The Great and Mighty EMR

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Image by nffcnnr via Flickr

For the last 2 years I’ve been involved with helping (not quite so)Mammoth Health Systems build and roll-out a new Electronic Medical Record.  It has been a time fraught with elation, despair, doubt and a good dose of “meh” followed by “WTF?”  When the cards are down, the reality is that our new Skynet is better than our old WOPR, but they’re both equally broken.  Why?  They are built to be everything for everyone.  But Skynet actually works and once you get used to it, truly is the wave of the future.

So our site rolled out a little over a week ago.  It wasn’t as big of a cluster-fuck as I was expecting.  The gods of medicine smiled kindly on us, no codes or RRTs that first 2 days/night, excellent staffing and relatively low census.  Then the storm clouds rolled in.  The house census went up and there wasn’t enough resource pool nurses to go around so places started going “short”.  Truth is, they weren’t really short, in fact they were at staffing levels that we normal run at, but for learning to use a new system with all of its foibles, we were short.  This was compounded by piss-poor planing by other shifts and other floors.  Our manager told the schedulers to post for extra shifts all three weeks of implementation.  The night shift scheduler did that, opened 3 extra shift slots a night for the duration and we’ve had really good results and have been staffed very well.  There were 11 of us the other night for 21 patients (although 2 were orientees and one was a “superuser”).  Day shift not so much.  They didn’t have slots for every day, and only 1-2 each day.  They’ve been getting mauled when it comes to staffing because most of the other units did the same thing so every unit in the hospital is scrambling to split up the few nurses in the float pool – day shifters are not happy – especially since many of them thought our manager had said that the ratio was going to the 2:1 (yes, 2:1 on a tele floor) for the roll out.  She never did.

But as for the system, it’s pretty great.  It’s a giant technical leap from our previous archaic steam-powered claptrap.  But we loved that claptrap because we knew it.  The new one is sleek and can present a dizzying array of information and once you get used to it, pretty easy to use.  But I’ve been spending my days a superuser telling people where to click to find what they need.  Muttering under my breath saying, “It’s right there.  Yes, right there under your fucking cursor. Click the fucking link.  Yes, that one!”  And that’s from the fatigue of being asked the same question repeatedly over and over again.

The funny thing is that I had never used the new on a real live patient until early last week.  As a superuser I’m supposed to be able to figure it all out from a over-the-shoulder perspective, but when you’re doing it at the bedside for your patient it is something different.  It’s little things like having to bar code scan the patient and the medication when passing meds, muddling through all of the extra rows of the flow sheets to find where I need to chart my findings (some people cannot leave and empty cell blank, they didn’t get that memo) and ensuring I get everything charted I need to in a shift.  And guess what?  I did. It was pretty simple.  Wasn’t as fast as normal, but that will come with time.

The biggest issue is that people got themselves whipped to a frothy fury over that changes.  Nurses were telling me they couldn’t sleep because of the roll-out, they were anxious and plain scared.  It didn’t help that manglement put a count-down clock in the lobby and have been über-involved in the hour to hour running of things.  IT’s been kind of a mess.  Sometimes to much support is a bad thing.  But there is a success or two.  One, in particular makes me proud.  She’s been a nurse with use since I was in elementray shcool and is well known for her clipboard that is loaded with papaers and covered in scribbled notes.  You know they type, they rely on that like a drowning man does his life jacket.  She publicly announced at the nursing station the other night that she was leaving her clipboard behind.  We applauded as we all knew how big of a jump it was.  And leave it she did.  The only time she pulled it out was when she had to bring in lots of things to the patient. She did not use it the rest of the week.  And that my friends, is progress.

Fun with Electronic Charting, part 2

Found some more bloopers that made me laugh, hope they do you as well.  Here is the first post on the subject.

First up…

Patient tolerating poi well.

I don’t know, that stuff looks petty dodgy, they must be feeling better if they can tolerate it!

Admission diagnosis:  sincopy.

While they probably meant syncope (fancypants for “fainting”), they might be having bigger issues depending on whom’s sins they are copying.

In a progress note:

D/C Meth!

No explanation needed here.  Wish they would have written it as an order though.

My personal favorite of late:

Bladder non-distended, uterus not identified…  …right pelvic cyst, question ovarian.

Patient was a male.  I hope you weren’t able to find a uterus and I can guarantee the cyst is not ovarian.

That’s all for this round.  Enjoy!


A Nurse’s View on the iPad in Healthcare

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According to the already gushing reviews, the iPad is a “game changer” and “the device health care has waited for.”

Not really.

