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Greetings, all, I am turning to my favorite board for input - thought of adding to Joelcorley's thread on "I quit!" but did not want to hijack it. I have posted very little here so far about what has been evolving at work but now things are reaching a fever pitch and I need some real help. My livelihood is threatened, but that seems a smaller issue in certain ways than does the outcome of what is likely to happen next and how limited my future options may be in the inbred world of medicine locally. For anyone who has read of my efforts to revolve student debt, I have enough savings to pay off the remainder of what I owe before next June so no worries that I will be caught short holding a high balance on a 0% credit card! I'd rather not dip into savings but, believe me, I WILL if I must. The other obvious worry is how to cover health insurance costs should I elect to become unemployed (or if it is elected for me) - I know all about COBRA, but like all other Americans who may not have a spouse whose insurance covers them, this is a pretty expensive hit. Fortune favors the prepared but I can't say I've been fully prepared for THIS circumstance.

I posted the current sad saga here on the "Physicians and Other Professionals" board. In reference to EMR in my post, this stands for "Electronic Medical Record" and refers to documenting and coding patient visits electronically (as opposed to on paper, how it has been done for decades). I've been at the mercy of a very user-unfriendly interface which has slowed me down to a crawl. Anyway, here is the link:

http://boards.fool.com/Message.asp?mid=23169433

I appreciate all comments but especially the gentler ones since I feel pretty raw about how this has shaped up. I'll probably cross-post this to the "Ask the Headhunter" board because the handwriting is all over the wall, and I am not personally accustomed to career developments akin to this. Thanks, dear Fools, for your anticipated input, especially those with happy endings!

xraymd

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No. of Recommendations: 2
It is pretty clear to you and from your post that you are going to have a job change, and the sooner the better.
You can:1) do locum tenens for awhile, 2) work for a practice that has coding as someone else's job, 3) set up your own practice and hire someone to code for your, or 4) learn to code with a lot less effort.
Certain codes come up over and over. Are you constantly looking through the ICD-9 book looking for codes? Or is the problem the CPT codes? Probably not the latter, because an internist uses only a very few of these. You can, or maybe already have, made yourself a "cheat-sheet" of common ICD-9 codes. 250.00 for diabetes, 599.0 for UTI, 401.9 for hypertension, in my practice these come up daily. After awhile you know them and don't have to look them up anymore. Why is typing codes into a data base more difficult than writing them on paper? Clearly you can type!
Why are others in your practice able to code this way better than you can? What pointers can they give you?
There are coding courses. Usually they are intended for medical records folks,but when this stuff was new I took a one-day version. Very helpful.
It isn't clear what part of inputting codes is causing so much trouble or why.
I'm a little puzzled about why this mechanical aspect of a practice would cause this much trouble.
Best wishes, Chris

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xraymd -
Sorry to hear of your struggles.

I'm a programmer not a doctor....and these are more about coping than job searching.

Do you have a tablet or laptop PC, so that you can add to the EMR where you are?
Are all the computers you code with (at office and home) set up exactly the same? (I think this would be a good idea, says she who works on Windows at office and MAC at home)

Can the office manager set up the EMR for the patients you are going to see? (I'm thinking that some of the information is available at the front desk)?

Do you have some canned text that you use to paste into records (Saw pt at _____ Pain is localized to ....)?

As for the job search, I second the idea of going somewhere for awhile (come to Alaska? cruise ship work?).

YeilB
hoping you find some calm moments - it's a crisp fall day here, so I refuse to be discouraged



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Greetings, Chris, I'd hoped you would answer. The coding aspects for codes that recur are not the ones that cause difficulty. Here's what does:

On paper, the chief complaint and a portion of the HPI are written by the medical assistant at the time she takes and documents the vitals. Then I see the patient, ask a few more focused questions, write the answers swiftly, examine the patient, write my exam findings just as swiftly, write any rx's and prepare any forms for imaging and labwork and record point by point what my diagnoses are and what I am doing to treat and investigate. The minute I think it, I can write it. I have not been obliged to hunt up the ICD-9 code for my diagnoses. It's quick and I am done once it is on paper. Next patient up next, nothing left over from the first patient.

