Home On the Wards What to do when your EHR is a dud

What to do when your EHR is a dud

September 2013

Published in the September 2013 issue of Today’s Hospitalist

YOUR FAVORITE PATHOLOGIST threatens to quit because of “lost” surgical specimens. The hospital nurses are billing huge amounts of overtime that they insist are due to having to learn computerized-order entry.

The chief of staff finds it hard to keep his language clean when discussing the EHR. And the once popular subspecialist who’s supposed to interface between the doctors and the software company? He won’t make eye contact with colleagues he sees struggling to find echocardiogram reports.

Does all this sound familiar? Even if it doesn’t, it soon will be a fact of life for us all. Medicare and Medicaid now offer financial incentives to hospitals demonstrating “meaningful use” of electronic health records. And having physicians enter orders in the computer means that hospitals don’t have to pay a secretary to do it.

You were out of the loop
Your hospital “or multihospital system “really did try to get a good software package. Odds are there are both MDs and RNs in your administration, and the software company had hands-on demonstrations that made their product look as if it could do anything needed for patient care and recordkeeping. The administrators have told you how pleased they are with their choice and that it will be easy to form new habits.

But none of those well-intentioned folks ever tried to run a code blue with a system that lists sodium bicarbonate six different ways, none of which is the approach taken by the average intensivist. Or tried to find the ICD-9 code for relapsing polychondritis or moyamoya disease. And they just don’t use sliding scale insulin in those nice executive offices.

Make the most of training
Before the big day when you go live, you will probably get a chance to schedule some training time. Use that time to admit, transfer and discharge a fictional patient with four or five major medical problems and a dozen medications.

Do not let your “trainer” speed things up by skipping over the order writing process. Instead, practice entering common items like telemetry, titrated meds and “call-me-if” orders. If the trainer doesn’t know how to handle these orders, the “coaches” the software people provide after startup probably won’t either.

And spend some time listing diagnoses because the hospital will sooner or later want to use them for coding purposes. If you can’t find “ascending cholangitis” in a quiet training room, it won’t be any easier when you have a septic patient with a hysterical family.

If your IT people can’t answer necessary questions, find out who can. This may be harder than you think and require multiple phone calls, but making those calls is absolutely essential.

The more that doctors call with specific complaints, the more likely it is that a responsive software designer will make the changes you need. But you have to be clear and objective, and stay on topic. The IT person cannot change the number of hours it has taken you to learn the system or rectify what all the EHR-induced confusion is doing to staff morale.

But he or she can make a list of the order sets you need, diagnoses that you can’t find and your recommendations to train newly hired nurses in how to use the EHR.

Give Dr. Geek a chance
Your colleague really believed that this system would help and probably knows how to do more stuff with it than anybody else you know. Stop telling him how much you hate it and get specific about what needs to change: common problems like pneumonia that should be managed with prewritten order sets, patient education programs that don’t appear on any menu and more ways to enter a diagnosis to get the right ICD-9 code.

The hospital has put a great deal of both effort and money into its EHR system, and it is not going to throw it out because of a few complaints. But software companies often offer more than one version of a product ” and a slightly more expensive one may cut down on the overtime the nurses report when they’re learning to use the system or training new staff.

Chances are too that other hospitals in your area use the same system or a different version of it; the three top vendors supply more than three-quarters of inpatient facilities. Ask around because many of your consultants regularly round at more than one hospital. Other facilities may have training programs you can start at home, better IT support, or simply doctors with more experience with the sneaky tricks of order entry and data retrieval.

In terms of your workload: Expect everything to take about 20% longer to do during your first week or so on the system until you get used to it. And as for EHRs prompting all the other doctors to never come back to the hospital again? In my experience, the specialists did not run from the building. Most of them use similar systems at other hospitals.

But the ones who ran were the primary care docs who admit only two or three patients a month. So expect the go-live to increase your business as a hospitalist, which is a good thing. But also expect it to widen the distance between hospitalists and office physicians.

Is the game worth the candle?
One final tip: Don’t go with the lowest bidder. My hospital was sold the least-expensive EHR, which was in effect the “Mark I” version. It had been updated and revised once its glaring inefficiencies and inadequacies became apparent, but the revised versions were more expensive. So we got the original and had to reinvent all those wheels again. Never underestimate the power of hospital administrators to screw up your patient care.

EHRs are here to stay, and they won’t change for the better unless the people who use them make intelligent suggestions for how they need to be modified and offer reasons why those changes are necessary.

Hospitalists spend a huge amount of time learning how to use these complicated systems. That means that we are in a great position to spot problems and make recommendations. We are also probably the best-connected doctors in our hospitals because we work with a wide range of specialties “and when we’re smart, we also serve on committees where we meet people who can get things done.

The hospital needs you, and so do your friends. Keep calm and be part of the solution.

Stella-FitzgibbonsStella Fitzgibbons, MD, is a hospitalist who holds two graduate degrees in engineering from MIT and was writing computer programs before most software salespeople were born. She is familiar with three of the most common EHR systems and believes that improvement is possible.