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More Joys of Electronic Medical Records

Go up to your favorite emergency department staff member and ask them what they think of “twofers.” Depending on that person’s mood, chances are that you’ll get anything from a scowl to a punch in the gut in response. Two patients from the same family both needing emergent medical care at the exact same time? It still happens … car accidents, fires, maybe a stomach bug. But it can be frustrating. There’s a saying in emergency medicine that the likelihood of a true emergency is inversely proportional to the number of patients in the family registering to be seen. That being said, a “fivefer” will raise the hairs on the back of the neck of pretty much any emergency department personnel. When the complaint is that everyone in the family has a cough, three of the five family members smoke, and none of them got their flu shots … well … you get the picture. One of the frustrations with scenarios like this is the charting involved. The nurse and the doctor are literally stuck at the computer for 30 minutes each, both entering useless information about different patients over and over again – instead of taking care of other patients. The medical records won’t let you proceed without entering the information. Is there a fall risk? Is there a risk for tuberculosis? Does the patient smoke? Nurses have to enter this information even on infants to satisfy government regulations. Is there a risk of danger in the home? Is there evidence of abuse? When entering an order for IV fluid, if the patient has a sulfa allergy, doctors have to acknowledge that there is some potential interaction between saline and the patient’s allergy and describe why we would dare to give salt water to a patient with an allergy to sulfa. And on and on and on. So I tried something that sounded easy when I thought of it, but was technically quite difficult when I tried to actually do it. I tried to log the number of times I clicked on different check boxes and the number of different screens I had to navigate in order to document on and discharge/admit a patient. This is easier said than done. I never realized how quickly I am able to navigate a byzantine array of computer screens. After clicking on one button to order a medication, I found myself subconsciously moving the mouse to the area of the screen where the next “OK” button would pop up. I had to literally slow myself down to count the clicks and the screens. I’m sure I missed a few in the process. The number of data points in each aspect of a patient’s history is quite large. There are 144 data potential points to click on just for a patient’s physical exam. The screen to the right is what must be navigated for each and every patient’s history. Each line in the white fields is a data point that must potentially be either right- or left-clicked depending on whether it is positive or negative. I didn’t even bother counting up how many potential data points could be clicked upon, but it numbers in the several hundreds – depending on the presenting complaint. So I set out to log the clicks and screens. The first few times I tried, I wasn’t able to do it. Finally, when it wasn’t so busy, I made a conscious effort to stop on every screen and mark down clicks and screens. I use some basic templates, so the amount of clicking that I do is actually less ...

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Do Electronic Medical Records Affect Productivity – Part 2

In case you didn’t catch the earlier version of this experiment that I posted, you can find that one here. I work at several hospitals and each uses a different electronic medical record system. When I switch from hospital one to another, I obviously have my favorite EMR systems and my not so favorite EMR systems. In the previous post, I was using the EMPOWER charting system, which I liked for its simplicity, but disliked because of the layouts of the charting interface and some of the macros it contained. After becoming rather frustrated with the function of another EMR system, I decided to repeat the experiment at a different hospital. This hospital uses the Meditech system. I also did the same thing at a third hospital using yet another EMR. Those times will be published in a future post. I had to do the experiment at this hospital a few times because several times I wasn’t consistently busy throughout the shifts as I am at other places. In the shift that I used, I only tracked 7 hours in an 8 hour shift because the first hour had a lot of down time that wouldn’t have fairly represented the effects of the EMR on my productivity. In general, the whole shift had rather low acuity with only a couple of admits. In theory, low acuity should increase efficiency because of less charting time. It didn’t. In fact, the percentage of time that I spent with patients during this low acuity shift was just slightly more than the percentage of time I spent with patients during a much higher acuity shift which required more documentation of several more admits and a transfer. As with the previous experiment, when there was overlap, I would generally count the time toward the task with which I was focusing most — if I was speaking to a doctor on the phone while charting, I counted the time as only speaking to the doctor. Out of a total of 420 minutes, I calculated that I spent the following amount of time performing the following tasks: Seeing patients: 156 minutes Time on computer: 237 minutes including … –Charting/entering orders and labs to be done/entering discharge documentation: 191 minutes –Looking up old medical records: 20 minutes –Entering admit orders/completing transfer forms: 13 minutes –Meditech program issues: 13 minutes Discussions with other physicians: 20 minutes Miscellaneous down time (bathroom, food, non-work related issues): 7 minutes Despite a lower acuity shift, more than half of my time was spent on Meditech entering data. I should take that back. Thirteen minutes were wasted due to Meditech program freezes and due to watching the little hourglass turn over and over on the computer screen while Meditech’s pages loaded. The rest of the time was spent entering data. I lumped patient evaluations and re-evaluations into one category, so I wasn’t able to calculate the total time I spent with each patient. However, based on the numbers, it appears that time with patients averaged between 6 and 10 minutes (with a couple of outliers) Out of a seven hour shift, I spent just over 2.5 hours with my patients and their families and I spent just under 4 hours with the computer program. Sad.