On the EMR, I must open the patient visit, go to the specific module intended to capture chief complaint/history of medical illness, put the individual complaints into their individual boxes (the medical assistant does some of this), put the vitals into a different module into their individual boxes, go to the review of systems module and click off each little box regarding Normal or have to open yet another module to detail any abnormal review of systems, go to the physical exam module and click on each little box similarly to the review of systems module - and every time I answer that something is not Normal, yet ANOTHER box pops up asking me to further detail the degree of abnormality which I have to answer or close, then I have to go to the Assessment module to search the ICD-9 database for every single diagnosis I wish to document (when I know the codes it's easier but when I can't find them it's a showstopper because the program WILL NOT PROCEED without ICD-9 codes for everything). Having spent time to find the codes, I then have to go to the Plan module to say what I am doing for each diagnosis, then I have to go to the Rx module to put in every single prescription (each time having to re-enter my password because it is not set up to allow me to input it once per session or even per patient) that I wish to print out - sometimes I can't even find the desired med when I search for it - then I have to go to the printer to collect all my scripts to sign. Then I have to go to the lab module to enter lab requests that I used to simply circle. Then I have to go to the imaging module to detail requests I have for imaging - xrays, CTs, mammograms, bone density scans. Then I have to encode the results of any EKGs I've done (can't just write it anymore on the EKG itself - have to ALSO do this). And this is just for urgent care visits. For Establish Care visits, I have not even mentioned what needs to be done to capture past medical history, social history or family history on this system - each with their own modules with multipart steps for each, and none of the modules passes information forward to the payoff Assessment module which, if not completed, causes a block to closing off the patient visit.

And all of this needs to be done in 15 minutes, otherwise the patients are stacked up waiting. I used to run on time (contrary to the schedules that several of the other docs keep) and I can STILL run on time if I do not spend time doing any of this during the actual visit. The problem is that the mechanical aspects of recording on paper were very fast - I could write nearly as fast as I could think, and I could do so simultaneously with my attention focused on the patient. But I am simply slower on the computer - the mechanical aspects of clunkily moving from module to module have really slowed me down since I evidently can't think and click at the same time, and the patients rightfully dislike being slowed up by my attention to the monitor and not to them.

How have the other docs done it? One of the docs is a superstar. He's able to be both fast and thorough simultaneously and is considered in a league by himself. I watched him for an afternoon - he never falters. It's like watching a piano concerto by a gifted master - he already knows what he is going to have to type and he is able to type and talk to a patient at the same time with blinding speed. The other docs admit to cheating on their coding - they enter fewer diagnoses and they cut out any detail that might be relevant for future lookbacks on how a patient was doing at the current visit. In other words, they've decided to compromise on detail rather than get bogged down - if they have a definite diagnosis that is too obscure to find in ICD-9, they IGNORE it. The most senior doc in the practice has already realized that having to code on this system is going to mean a major overhaul of how he has done things successfully for nearly 30 years and he has delayed his start date yet again because of realizing that he can't afford to adapt or die given the hit it will mean for revenue. I've sort of hoped that when he tries it, should he realize that he's better off doing what he's always done and handing off his paper documentation to someone else to enter, that maybe the same courtesy would be extended to me. Not everybody is likely to be as successful at assimilating this method of data capture, and apparently I am not. If I were to compromise and enter only a couple of diagnoses per visit - even if there were yet more that were pertinent - perhaps I would be faster, too, but what does that say about how I will recall the plans 3 months down the road?

The bottom line is that I have been struggling with this for too many months and am by now just exhausted. It has been made very hard not being able to be fluent in documenting simultaneous with the visit itself. I have been spending effectively an additional half-day after seeing patients on pure documentation and there just are not that many hours in the day. So I am doing less than ever before and taking longer to do it, and nobody is happy.

Are you on EMR and have you adapted? Thanks so much for your comments. I agree it shouldn't have to be this hard!

xraymd
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{{{{{xraymd}}}}}

I'm so sorry to hear this. I can't believe they're being so draconian about their data entry. Did you ask them why it's not an option for you to enter data on paper and have someone else enter it into the EMR? Are they concerned about the cost? What about other practices in your area, are there offices where they don't use EMR, or they'd be willing to accomodate you?

xraymd, I know you're a wonderful person, and I'm sure you're a wonderful doctor. My mom is a doctor, and she has had to change jobs several times, sometimes just because the place she was working wasn't making enough money, sometimes for other reasons. I know it's really hard, but maybe it would even be better for you if you leave and work somewhere else. If they can't be flexible enough to work with you, if they're just saying "Our way" without even being open to your point of view, I frankly think you deserve to be treated much, much better than that.

My mom switched to a different office in the past year, and because of better accounting and billing at the new place, she has been able to stop working Saturdays (which she is pretty happy about, and me, too). The change was initially scary, but it worked out for the best. You are such a talented and skilled person, I am certain that you can find another place to work, and hopefully it will be one that will treat you as a valued employee, instead of some kind of interchangeable part. :-(


--Booa
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Greetings, Booa, thanks for your thoughts. The reason given that the practice will not entertain having a coder translate my paper documentation to EMR capture is that "we have made a commitment to be a 100% EMR practice." So the implication is that if I am not keeping up, then I am falling below their standard of capture. I've been effectively told to streamline and to get simultaneous - but there has not been any alternative given to what happens if I don't (or can't). I am now a liability to the practice because by not adapting, it makes extra work for others that they had not planned on in their business plan. Again, the fact that my patients are very happy means less than that I am an outlier. And it really is pretty dreary not being listened to nor respected when I have said repeatedly that they will indeed get the old productivity from me if they back off and allow me to do what I've been able to do demostrably before. That appears to be worth less than being able to continue to say that we are "100% EMR." (Okay, that sounded bitter and I am trying not to become that way, but it is not easy.)

