Random Thoughts from a Restless Mind

Apple just released a smaller Tablet, the iPad Mini, and was razzed by the cognoscenti because it broke no new ground. “Reactive.” “The first  time Apple plays defense.” “Nothing to see here, people. We’re walking…we’re walking.” While the Apple Fan Boys (and Girls) were lining up to add to their Apple quivers, the rest of the consumer world reacted with a communal shrug. Why? No real innovation, and that was a surprise in the world of consumer electronics recently dominated by Apple’s serial innovation.

It makes you wonder a bit, doesn’t it, why there’s so little innovation in the world of medicine when it comes to the storage and transfer of information. With all of the cool stuff already available (voice recognition, “pens” that convert script to text, intuitive “next step” software), why do we have such stodgy, clunky software attached to yesterday’s hardware in all of our EMR choices? For heaven’s sake, we don’t even have a universal platform upon which the various and sundry products are built, and so we continue to have interoperability issues more than 10 years after folks started putting this stuff into play. Why is that?

Every computer product I’ve bought and used over the last 10 years has been easier to use than the one it replaced. Each one has allowed me to do more, and usually with a smaller and less expensive gadget. I know it’s a cliche by now, but my phone has more computing power than the first SERVER I bought to run an entire medical business. For $400. I can talk to it, order it to do stuff, and get all kinds of help I never needed faster than I could realize I needed it, and it fits in my pocket. Yet in a medical office state of the art consists of serial drop-downs and mandatory field entries that may or may not include anything germane to my patient. Able to chat with my cell phone through a bluetooth headset, my EMR demands my full, undivided attention, with gaze fixated on screen.

How come?

In the world of consumer electronics the game is all about predicting what the next, big “gotta have it” gadget or service will be. The most exciting and successful products almost invariably carve out new territory and then go on to viral-like growth because they fulfill a need. This kind of technological progress is so powerful that the people who buy this stuff abandon perfectly functional gadgets that do everything one needs or wants in favor of that next, new-better gadget. This phenomenon in turn drives the makers of consumer electronics to create, to innovate. But not in medicine.

Why is this so?

The so-called “market” for EMR is simply non-existent. The power of innovation, either in response to consumers established, stated needs and desires or in anticipation that something new and better will simply take off in the marketplace is non-existent. The kinds of companies that seemingly come out of nowhere were bludgeoned by government mandated requirements that tiny, bootstrap companies just couldn’t fund the effort. Big companies that innovate like a tiny start-up and create whole, new categories, like Apple, simply didn’t. They all just doubled down on old tech and old ideas, an entire industry making iPad mini’s and calling it progress. The perceived danger of innovating and then having a revolutionary product found to lack “meaningful use” stifled the entire industry. Innovation in EMR was DOA.

And now? Now we have the largest medical institutions in the country abandoning their own efforts at software development and marching like lemmings to the Epic sea. The real-world analogy would be the government saying that you could create any type of gadget you could think of to listen to music, but you can only sell record players and vinyl albums on which you must listen to the songs in the exact order in which they appear on the disc to be assured that the check would clear. Oh, and the doc or nurse could only listen through noise-cancelling headphones that would need to be removed in order to talk to a patient.

It doesn’t have to be like this, of course. All it takes is one company with a little vision and some gumption to find a single big-name player with the courage to see that the status quo is sick. Sure, the vast governmental bureaucracy needs to fix a target and then get out of the way so that something that looks like a real consumer electronic product can emerge. That’s all, really. One product that feels like as “0f course” as the iPod, discovered and purchased by one person who folks watch like TechCrunch, a dispassionate and largely uninterested government standing to the side, idle.

A 7″ computer that could power my company 7 years ago hits the market to a collective yawn? Is it really so much to ask for this type of innovation in EMR?

OK, so maybe this part was my fault. I probably would be a bit better at this Epic thing if I did it more frequently than once every two months. Guilty. The thing is, though, that every little thing Epic asks me to do has either already been done on paper, would go faster if it was done on paper, or both.

It takes two discreet steps to enter the software program, even if you are in a CCF institution and working on a CCF computer; it’s even more complex and takes three steps from the comfort of your own computer. I get the security thing; really, I do. I tried it both ways and failed. Epic failure. Again. So once again I had to call in the cavalry in the guise of the physician support team just to get into the system, finally achieving this milestone event after 3 attempts and a total of 100 minutes of work.

