A Country Doctor Writes:

It happens in eClinicalworks, I saw it in Intergy, and I now have to maneuver around it in Epic. Those EMRs, and I suspect many others, insert a stop date on what their programmers think (or have been told) are scary drugs.

In my current system all opioid drug prescriptions fall into this category. For a short term prescription that might perhaps be a good idea but for a longer-term or occasionally needed prescription it creates the risk of medical errors.

In Epic there is a box for duration, which is very practical for a ten day course of antibiotics. If I fill in the number 10 in the duration box, the medication falls off the list after 10 days. This saves me the trouble of periodically cleaning up the list.

But if I prescribe three oxycodone tablets a day for a patient with inoperable back pain and follow the convention of saying for 30 days or 28 days, that creates a problem: If my patient is careful not to take more pain pills than absolutely needed and the prescription indicates 28 or 30 days duration, the text on the prescription will read for up to 28 days or for up to 30 days. That language actually suggests they’d better hurry up and finish it and not have any pills left over. The other consequence is that if my patient doesn’t call for a refill until day 32, the medication has already disappeared from their medication list and cannot easily be “restarted”. I have occasionally restarted/re-issued a medication from memory and gotten the dosage wrong. Of course, I can check the state prescription monitoring program display for the pill strength and dosage frequency, but I still have to memorize it and then switch to the prescription screen. And the slightest distraction or interruption creates the potential for errors.

Across the EMRs I have used I have also seen the diuretic spironolactone get a stop date even if I leave the “duration” box empty. I don’t think that’s necessary: I went to medical school and already know this drug can raise serum potassium levels and precipitate kidney failure.

Back to the opiates: I think the plain English printout should say “X tablets daily for no less than 30 days” so nobody gets the idea to take more than the absolutely need because the doctor wants them to.

B.C., or “before computers”, medical charting was quick and information retrieval in small practices’ paper charts was effortless. Younger clinicians who never experienced well organized paper charts have been brainwashed to believe they were always chaotic and inadequate, perhaps like children born after the communist revolution in China… Oh, never mind.

With larger clinic sizes and with outside forces, Medicare, Medicaid, insurance companies and middlemen, demanding more and more statistics, computers became the only recordkeeping modality that could deliver to all those “stakeholders”.

Clinicians like me were told that computers would make our charting, data retrieval and lives in general much easier. That was stressed more than the fact that all those people looking over our shoulders would have an easier time doing what they do.

For several years now, with the painful introduction and abandonment of one “new and improved” EMR and chaotic adoption of another even more complex one, I have had reason to think about how much longer it takes to do my work than it used to.

I posted once about how quickly I retrieved medication information from a handwritten medication list inside an old paper chart in my clinic. I have also written about how simply we entered INR values and Coumadin orders on paper flow sheets and how cumbersome it is in the EMR. To this day I have a (secret) reddish three ring binder with a flowsheet for each Coumadin patient I have.

I think I am particularly bitter about today’s EMR’s, their clumsiness and their intrusiveness because I was around before they came about (and happy with the paper charts) and because I was fed manipulative misinformation that they would make my life easier when the main purpose was to help the onlookers, the Wizards of Oz, the men behind the curtain and the ghosts in the exam room.

If you grow up with something that was there before you entered the picture, I don’t think you expect much more from it than what it is. But if you watch the introduction of it after listening to all the promises and then see how those promises were broken, you are more likely to be critical about its shortcomings.

But lest y’all think I’m an old Luddite who could never love a computer, or an EMR at that, let me tell you about the Saturday 5 years ago this month in Bucksport when I saw 27 walk-in patients in 7 hours, charted them all in eClinicalTouch on my iPad Mini and walked out the door 20 minutes after my last patient:

Driving my Mini (iPad)

I’m winding down my “company page” on FB. And I’m not looking to be “friends” with more people than I can follow, but my public Facebook posts may explain a different side of the life of this country doctor than my regular blog posts can.

https://www.facebook.com/hans.duvefelt.1

I wonder if there is a difference between older and younger physicians when it comes to how much time we actually spend and would prefer to spend with patients. In 1984, fresh out of residency, I was the young man trying out a position in Livermore Falls, Maine. The two fifty-something family docs wrote their notes by hand standing up at the counter in a shared area. There wasn’t a whole lot of other paperwork to do.

Now, I read statistics from the American Medical Association that doctors spend more than 50 percent of their time with their EMRs, which at least to a degreee means away from their patients. I guess I’m a little slow, but it’s finally becoming clear to me why I am always behind on my charts.

Being old school, I have little patience for the fact that I am expected to tear myself away from my patients – worried, suffering fellow human beings – because the technology I’m required to use is pathetically clumsy and obviously not created by people like me who know and respect what I need in order to help my patients.

In the early years of my practice, nurses and medical assistants, like veterinary technicians today, were allowed to give medical advice and order tests based on common practice, verbal orders or “common sense”. In my Epic EHR, I have to “touch” everything, down to signing off on a “conversation” after my nurse has done what I asked her to do. And only I am allowed to give advice that any available grandmother would have dished out instantly and free of charge – if people had them around anymore.

I feel I’m in a culture clashing time warp.

How understanding can we expect patients to be when half of the time they hoped to spend with us, we’re interacting with a machine, ultimately for their benefit, but often in ways that are invisible to them.

I grew up before there were computers, smartphones or EMRs. But yet I think I’m more impatient with their inadequacies than younger providers who grew up playing video games. Not that I quite understand why they’re more tolerant of bad technology than I am, but I guess I expected that the future would bring more seamless, unobtrusive technology than it actually did.

And, speaking of computer games, compare them with today’s EMRs:

Walter speaks slowly and always thinks before he opens his mouth. I would not have guessed he used to be a soldier. He seems more like a philosopher. He has suggested books for me that have helped me make some sort of sense of what is happening in the world today.

He is part of my team and I find him a great asset. He is a calming influence on my patients and never seems to make snap judgements, which is how I pictured people in the armed services had to function.

Tonight we were talking about my latest article about burnout. Walter surprised me again about his Coast Guard experience. They have policies and officers focusing on work-life balance. As far as I can see, healthcare does not. But in many ways we are similar organizations. We have some fancy equipment but our most important resource is our human capital, specially trained to work under stressful conditions in keeping their fellow human beings safe from harm.

Walter explained that the Coast Guard is ready to step in to prevent burnout and undue stress, to protect their workforce from overextending. I found this striking, to borrow a military term. The armed services are prepared for crises and disasters but make it a priority to consider what their staff can handle. And not every day is a crisis. But in medicine, we sometimes feel that every day is a crisis.

There are more tasks/messages/results and refills than there is slack in our patient schedules to carry out. Our patients have more concerns than our allotted appointment times can give justice to. For many of us, the constant backlog is a major burnout factor.

I have read the Coast Guard’s 2017-2022 Strategic Plan for their Health, Safety and Work-Life Directorate. It may be just a bunch of words, but I haven’t seen anything like it in my line of work.

Maybe there should be something like this for the nation’s healthcare workforce?

.