Looking for another job is going to have to happen. It's hard for now since I am working literally from 6am (when I take the signout from the on-call doc the night before) to when I leave the house between 8-8:30am to round at one to three hospitals (depending on where we have patients) to returning to the office by 2pm (earlier if I can get there earlier) to see patients in the afternoon till 5pm, then spending until generally 9pm signing off on labs/reports and documenting. Not much chance to job hunt. I will say, though, that I COULD devote my half-day off per week to doing this and it is apparent that I sure better start.

This EMR crisis is not unique to me. Plenty of other practices are in "adapt-or-die" mode and there are many ways in which this could be handled - not every practice demands electronic coding in front of a patient. Ironically, I have thought that it would not be such a bad idea to draw upon my prior experience as a graphics-based programmer in pharmaceutical research to switch jobs and turn some attention to ease-of-use principles in user interfaces for this purpose. How well I understand some of the bog-downs! But that sort of job opportunity is not available locally and maybe amounts to wishful thinking. For me to meet the practice's nut, I need to see between 10-14 patients daily after my hospital mornings (certainly there is revenue in seeing hospital patients but that is just one side of the coin) and I have not come anywhere near this target since being forced onto EMR since March of this year. I have not wanted to admit defeat but I am getting ever readier to, given the bad blood this has engendered. I miss having fun at work and laughing with everyone and checking in with the other docs - that's all vanished since it has felt so grim. Only with the patients is that good mood still prevailing (I don't share my frustrations with them at all about this). Sigh.

Thanks, everyone, so far, for your great support. I can't tell you how much it means to me.

xraymd
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No. of Recommendations: 5
As you describe it, no, I am not on EMR.
We tried electronic order entry. We really tried. The system we had just was not sufficiently user-friendly, and we went back to writing orders longhand. Now, I am hospital-based, and this hospital just has an attending staff of seven, and we don't have any personality conflicts. It was unanimous: this system won't work! Too many errors! So it went to the trash heap.
Your next conversation with the boss goes along the line that you love your patients, you love being an internist, you enjoy your associates, but they are doing their record keeping in a manner that does not allow you to be the doctor you can be, and the Creator has consistently ignored your requests for more hours in the day. It is possible that the software problems that make it impossible for you to function effectively will cause them to change at some point, but for now you need to work in a different setting. Most medical journals have classified ads for CompHealth, Vista, Kron, Doctor's Associates (I think they changed names a few years back) and they'd be delighted to put you in more agreeable practice settings.
If I were a patient and my doctor were fighting a computer program instead of listening to me, I'd be pretty pissed!
I'm sure you will solve this problem with your usual logic and charm,and if it involves a change in venue, so be it. Long term, the change is likely to be for the better.
Best wishes, Chris
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A big kiss to you, Chris, for helping me to feel better and for reminding me that my future has a fresh vista when I next turn towards it. VERY MUCH appreciate the practical info you have provided.

xraymd
everyone has been so soothing, really a help!
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When I left FHP in California, I was told on a Friday that my services would no longer be needed, and was at work in Wisconsin a week from the following Monday. I'd done locums before and had some contacts. It was necessary for them to check references, and get me a Wisconsin license, which involves passing an open-book test on Wisconsin law as it applies to the practice of medicine (200-page book came with the test). You can bet there were a lot of Fed-Ex packages that flew back and forth, and of course the 3 days it took to drive from Anaheim to Madison. You could call a locum company in Atlanta before you go to work on Monday, taking advantage of the time differences. Or leave a message and ask to be called at an hour that is convenient for you. They will. You don't even have to go for an interview. The paperwork is daunting, but you only have to do it once per agency.

Best wishes, Chris
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xraymond

This sounds like a horribly horribly designed system. Perhaps you could offer your (expensive) services as a consultant to the software company when they redesign the interface because of the flood of complaints.

Morons. That's why there is usability testing in the world.

My goal is to change the world through better document design


bleplatt

Hoping things go better for you.
ps. can I use your example in my tech writing class of computer scientists of what happens when there is bad design?
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Greetings, bleplatt, indeed you may use my example under the cloak of identity protection (omit the xraymd!). Take note of how brief the first paragraph was in describing how I've documented on paper. Then again note how LONG the subsequent paragraph was in describing documenting on EMR. I am sure you already "got" it and realized that the length of effort it took to describe the differences is a direct correlation to the length of time it actually takes to DO the documentation by these different methods.