Success, right? I’m in. Nothing to do now but clean up my charts, sign this, attest to that, and away I go. Sure…about that. In the interim between my visits there’d been an upgrade, ostensibly to make using Epic easier. Another 45 minutes of frustration ended up in another phone call and a personal visit by one of the support staff to guide me on my adventure. Kinda like being roped to a mountain guide when you really have no business climbing that particular mountain, except on the mountain you chose to be there.

You’re probably wondering why there was such a big interval between my visits to the “mountain”, and why I chose to continue my Epic adventure now. Both have rather simple answers. I hate everything about this process and this program; I feel oppressed, literally, forced to use a bloated,  inefficient bureaucratic load of “make-work” that adds nothing but time and effort to my day, and so I naturally avoid it for as long as possible. How long? Well, long enough this time that the reason I found myself roped to my guide was the Registered Letter informing me that I’d ignored all of the notifications that I was delinquent in my charting and had therefor “voluntarily resigned” my staff position. Another 30 minutes with my guide and my slate was clean.

How, you might ask, had I possibly allowed myself to “voluntarily resign”? I’ve been a doc for some 25 years; I know the medical staff rules. I’ve been signing charts forever. My address, fax number, and email are all unchanged, and I’ve never missed a notification from the hospital before. Despite my obvious, transparent disgust with Epic and everything it imposes on me, it doesn’t make any sense to let that jeopardize my ability to do surgery at this institution by petulantly ignoring my medical staff requirements. How did this happen?

Easy. All of the notifications were messages only available when you log into Epic.

As I posted a few weeks ago, in order to continue to use an outpatient surgery center where I have performed surgeries for 15 years or so, I am now required to use the electronic medical record EPIC. My hope had been that I would be able to continue to run “under the radar” by utilizing my pre-–dictated notes and standard orders, signing the papers as I have done lo these many years. Tragically, this was not to be. Having come to this realization about a month ago I reached out to the IT department and asked for training on the system. Being the somewhat self–involved surgeon that I am, I naturally assumed that a single phone call or e-mail would see multiple individuals leaping into action in order to help me so that I might continue to use that surgery center and generate revenue for the hospital. Silly me.

Four weeks, a dozen conversations, several e-mails, and I am assured more than several telephone calls later, I finally received a call from IT and one of the physician–advocates/trainers. I explained that I had a back log of signatures (little did I know!), and that I would be taking ER call soon, and did he perhaps have some time available to show me how to use the EMR? In the first of several remarkably positive little things in this process, Andrew did, indeed, have some time available the very next morning when I, too, could sit with him for a little bit.

Andrew himself was one of those little surprises. And ex–cop who had put himself through nursing school with the intention of using his nursing degree as a springboard to management, he informed me that he was one semester away from an MBA. It was clear he was anticipating a hostile interaction; this had been his typical experience when teaching physicians the system, especially private practice physicians. I liked him instantly, we connected, which probably contributed to the speed with which we flew through phase 1 of my indoctrination.

This can’t be all good, of course, otherwise there would be no reason to do this series! After learning how to get into the system (no, you cannot change your username), we looked at my chart deficiencies, specifically op notes that needed to be signed tracing back to November. I cleaned up all the old stuff, and then we got stuck with all of the charts that were sitting there from last week. Apparently part of the efficiency of the system allows the medical records department to put you on the “bad boy” list as soon as the case is done! We agreed to ignore these deficiencies since these would still be paper charts needing to be signed and moved on to pharmacy orders.

This was rich. I looked at about 200 orders with a “signature required” tag. Things like IV orders, and medicine injected to into the IV. Some were anesthesia orders which have no business on my list, and essentially all of the rest had already been signed. Andrew told me he’d taken a look at my in basket before we met and deleted three or four months of the pharmacy orders. I think the number he used was 800,000 orders! Whoa, maybe this isn’t going to go as well as it looks like it might. There is no connection between the electronically entered pharmacy orders and the signatures on the order sheets! 30 some odd orders per patient, each one individually entered and requiring a signature. I did 22 cases yesterday! Are you kidding me? This is what my colleagues were talking about when they mentioned the four minute per chart rule.

Like I said, though, this was a surprisingly positive interaction. Andrew took a couple of screenshots and said that he was going to sit with the IT magicians and see if we might be able to figure this particular one out. Man, that’s gotta work. I mean, the whole exercise took me about 45 minutes, and I didn’t even learn how to ENTER an order.

I can sign one, though. I’ve got some ER call coming up, and I’ll have to do some–patient consultations as part of my responsibilities. I’d better polish up my “helpless look” and rehearse my supplications. Getting someone to take verbal orders is gonna be the key to salvation.

More to come…