I do believe that there will be areas in health care where it could be very useful and could make a difference.  One example that comes to mind is the typical office visit.  My primary care doc uses the computer in the exam room while in the midst of our visit.  He can look up past visits, lab values, meds and all the ephemera of a medical visit.  Instead of staring at a computer through the visit, he can look at me and be more engaged with the patient, instead of being engaged with the computer.  Another w0uld be for rounding on the wards.  How useful could it be to have everything at your fingertips when you’re at the bedside conducting rounds?

But for the average nurse at the bedside it is a horrible idea.  First, it does not appear to be very durable, able to deal with the crap a bedside nurse could unleash upon it.  Us nurses are hard on equipment, especially things we use near continuously in our work.  It is more a repetitive stress type brutality than “give a shit” mentality.  I don’t think Jobs’ fancy, purty piece of engineering could stand up to a typical 12-hour floor shift.  Then there is the issue of exposure to bodily fluids, urine, blood, mucus, poop.  Bedside nurses deal with all of that on a daily basis and while we wold probably be careful with it, shit happens.  No one starts a shift wanting to get pooped on, but it happens y’know?  Then there is the infection control issue.  We have enough issues with nosocomical infections like MRSA and VRE in health care and a portable tablet could be a very effective fomite.  Not only would we then be reminded to wash our hands, but to sterilize our iPads.

Second, it’s lacking in important features.  Bar code scanner?  Nope.  With our new EMR, all meds will be bar-coded, lab slips will be the same, even the patients will be bar-coded, so not having that is fairly significant.  If you’re going to have a device to help with the  tasks and functions of a bedside nurse, we better not have to carry multiple devices, like the pad and a bar code scanner. Swappable batteries?  Uh-uh.  We work 12-hour shifts and according to the press, battery life is around 10-hours.  I don’t have the time on shift to stop, plug in my device for an hour to get more juice so I can finish my work.  Device integration to monitoring equipment?  Not yet and probably not without a very expensive software patch.  In our new EMR, our monitors and vital signs machines are supposedly going to be integrated so that instead of entering values, we click and the values populate.  Now I’ll believe it when I see it, but having used that before, it is cool beyond a doubt.  But is Apple going to open things up to support multiple standards?  Not without a hefty price tag, if at all.  And these were only the first three I came up with.

Third, and probably most important is price.  Even if we get the barebones version, with academic pricing, it’s still going to be expensive.  And if each nurse, on each shift needs one…that could get costly.  If my floor is full, we have 7 nurses, 2 aides, a unit secretary and a tele tech on days, at night, it’s 7 nurses, 1 aide and a tele tech.  To cover the needs we would need to have 14 tablets – at least, probably with one or two for back-up.  That’s one unit.  My manager handles 3 units of varying size, so you do the math.  And that’s just one group of units.  So what?  Do you issue them to nurses on hire?  Are we now responsible for the upkeep and cost should it be damaged?  Hard questions.  What about the “walking away” of the devices?   Some people will steal anything that isn’t bolted to the floor (and some will try to steal that as well) so a tablet you can slip into your coat could disappear quickly.

Would I love to see imaging results live at the bedside?  Sure.  Would it be great to have the last set of vitals, labs and meds at my fingertips when assessing the patient?  Yes, but we already have that thanks to in-room computers.  Would it be awesome to have a cool Apple toy to play with every day I work?  Yeah, it would be cool.  But cool doesn’t always make sense.

So what would I find useful as a bedside nurse when it comes to a tablet-type device?  Here’s a short list:

  • Small form factor – bigger than the iPhone, not quite so big as the iPad.  Big enough to view screens without scrolling too much, but possibly be able to slip into my scrub pocket.
  • Durability/ease of cleaning.  It’s going to get dropped, exposed to fluids and bugs.  It needs to be able to stand up to that.
  • Bar-code scanner.  It’s the wave of the future in EMRs, so any device coming into the arena will need that.
  • Good battery life.  At least 12-hours worth, or with hot-swap capability.
  • Easy transfer of notes.  I can think of how this would revolutionize the report-process.  You gather the info needed and send it to the next caregiver’s pad, report becomes easier.
  • Solitaire.  We need a moment of brainless fun every now and then!
  • Device integration.  I want to see the current telemetry on my patient and be able to review past alarms.  When I take vitals, I want it to populate the fields with one click.  I want to see what pumps I have going, volume left in an infusion and even order new meds if necessary from another patient’s room if I need to.
  • Multi-tasking.  We’re doing it all the time, why can’t the device?  I want to be able to look up a drug in the database while calculating the dose, as one example.

These are just few things I came up with off the top of my head.  Sure some of this may sound like it based off of laziness (see infusion pumps and ordering), but I believe in working smarter, rather than harder, so if I can see what’s going on in another room without having to go there,I’m all for it.  I do think that at some point we’ll have tablet-type stuff at the bedside.  But right now, I think devices like the iPad are more suited to physicians and non-bedside nursing than to the bedside nurse.  Time will tell.