Horribly designed or no, there are docs succeeding on it. I am just not one of them. Interestingly, last November I attended a user's group meeting of other physicians and practices who have adopted this system and spoke at length to one of the superstar physician users of it in a New York State practice. I also spoke at length to the actual physician DESIGNER of the system. Both of them heard how I was asked to use it and both shook their heads to say that the system was NOT designed for real-time capture of information in the way my practice intends for it to be done - in fact, the system designer offered our practice a free two-hour solutions session to see how the modules could be customized for easier face-to-face use, and the management DECLINED to take him up on his offer (too busy to spend time customizing the modules!).

The point is that since the maximum number of docs in our practice HAVE adapted (no matter the compromises to their level of prior detail), I am the odd man (woman) out and thus require an extra level of "coddling" to get me in line. I am not very good at capitulating to the demand that I decrease the amount of information to input, given what I USED to be able to capture that served me well later in case I needed to rely on prior observations important to document at the time. In fact, I have already been subpoenaed in one Worker's Comp hearing that focused on what was recorded on the electronic document compared to what was actually told to me by the defendant. There were gaps and I was asked about why I had not recorded in greater detail what she'd said 6 months before. That was hard to defend - it could only be said that I had recorded what I deemed the essential complaint she had at that time despite all the other level of detail she says she'd gone into. And the management of my practice KNOWS about this instance yet still demands EMR data entry from each of the docs in spite of its potential for deficiencies or incompleteness.

The newest doc in the practice who has already adapted to EMR freely admits that he does not record info for future reference. He says he will just "reconstruct" the history from hearing about how the patient is doing weeks to months later. I don't think I want to rely on my memory to be able to do this, nor do I believe I would be any faster at trying to do this than if I'd written it down timely and in full. Yet he is easily seeing his 23 patients a day and encoding at least 14 of them and leaving the office by 6:30pm - so however imperfectly, he is apparently doing it. He acknowledges that even if he shows me HOW he does, that I might not opt to mimic him if I would prefer to capture a greater level of detail. He is in no way a better, nor worse, physician than I am, but he has been able to record less because it suits his comfort level. It does not suit mine. And that fact alone may indeed spell the end of my present job.

xraymd
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usability - I love reading
Alertbox: Current Issues in Web Usability. Bi-weekly column by Dr. Jakob Nielsen

YeilB
working in a place that reminds me of a stern school nurse -
you say this hurts - where's the blood?

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(((((((((((xraymd))))))))))))))

It really sucks when you have to work with inflexible jackasses. Been there done that.

I have been to some med practices with computers in the examination rooms (I am assuming this is what you are describing where you are expected to imput right there?). On the first visit, the doctor never imputs while there. But it is in the computer by the next visit. Even with the simplest interface, it would be difficult for anyone to give an exam and imput a med history in 15 minutes.

Did you ever take shorthand? Maybe you could come up with your own style shorthand for the computer program and still have the detail?

ARR
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Greetings, ARR, thanks so much for the vote of confidence. The problem is not so much with shorthand (since I am already fast in paper documenting). To me, it is the byzantine number of modules I have to distribute data among, each in its persnickety little format, and the overall showstopper is the requirement to have a code for every diagnosis before the program will even let me MOVE FORWARD to the module that captures the visit and closes it out. Heaven forfend if I forget something for then I have to re-open the program and start over again! It amounts to data input paralysis. When I could simply WRITE, on a SINGLE SHEET OF PAPER, the essentials of the visit (without hunting and searching and click click clicking to find what I need the moment I need it), it was do-able in 15 minutes. And let me also remark that the 15 minutes I refer to includes the amount of time the medical assistant has to take the vitals and the chief complaint. Then the way the system works is that if she is occupied entering this data, I can't even use it till she is done because there is a conflict (can't have two open sessions at the same time). So before, when I would see a patient, I would have about 8 minutes left to do everything else I've already described, but I could also be doing something else on that patient (looking up old data in the chart, for instance) while I was waiting for the medical assistant to finish her part. And now I CAN'T since I cannot touch the session till the assistant signs off. Could this be any more idiotic? But even so, since I am the only doc not getting it done, there you have it.

xraymd
frustrated - but that's pretty obvious!
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From what I read, it seems like you're slower at using EMR because you're not "cheating" and reducing/omitting data input the way other doctors are doing.

Electronic records do seem to be the way things are headed. Perhaps not the software system this practice has chosen, but I think you will have to adapt to computerized record keeping at some point.

