger loss, than the loss of your productivity. They're smart. They know the money. They've already run calculations as to what minimizes their losses, or maximizes their gains. EMR is a long term win for managememt.

Oh, I get that already, brother - its that time spent doing one thing (toiling through EMR) is time that cannot be spent doing things like 'greeting the hordes of incoming level-3s to capture the timestamp'. I can't finish one job and start the next simultaneously... and be honest about it.

 

[docB]

The EMR transition happened 1 month into my new gig. Goddamned mess. It now takes me thirteen distinct and separate actions to sign a midlevel's chart. It used to take me a hot second to glace it thru and scribble on the line. Now, its: click.... wait... click.... wait.... scroll.... wait.... click.... doubleclick... PIN... click... wait... scroll... click.... wait... verify.... sign.

Thirteen actions. Thirteen. Freaking. Actions. That doesn't count "wait for a hot minute while the laggy, cache-overburdened PC catches up". Add to that the fact that every nurse and midlevel takes this time to interrupt you, because they see you sitting there and well... "you're not doing anything right now." Thirteen actions quickly becomes seventeen when you add "tell RN staff three separate times to come back in 90 seconds", then "tell RN staff again that you can't put in that order for a foley right phucking now because you'd have to interrupt your present stream of clicks and start it all over again. "

What "management" needs to learn is that while EMR is legible and easy to transfer... it takes... wait for it....


t... i...m...e...

You have hit the nail on the head here. I posted something awhile back about how something that takes just one minute per patient kills 1.5 patient visits of productivity per provider per shift in my shop. That comment was based on my experience with EMRs.

 

[RustedFox]

You have hit the nail on the head here. I posted something awhile back about how something that takes just one minute per patient kills 1.5 patient visits of productivity per provider per shift in my shop. That comment was based on my experience with EMRs.

I remember that - "it only takes a minute".

Bump it for re-reading/discussion ?

 

[Arcan57]

The EMR transition happened 1 month into my new gig. Goddamned mess. It now takes me thirteen distinct and separate actions to sign a midlevel's chart. It used to take me a hot second to glace it thru and scribble on the line. Now, its: click.... wait... click.... wait.... scroll.... wait.... click.... doubleclick... PIN... click... wait... scroll... click.... wait... verify.... sign.

Thirteen actions. Thirteen. Freaking. Actions. That doesn't count "wait for a hot minute while the laggy, cache-overburdened PC catches up". Add to that the fact that every nurse and midlevel takes this time to interrupt you, because they see you sitting there and well... "you're not doing anything right now." Thirteen actions quickly becomes seventeen when you add "tell RN staff three separate times to come back in 90 seconds", then "tell RN staff again that you can't put in that order for a foley right phucking now because you'd have to interrupt your present stream of clicks and start it all over again. "

What "management" needs to learn is that while EMR is legible and easy to transfer... it takes... wait for it....


t... i...m...e...

Our particular EMR (electronic T-sheets) has improved from implementation but it's still (assuming already logged in) 6-7 steps to sign an midlevel's chart and it's possible for an errant mouse click to cause you to take over the midlevel's chart causing them to be kicked off the chart from a billing standpoint. What I despise most about it is that unless I take the chart over I can't see the electronic t-sheet, merely the converted into text output that it spits into the medical record. It's essentially uninterpretable without spending minutes reading the output to make sure they didn't accidently click +meningismus or leave out a reflex exam on a back pain patient. Whereas I can glance at a paper t-sheet and know within 15 seconds if it's a defensible chart.

Nobody but us really cares about time though. Hospitals always assume that if you just throw more docs into the shop then you can make up for any loss in time (especially if they're working with a CMG so adding docs is budget neutral for them). They get to ignore difficulties with recruiting, finding a doc willing to work short shifts, or everyone being ok with taking a hit in income without jumping to a better paying shop. If they are an employee based, then they can raise productivity quotas on existing docs or there's always a CMG that's willing to promise better metrics.

 

[Groove]

I feel you... I've had three horrible experiences with EMR transitions. One during residency when we switched to Epic overnight. Once with McKesson with a hospital system I moonlighted with for a couple of years, had one day training and it was about 2-3 weeks after GoLive from what I can remember. I can't count how many times it crashed, we had to go to T-sheets, labs and all diagnostics had to be faxed, what a mess. It was still buggy 2 years later. Current gig... Allscripts went live several months ago and has it's own set of problems that are still being ironed out. I really hate the EMR but rank it somewhere between McKesson (worst) and Epic (best) but have found a reasonable way to navigate it albeit slowly.

 

[RustedFox]

I feel you... I've had three horrible experiences with EMR transitions. One during residency when we switched to Epic overnight. Once with McKesson with a hospital system I moonlighted with for a couple of years, had one day training and it was about 2-3 weeks after GoLive from what I can remember. I can't count how many times it crashed, we had to go to T-sheets, labs and all diagnostics had to be faxed, what a mess. It was still buggy 2 years later. Current gig... Allscripts went live several months ago and has it's own set of problems that are still being ironed out. I really hate the EMR but rank it somewhere between McKesson (worst) and Epic (best) but have found a reasonable way to navigate it albeit slowly.

I second the vote for "McKesson = teh worst".

We presently have pDoc. Its not bad; could be better.

 

[docB]

I remember that - "it only takes a minute".

Bump it for re-reading/discussion ?

Sure. If you could bump it for that'd be great. I'm on vacation and doing SDN via phone. Thanks.