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Microbial Armageddon

Any patient who demands a ZeePack for a runny nose, who wants amoxicillin for sinus congestion, or who wants Levaquin to “keep this bronchitis from developing into pneumonia” needs to read this Bloomberg article. We are heading toward a situation where people die from infections that no antibiotics can treat. The article discussed one infant in a pediatric ICU that died because the infection that the child developed was resistant to all antibiotics used for treatment. Six similar incidents occurred during the course of 16 months. Estimates are that 100 million people in India have been colonized with organisms carrying the genetic mutation. Medical tourism in India is decreasing as a result. Even the director of the CDC cites the situation an example of why we have to limit antibiotic prescriptions: “We are looking at the specter of untreatable illness.” Oh, and remember how the Centers for Medicare and Medicaid Services assert that if hospitals don’t give antibiotics to every single pneumonia patient within 6 hours of arrival – even though a large proportion of pneumonias are viral in nature – that the hospitals are falling outside of “quality” guidelines? Our government’s own “quality” guidelines may be contributing to the looming microbial Armageddon in this country.

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Dr. Google, meet Pharmacist Bing

FDA decides whether to allow patients to purchase prescription medications over the counter for many common ailments. This idea is controversial. On one hand, deregulation would remove one of the largest barriers to receiving treatment for some conditions – the doctor’s visit. If no doctor’s visit is necessary to receive necessary blood pressure medications or diabetes medications, then patients don’t have to wait for an appointment and the patient/government doesn’t have to pay for the doctor’s visit. The move would also purportedly cost patients more money for their prescriptions because insurance companies (including Medicaid) don’t pay for over the counter medications. Therefore the costs for medications that go over the counter would be shifted to the patients who purchase the medications. But on the other side, I’m sure that patients will “Bing” what medications they think they need, and the proposed plan would require patients to answer questions online or at a kiosk and then get input from a pharmacist before the prescriptions could be purchased. So there really isn’t unfettered access to the selected prescription medications. According to the article, the American Pharmacists Association is embracing the concept while many doctors’ groups are opposing the idea. Pharmacists believe that their increasing role in a patient’s medical care will be a good thing while physicians see many of their “bread and butter” patients skipping appointments and instead going to the pharmacy kiosk. Some of the conjectures about such a policy should be addressed. Will prescription costs for patients go up? If patients have to pay out-of-pocket, then perhaps they would be paying more money for prescriptions, but I doubt that the amount of money would be much more than the copay they were previously paying. I imagine that most of the medications considered for over the counter use would be generic medications from the notorious “$4 list,” so the financial burden on a vast majority of patients would not be great. However, there are certain medications that have no alternatives. Consider colchicine, vancomycin, and Plavix. Medications similar to these would continue to command a higher price. If patients need such medications or desire name brand medications, then they will keep going to the doctor in order to get their designer medications for a $20 copay. However, medications that do have a generic or over the counter equivalent will see downward pressure on their pricing. Who in their right mind would buy a $300/month name brand medication when the $4 generics (or a combination of $4 generics) work just as well? So pharmaceutical manufacturers would have to justify the price of their expensive medications or would have to lower the price until patients felt that the price justified the benefits over generic medications. That’s free market at work. Will the public be in imminent danger if they are allowed to self-prescribe? I doubt it. The Angry Pharmacist has a different take on the matter (read the post from behind a blast shield because it is rife with f-bombs). He believes that patients who take some medications need to be medically monitored for adverse effects from the medications. For example, patients who take ACE inhibitors may have deterioration in their kidney function from the medication and may even develop renal failure. If patients are worried about the effects on their kidneys, they can see their doctors for such testing. There are also some online labs that will provide direct-to-patient testing. But if we consider the renal function example, we can also look at Mexico where patients can purchase many medications over the counter. The rates of chronic kidney disease are no higher ...