This job may well be over. With your description of events it's clear you don't feel like a valued and respected collegue. Get your info together for the job search.

In the meantime, make a committment to yourself. You will do the EMR with the patient in the office. If that means having to have a 30 minute or 45 minute block per patient instead of 15 minutes, then that's the way it will have to be for awhile. With you taking the work home with you, only you feel the pain. The pain has to be felt by your collegues before their best interest becomes your best interest.

You are clearly not computer illiterate. If the interface has you stumped, apologize to the patient who will probably totally related. Ask the practice to call the rep that sold the them the system and see if they have someone who can come shadow you for a day. Hey they have reps in the operating room showing doctors how to install the newest do-hickey inside a patient; they must have someone who can come over and help you get around the blocks in the software.

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Greetings, rozina, thanks for your thoughts. I am indeed not computer-illiterate. But this interface really has gotten in my way. I used to be given more time per patient when I was first learning but that had its limitations because the same issues that trip me up now tripped me up then - multitudinous clicks to do something that used to be done in a flash, plus a new requirement to search for the right code which was previously done by a trained coder asynchronously from the visit (in other words, not my direct responsibility). I have been shadowed before when I was on paper and the consensus was that I was appropriately fast and thorough. I am completely willing to be shadowed again but someone would be watching me enter data into EMR offline since I can't afford either the time nor the bad will of the patients to try to clumsily do it in front of them (been there, done that and completely forgot to do major portions of the evaluation that were second nature to me without EMR data entry interference). The issues revolve around how cumbersome it is to put info into THIS system - as I've said, heaven help me if I forget to enter something in its proper sequence (the other docs are just ignoring whatever they forget because they can't afford to be held back by having to return to update it).

The nurse practitioner who joined our practice thought "no sweat" when she was asked to input onto EMR - the one she was accustomed to was a single window (no modules) not very different from a single sheet of paper as we'd all been trained to record on. She now codes on our EMR but admits to me that she hates it and that she can only do it because she burns patient slot times to get her documentation done so she can go home on time to be with her family. Those are patient visits that go missing due to satisfying documentation requirements. Management knows this and still agrees that it is worth it to them to have the bulk of the documentation on this EMR, no matter how klugy it is.

I am indeed worn out from trying to cope with this for months on end. I am depleted, working in effect 15-hour days not unlike what I did during my medical residency. The management knows this and STILL is offering me no option to offload me apart from having someone sit with me during patient appointments to judge where I am inefficient. Great - but where was that plan 12 months ago, for by now I am so tired I am not sure I have enough reserve to recover well enough to make a change that feels like yet another major hurdle in an environment where I feel like the deck is already stacked against me. That's why I've referred to bridges burned and it's a damn shame. I come home sad every day and it's been that way for months. That's a pretty sorry result, eh?

xraymd
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It sounds like an opportunity to create a better piece of software, one with a reasonable workflow and one single sign-on. Without knowing anything about your particulars, here are my thoughts on how to do the workflow part right:

each diagnosis requires a code to complete a write-up, but this is only necessary for closing the session. You can add diagnoses and write free-text descriptions in place, then code later.

Code lookup is integrated and can be searched in multiple ways (hierarchial, string, similar diagnoses)

Someone else can do the coding once the diagnosis is in (subject to permissions). You must approve all codes entered by another as part of closing the write-up.

advantages:

Liability. You won't have to explain why you (or the newbie doctor) don't record historical data, as it's done because it's easy.


Fewer mistakes, due to better records

Division of labor. One or two people can code for several docs, and mistakes can be tracked and reduced. This last part may be controversial, as people don't like being watched.

Depth, speed similar to paper, but nobody has to worry about doctor chickenscratch.
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No. of Recommendations: 8
What makes me so mad is that none of this
has ANYTHING to do with your skills as a physician.
The idea that you would go through all it takes
to become a doctor, do a good job in what you
trained to do, and then get tripped up by some
bureaucratic nonsense about the right way to write
down what you've done is infuriating.

But I bet you've thought about that . . .

{{{{ xraymd}}}}
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Greetings, Abfacken, your thoughts are all good - they've been suggested in various ways to the practice - but it would take a commitment on the part of the practice to implement these changes along with required companion software (which then has its own maintenance and upgrade cycle). The proprietary software is rigid in its design - no free-text allowed! It will move forward only when the results of a search have been satisfied. To try to get around this, the support team (basically the office manager) has come up with a special code she calls "Spot Holder" but now the database is riddled with "Spot Holder" codes that have gone unresolved for nobody has time to learn enough Crystal Reports to find and to resolve them. Are you getting the picture that this is just too bleeding-edge in some ways? Logic such as you have shown is not in play here, for there is literally zero computer expertise on staff and the docs who have adapted are operating in the environment completely without regard to valid data in. If they can find the code when searching (as is REQUIRED), hey, great, and if they CAN'T, in the interest of time they either ignore it or input the "Spot Holder" and exactly how valid is the data in the database then? But that is not of much import at the moment when 4 patients are yet waiting to be seen and the pressure is on to MOVE ON.

