A Country Doctor Writes:

” I can’t help reflecting on how focused we are in medicine on the subject matter and how little we speak about the delivery of subject information. The business world seems to talk more about how to sell something than how to produce it. I think as physicians or scientists, we look down on that, thinking that a cup of coffee is a cup of coffee, so why are all these people devoting their lives to how to sell that cup of coffee?

We need to get off our high horses and take a look at how we present information about what we “sell” because what we try and hope to sell may have a greater impact on our “customers” future health than which brand of coffee they choose to drink.”

— Read on www.kevinmd.com/blog/2020/09/we-need-to-give-more-thought-to-informed-consent.html

I wrote about this three years ago, which is long enough to make a cell phone outdated, if not downright obsolete. From what I can see, nothing has changed in terms of what EMRs look like. In one of my practices we have a new (?!) EMR that’s even clunkier than its predecessor from the same company (Greenway, you know who you are: Why do you make me SCROLL down Every Blood Test Known To Man instead of starting to type in a search box???).

Doctors are still mostly charting on laptops or even desktops. Haven’t the EMR companies heard of iPads? eCW has a fair app, but with bugs that haven’t gone away in the last three years and new ones that are appearing. Nobody has an interface that works like a doctor thinks, and nobody has the user interface simplicity of the technically sophisticated games my grandson plays on his Xbox. Actually, video games allow you to do everything without awkward commands or click boxes. And they go back to the early 90’s (see post script below).

If I open a patient’s “chart” today and try to prescribe a drug, the software asks what day’s encounter and what type of encounter I want this to be under. Excuse me: It’s today and I’m sending in a script. Why do I have to tell my multimillion dollar system that?

The technical unsophistication of EHRs is mind boggling, but even more appaling is the worse-than-DOS-era interfaces we have to deal with. My nurse gets a paper depression questionnaire from my patient. It is abnormal. She enters the details and the score in the computer. I don’t get a pop-up. Instead, I have to remember to click FORMS-Nurse Work Flow-Screening-PHQ9 and then see the score and click one of the boxes to document my action. How sad, how nerdy, is that?

I would like to know what the excuse is for the fact that children’s games have better interfaces than EMRs. And don’t tell me that medical records are more complex. They are not, at least not yet. I can mark a patient as allergic to iodine and having stage 3 or 4 kidney disease but many systems would still let me order a CT scan with iodine contrast. Someone (many of them) is making indecent amounts of money selling indefensibly inadequate, incompetent software to the nation’s health care providers. And laughing all the way to the bank.

P.S. Historical footnote: My Brooklin home was once owned by Mark Lesser, who was the programmer behind NHL 94, one of the most famous video hockey games of all time. His office on the third floor of the barn was my “man cave” for several years.

I was left wondering exactly what was what, not an unusual situation in primary care. Was there cellulitis? Did he have shingles with mild encephalitis? Does he have a disc problem in his neck that might flare up again when he is off the prednisone? And did his blood sugar play any part in his altered mentation? I’ll probably never really know.

I keep coming back to the famous quote by Sir Willam Osler, “Medicine is a science of uncertainty and an art of probability.”
— Read on www.kevinmd.com/blog/2020/09/i-cured-my-patient-but-what-was-his-diagnosis.html

The second book in my A Country Doctor Writes series is now available.

This book is more specifically written for a medical audience than CONDITIONS, which has many general interest essays. IN PRACTICE contains lessons and reflections from colleagues’ and my own practice and also essays about how to be the kind of doctor each patient needs. Several chapters on professional burnout make IN PRACTICE relevant to both seasoned and aspiring medical providers.

Medication errors are serious business. Transitions of Care are dangerous, in large part because of the many pitfalls in medication reconciliation.

One of my clinics is collecting the extra money Medicare offers for having care coordinators track hospital discharges, reaching out to patients to make sure they have what they need, and poring over discharge summaries to reconcile the hospital and the outpatient medication lists. They also keep track of pending test results, all in an effort to make the transition from inpatient to outpatient care safer.

My other clinic doesn’t do this. The medication reconciliation is done by the primary provider-nurse team during the sometimes hectic office visits.

I see too often that a patient admitted through the emergency room has the wrong medication information entered in his admission history and orders. Then the hospitalist changes what was incorrect in the first place and the patient ultimately gets discharged with new orders to double up on something they already took in exactly the new dose, or to continue a medication that they already may have stopped.

The technology to avoid such errors already exists.

In both my EMRs, I can click on a virtual button that lets me see in full detail what medications have been prescribed electronically, as long as we record the patient’s consent to do this. I can then manually import this information into my own EMR’s medication list.

I don’t believe our local hospitals can access this information in the middle of the night from the emergency room. And I can’t access it if there is a delay at the front desk in documenting this and other consents lumped in with it, which all require annual updating.

If we really must tolerate the non-interoperability quagmire of Epic, Cerner and all the small EMR companies, I think in the name of patient safety, we should at least do this:

Make all these for profit companies use one universal medication module that automatically updates through the already existing technology. This would save lives and prevent countless medication errors. It would also save a lot of time, effort and frustration in our already stretched-too-thin primary care clinics.

And let every hospital EMR in on this, too.