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Drug Shortages

Just got word that several additional medications have been added to the national list of “drug shortages”. Doctors better start learning more about wilderness medicine at this rate. I can see the management of our next unstable patient now … [Call comes in on telemetry line] “We’re coming to you with a 44 year old male hypotensive and unresponsive. Short transport time.” [15 minutes later, the crew arrives] “Sorry it took so long, our ambulance ran out of gas because we couldn’t afford to fill the tank due to the high gas prices and low Medicare/Medicaid reimbursements. We had to call for assist with transport from the Amish Ambulance Service with its horse and buggy. By the way, do you know where I can get a broom and a very large shovel?” [Patient is hooked up to the monitor. Wide complex bradycardia. Pressure 60/40. Dialysis graft is noticed in his arm.] “Dialysis patient. He may be acidotic and hyperkalemic. Give him an amp of bicarb STAT.” “Sorry doc, we’re out. There’s a national shortage.” “Keep that fluid bolus going. Let’s start some Levophed on him to raise his blood pressure.” “Sorry, doc. We don’t have any of that either. National shortage.” “Well let’s at least give him some Vancomycin in case he’s septic.” “I’d like to, but I can’t. That’s on national shortage, too.” “Well, he’s not responding very well. At least let’s get him intubated. Can someone push some Rocuronium?” “Don’t have that, either. National shortage.” “Vecuronium?” “Nope. That’s out, too.” “Pavulon” “Nope. National shortage.” [patient now loses his pulse] “He’s CODING! Start CPR. Give him an amp of epinephrine, STAT.” “Sorry, doc. National shortage. Don’t have any.” “OoooKayyy. Give him an amp of atropine, then.” “Don’t you know that atropine isn’t part of ACLS protocol any more? Besides, we don’t have any and there’s a national shortage of atropine, too.” [patient is unable to be resuscitated and dies] Six weeks later, the doctor receives a letter from the Arizona State Nursing Board [for those who don’t regularly follow this blog, this is parody — background here] informing him that he is being investigated for failure to properly manage the patient and failure to properly look out for the patient’s best interests, too. He must submit to a psychiatric evaluation, must submit to a genetic test to assess his future intellectual capacity, and must submit to a hearing in front of the whole nursing board to explain himself or else his name will be posted somewhere on the Arizona State Nursing Board’s web site and he will never be allowed to be a nurse in Arizona. “I think I’m going to be sick.” “Hope not. We’re out of Zofran, too. National shortage.” [fade to black] UPDATE Good thing I had extra coffee and some old jumper cables laying around to jolt my heart back into a normal rhythm after seeing the Instalanche! Thanks, Glenn!

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Legislative Fixes

Washington State drops its plans to limit Medicaid patients to three emergency department visits per year. Instead, Washington plans to institute a policy of refusing to pay for any emergency department visits by Medicaid patients that are deemed “unnecessary.” What effect will this policy have? Medicaid patients can’t/won’t be charged for the “unnecessary” visits. Washington state will no longer pay for the “unnecessary” visits. Therefore, hospitals and medical providers take a financial hit if the state makes a retrospective determination that a visit is “unnecessary.” In order to make the determination whether a visit is “necessary” or not, Washington State officials must rely upon what is written in the patient’s chart to determine a patient’s complaints, diagnosis, and workups. Who controls what complaints are emphasized on the charts and how the complaints are worked up? The same providers that will be financially liable if the visits are deemed “unnecessary.” If this policy survives the legal challenges that are being mounted against it, look for a sharp increase in the number of patients diagnoses that Washington State does not deem “unnecessary.” The funny thing is that when you pay for a result, you often get the result. Remember when Medicare started docking hospitals that had central line related bloodstream infections? When hospitals don’t get paid for patients with central line related bloodstream infections, the incidence of such infections plummets. But the incidence of bloodstream infections in general goes up. It’s all in how you define the issue. With emergency patients, the demographics won’t change. The patient complaints won’t change. The diagnoses will change a lot – especially if patients know that they might be triaged out of the emergency department without receiving care and sent to a medical clinic if they have certain “unnecessary” complaints. If I was running a hospital, I would even put a sign up in the waiting room stating which complaints/conditions that Washington State would pay for and telling patients that after they receive their federally mandated triage exam, they may be sent to a clinic for their care if they do not have one of those conditions. Because reimbursable diagnoses are usually paid at a higher level, I think it’s a safe bet that Washington State will end up paying out more money for emergency department visits by Medicaid patients. Your baby needs to be seen for a cough? Coughing is an “unnecessary” complaint. But, that cough could represent RSV pneumonitis or pneumonia. Those aren’t “unnecessary” diagnoses. Instead of giving you some cough medication and discharging you, we should probably do some blood work, a chest x-ray, and get a nebulizer treatment going just to make sure that there’s no pneumonia or RSV present. When legislators try to fix a system that they know nothing about, they often just make the system worse. And then they need to create more regulations to try to fix the problems they created with the initial regulations. We’re from the government. We’re here to help.

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