In defense of the EMR, it is actually handy once the data is already in there. It's just the act of having to be the one cut up day by day by the bloody complexities of poor interface design in a production environment that makes the effort so unpleasant.

xraymd
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> Are you getting the picture that this is just too bleeding-edge in some ways?

It isn't bleeding edge. It's alpha quality crap from the 70s.

> Logic such as you have shown is not in play here, for there is literally zero computer expertise on staff and the docs who have adapted are operating in the environment completely without regard to valid data in.

It sounds like nobody bothered to get proper requirements, nor have they really got acceptance testing involving actual doctors.

> In defense of the EMR, it is actually handy once the data is already in there.

True, however you don't have data you can trust, so that's kind of an empty victory.

I've done some snooping - do you use the ICD-9 or ICD-10, and is it the CM variant? I figure that I may be able to write a parser and put together some prototype stuff. Also, is this a web-based tool or no?
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Greetings, PineLevel, I did not know how medicine was done in the days of old (though I've heard tell that there was indeed far more time to LISTEN to a patient). The bureaucracy of medicine is not new, either. But the manner in which it is getting implemented is not, in my estimation, logical - there is a "prestige" to saying that we are 100% EMR. But somehow that trumps the decisions about whether it makes SENSE for every physician to do this once proven that it has a negative impact which is mystifying at best. How could it possibly have benefitted the practice to lash me to this schedule? It's just created a burned-out, alienated physician. Should I leave, a lot of my patients are going to be forlorn (they will be offered slots with the other docs but I am the only female MD in the practice and certain of my patients are there because of that). And the practice has had trouble recruiting other physicians for a myriad of reasons. There is no doubt that they will replace me without ultimate duress, but why it has had to reach this point just does not make any sense at all.

xraymd
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Hi xraymd,

This EMR sounds like a truly nasty system for detailed charting. Does it have sections where you can just type your impressions w/o having to search codes for tests or diagnoses ? If you are a fast typer, maybe you could record the zebras that are hard to look up or the extra details there. Also, would the system be compatible with a voice-recognition software that types dictations ? If you skip on the details like the others in the main application, maybe you could still somehow attach a file with your own detailed dictation for future reference.

Set (who wishes she could help)

PS. I know that this is a serous issue and you are not in a kidding mood, but if you would ever consider coming back to Quebec, there are many beautiful places there that are desperate for MDs (especially family docs and internists) and will do everything to make a newcomer feel welcome ;) On a more serious note, spending as much time on charting as you have been describing is excessive. I wish you best of luck with your future decisions whatever they will be if the situation does not improve.
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It isn't bleeding edge. It's alpha quality crap from the 70s.

Greetings, Abfacken, this made me LAUGH OUT LOUD! I've been saying that since this was implemented. It's not even up-to-date enough to move a window for a module that opens which happens to obscure the data behind it without CLOSING it first. I began programming in 1977 and what this system is like to work in is really reminiscent of the limited techniques we had then (or at least into the early 1980s).

It sounds like nobody bothered to get proper requirements, nor have they really got acceptance testing involving actual doctors.

This system was selected 2 years ago on the basis of a single site visit by the CEO and only one of the partner doctors. That's why, in part, the most productive senior doctor decided to bail one year ago since he kept seeing the signs that this was going to be very expensive not just to purchase and implement but also to the potential hit on his productivity as it has been on mine. My hat goes off to the docs who are succeeding on it but some of the coding issues they had before still remain: the docs who were cited for paltry documentation certainly are not rushing to start adding on detail within this EMR interface!

I've done some snooping - do you use the ICD-9 or ICD-10, and is it the CM variant? I figure that I may be able to write a parser and put together some prototype stuff. Also, is this a web-based tool or no?

Great question - nobody in the practice is likely to be able to say, since there is no computer literacy there. We just get the database updates from the vendor. My fiance is quite computer-literate but has been rebuffed when he's made efforts to offer his services for just this reason (even for free because he sees every night what I am going through and has gone from puzzled to actually angry at how this entire application was chosen and is now implemented).

Web-based? *Snort!*

xraymd
:-)

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Should I leave, a lot of my patients are going to be forlorn (they will be offered slots with the other docs but I am the only female MD in the practice and certain of my patients are there because of that). And the practice has had trouble recruiting other physicians for a myriad of reasons.

Um, dare I point out that it is an American tradition for patients to follow the doctor they like when a physician leaves a practice? Dare I suggest that you might have the start of a respectable practice the day you hang out your own shingle?