 

[Hercules]

I'll third the vote for McKesson being hands down no questions asked the worst EMR I've ever worked with. Our group currently uses Sunrise with a lot of templates and macros and its pretty efficient as far as EMRs go. The order sets in sunrise work pretty well too.

 

[deleted6669]

have done this several times at several places.
IMHO dictation>paper>electronic T system>cerner>epic>meditech>mckesson.
any emr drops your productivity art least 50% vs paper or dictation.
it's the secretarialization of medicine.
embrace the suck.

 

[deleted206819]

The issue with EMRs is that you (as the physician and the department) are not the customer. You didn't buy it based on its simplicity, ease of use, intelligent UI, increasing flow, and decreasing the number of clicks to. The government is the customer and the layout of the EMR whether that's EPIC, Allscripts, Mckesson, ... were geared towards those specs. The hospitals and eventually the department purchase these systems to become compliant with meaningful use and grab a chunk of the incentives (cash).

We use Allscripts at our shop and even now after our latest upgrade we have bugs that have gone unfixed for the past 6 months. Do the vendors care? No. Do the vendors come under any pressure to provide fixes? No.

What can be do to hold the vendors responsible for their barely usable product? Absolutely nothing because we are stuck with it and cannot move from one platform to another with ease.

Has anyone asked where all of this data is kept and how it easily (or with great difficulty) can be exported? Has anyone thought about vendor lock-in? As a medical informatician, I have and I can easily say that lock-in is assured for all of the vendors.

 

[deleted6669]

As epic becomes the dominant system many places are switching to it to have access to pt visits from other facilities that have epic. we switched from electronic-t( a better system) to epic for just this reason.

 

[Doctor Bob]

As epic becomes the dominant system many places are switching to it to have access to pt visits from other facilities that have epic. we switched from electronic-t( a better system) to epic for just this reason.

Hmm... I see I'm in the minority here but I liked epic... I could chart a lot faster than I could with paper T-charts.

But then again, I spent over 10 hours on a day off, the day before the system went live building all sorts of templates, macros, dot phrases, and so forth.

Whether or not I got those 10 hours back amortized over the next year's worth of shifts is another matter... I think I did, but who knows.

 

[WilcoWorld]

Hmm... I see I'm in the minority here but I liked epic... I could chart a lot faster than I could with paper T-charts.

But then again, I spent over 10 hours on a day off, the day before the system went live building all sorts of templates, macros, dot phrases, and so forth.

Whether or not I got those 10 hours back amortized over the next year's worth of shifts is another matter... I think I did, but who knows.

I've used 4 different EMR's and have done paper charting. Epic is my favorite by a long shot.

 

[deleted6669]

the issue with making your own dot phrases and macros in epic is that if every ankle sprain, chest pain, etc looks the same the govt says that constitutes chart"cloning" and will refuse to pay for medicare pts charted in that fashion.
it's a catch-22: there is a way to make the emr faster but that way violates govt regulations and requires you to be slower.
I used to work at a well known level 1 trauma ctr which was audited for this, found not to be in compliance, and charged some hefty penalties.
take home message for us was this " don't use dot phrases and macros for level 5 coded pts or critical care as these are the ones most likely to be audited as they generate the most income".
so fudge the ankle sprains and uri's with macros but write individual notes for the really sick folks.
article on cloning:
http://www.medscape.com/viewarticle/771548

 

[deleted6669]

if no one has seen it, Dr. Edwin leap's version of "go live in purgatory". worth a quick read:
http://edwinleap.com/blog/?p=2504
scroll down page 1 a bit to the start.

 

[VA Hopeful Dr]

the issue with making your own dot phrases and macros in epic is that if every ankle sprain, chest pain, etc looks the same the govt says that constitutes chart"cloning" and will refuse to pay for medicare pts charted in that fashion.
it's a catch-22: there is a way to make the emr faster but that way violates govt regulations and requires you to be slower.
I used to work at a well known level 1 trauma ctr which was audited for this, found not to be in compliance, and charged some hefty penalties.
take home message for us was this " don't use dot phrases and macros for level 5 coded pts or critical care as these are the ones most likely to be audited as they generate the most income".
so fudge the ankle sprains and uri's with macros but write individual notes for the really sick folks.
article on cloning:
http://www.medscape.com/viewarticle/771548

My understanding (and the article seems to back this up) was that cloning was more about copy/pasting from the same patient's prior visit, not from using a macro for the same problem in different patients.

 

[WilcoWorld]

My understanding (and the article seems to back this up) was that cloning was more about copy/pasting from the same patient's prior visit, not from using a macro for the same problem in different patients.

I also think emedpa is over-stating the fraud concern a bit. If every chest pain chart is exactly the same or careless use of dot phrases cause you to write internally inconsistent charts (afib with RVR pt has "regular rate and rhythm" in your CV exam) then you'll get burned. But using a .chestpain template wisely is totally defensible and legal.

 

[deleted6669]

My understanding (and the article seems to back this up) was that cloning was more about copy/pasting from the same patient's prior visit, not from using a macro for the same problem in different patients.

A coding seminar I went to recently stated that both counted as cloning .
this addresses some macro concerns:
http://www.pracfirst.com/blog/?p=158

I agree that if someone is diligent with their macro use they are probably ok but if they chart anything that didn't actually happen because it is part of a macro they are potentially toast. so the chest pain macro that says "skin free of rashes " in the guy with multiple petichiae on his lower extremities will get you in trouble. or " b/l lower extremities with full rom and no edema" in a diabetic pt with a bka, etc.