If the software is truly as wretched as you describe, perhaps it makes sense to find out how bad it would be to assume the overhead of running your own practice. At least then you could make rational decisions on what software to use.

Patzer
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Greetings, Set, what a nice response! The system is not customizable in the way you describe. I only WISH it had a voice-recognition capability because I dictate every day in the hospital and am fast enough at that. There is no free text capability, either. Trust me, when I am on a rock for a zebra of an ICD-9 code, I am ON A ROCK.

There was at least one med student in my class from the States who decided to stay in Quebec and practice. How she got through the mandatory French language exam, I will never know - that would have stopped me in my tracks right there (have posted about same on the Living Below Your Means board). But I do say that I loved training in Montreal and feel like the hands-on medicine I learned was taught in an exemplary fashion there, plus I have deeply fond memories of living there and of several of my patients and instructors during that time.

I am drawing great hope from all who have responded to me that this demand on me has been an aberration and that something else good is BOUND to happen. No matter how down I've been over the past few months (have not wanted to go into it much before now), it is so HEARTENING to get so many supportive responses. You guys are just the greatest!

xraymd
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Greetings, Patzer, I actually looked into the overhead of running my own practice almost 3 years ago when I was considering this job offer over another that would have involved practice start-up costs. I realized very quickly that I could be a good physician without having to fret overhead or I could be spending at least as much time as I have been doing lately (how ironic) trying to learn to be a small-businessperson. I did not feel then that diluting my energies would have served me nor my patients well, and opted for the salaried position.

And, yes, the software is wretched in its raw state. Though, again, I am apparently the only one not coping.

Were I to leave, I would not want to open a practice without thinking LONG AND HARD about just what do I want to do now. I would be benefitted by a real break since I have been working at fever-pitch essentially nonstop really since beginning medical school in 1994. Not meaning to whine here - it is simply the reality, but I would want to take some time for myself and really reacquaint myself with the true gifts I have to offer. My fiance thinks that with my manifest love of detail, I'd be excellent in some sort of forensic role, and perhaps that is true. I also used to be a decent programmer - not surpassingly inventive but my code generally did not break. I have a lot to think about and would wish to create some silence around me in which to do so given the din and clamor I've been operating under.

There is some sort of non-compete clause in my contract that says that I cannot solicit patients to follow me, nor would I do so anyway. But some would, since their loyalty is to me and not to the practice. Others would opt to stay aligned with the practice and I certainly understand that. We'll just have to see what unfolds here.

xraymd
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I read your LBYM board message. This is how I know that you trained in Quebec and your "French HPI experience" made me laugh :) Looks like we went to the same school and I am glad that you enjoyed it. Now there are special medical French classes to help the confused Americans and other international students face what waits for them on the wards. However, we do have a lot of fun overhearing you guys trying to understand what's going on. To come back to EMR, there is also a lot of talk in the Montreal hospitals about switching to electronic records keeping. Looks like this is the way of the future, but this does not mean that we should sacrifice quality and efficiency. Most staff would not stand for it. I am sure that there must be better ways that what you have been describing and the changes might be gradual at first. For example, we already have a software in peds for drug prescriptions but it is useful (we can look up what is available & calculate doses) and most people love it.

Set

(who is very far from being finished with training but who found your view of issues that can arise in a private practice very insightful)
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> Web-based? *Snort!*

Heh. If I put a prototype together, I'll be sure to let you know.
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In our society, when job conditions become intolerable, an employee has one final right, and you certainly sound like it is time to exercise it.
You've said you can't get another job locally, and perhaps your fiance isn't in a job as geographically mobile as yours. You have a house, and running off to another state isn't as easy for you as it was for me in 1993. But I'd say talk to the locum tenens companies. You can take a job covering a solo practice for a month while the doc takes a vacation. On some of these you stay at the doctor's house. That's easy on the nurses at the hospital, because they know the number well. At the house you may be asked to feed his dog, and of course you will bring in the mail. Staying in a motel isn't as nice--if you are on call all the time, what if you just put your wash in the laundromat washer and the beeper goes off? When he gets back from vacation, you sit down at the kitchen table, go over the patients you've treated, and home you go. You work as few or as many weeks a year as you wish.
My suspicion is that you do a couple of these and your present employer becomes more accomodative--and perhaps by then has a better program, especially if one of the principles has had to try the old one himself. Your reason for leaving is the computer program only--you cannot in the time alotted practice medicine as you wish to practice it, and it is because of the obstacles placed in your way. You'd be happy to consider returning if/when they have resolved this problem.
Your skills are in demand. You don't have to put up with this nonsense. You've had some luck, and it may be a few years before you know whether it was good or bad.
Best wishes, Chris
who is most grateful she left FHP in 1993!
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Thanks xraymd. I appreciate it.

YeilB, you might also be interested in Steve Krug's *Don't Make Me Think*--short, sweet, usability testing.

sigh. I'm still trying to get the boss to cough up the 1500 bucks it would cost to go to a Nielson seminar. I love usability. I wish I could do it full time.

b
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My boss looked at Nielson's website and told me I was staying home.
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xraymd--

Can you chart on paper and hire someone to input the data? Just to save your sanity? Until you find a better job? (While you find a better job <grin>) I know it's not really a good solution--or even a solution--but it seems to me your mental and physical health is at stake here and that's gotta count for something.

Of course, I don't know how HIPPEA plays into this.

bleplatt
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My boss looked at Nielson's website and told me I was staying home.

Greetings, COJones100, could you elaborate on this? (Very curious. I know nothing of Nielson - Nielsen? - and am very interested to hear more about what it purports to do as well as why someone would deny the chance to attend a seminar.)

xraymd
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My boss looked at Nielson's website and told me I was staying home.


well, it's not pretty, but it sure loads fast (a LOT faster than anything else) and it is highly functional.

(My internet is messed up and acting like dial up, so I really appreciate the fast loading and no graphics.)

b
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(This go longer than I expected)
xray,

I'm not going to be much help here, and I've only read partway through the thread, but I have some commentary about the "super-star" doc who is entering stuff into the computer as he is seeing patients....I absolutely HATE it when doctors do this.

We left our previous pediatrician's practice because entering data into the computer as DH or I talked was standard practice. Drove me nuts, because I felt like the doctor was talking to the computer instead of listening to what we were saying. At least half of her attention was going to navigating the computer, entering information, etc. Our talking was almost background noise.

I enjoy having a one-on-one relationship with my doctor and my kids' doctor. I appreciate doctors who actually listen to what I have to say and pay attention to me, not the computer.

I know this doesn't help solve your dilemma. Honestly, I think the practice should be more concerned about keeping the patients happy. And how much does it cost to hire someone for data entry for the whole practice? Not that much. But if the practice and CEO are more concerned with the bottom line, they aren't going to go this route; they'll just keep upping the pressure on you to do your job.

The problem is, as I see it (and I agree with you), is that you can't do your job to your satisfaction and standards within the parameters your bosses have set. No wonder you are tense and depressed.

You have a choice...continue to be depressed, find a new job, or compromise your standards and do what some of the other docs are doing by entering data piecemeal.

I vote for find a new job. Easier said than done, I know.

Katy
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Thoughts from a simple mind, xraymd, Have you ever tried to bury a ping pong ball in the sand? Its very difficult to keep the ping pong ball down. Its easy enough to cover it but if something comes along to shake the sand it makes its way to the surface. The one way that I can think of to hold that little ball down is dig a large whole put the ping pong ball in the middle and place a huge rock on it , call the rock EMR if you like, and put it on. That should do it. That should be the end of ever seeing that little ball shinning in the sun again. But, there is a flaw in my solution. Life is constantly changing there is still sand in and around the poor little ping pong ball. Even if one grain of sand a day gets out from under the rock to ball will have its freedom.
If this little ball accepts that this pressure and frustration is its fate and does not follow the flow of the sand then yes it will just sit there frustrated and depressed.

It was a good little ball it had gone so far in life put it self through med school it would not be denied. Why because it followed the sand and shined in the sun light. It had its troubles, rocks came along but you made it through. Xraymd, it is very evident that you are a very caring person (ah ball) and for may of us you are our sand that help us get out from under our rocks called DEBT. I have no doubt that you are a wonderful physician. I just wonder though if maybe in these case you're accepting the rock. Letting it crush you, you would probably know much better than I that eventually frustration will eventually lead to bitterness and anger to everything even our beloved sand.

Your are a bright shine Ping pong to all of us. We only get to see a small portion of your caring through your posts hear in helping us. I would encourage you to follow your heart again and not to accept the rock that is holding you down.

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Dearest Roy, your post brought tears to my eyes; it was so kind and sweet. And you are so right about how skewed I've been and so unlike myself - I'm normally a sunny person and enjoy smiling and laughing with the people I work with (though as you can also surmise I do like to get down to the details to get everything done so I'm not a 100% cut-up but I enjoy being a positive force). In the past few months and especially in the past most recent few weeks since early September when my job duties changed (now I round every week in the hospital rather than every other week so that's even MORE hours on duty - and now I am no longer receiving any new patients), my attitude has turned dark and gloomy. I really have stopped smiling overall and people are being unbearably delicate with me because they are aware that I am mega-stressed.

That is no way to live in the long run. There is no relief on the horizon and I have not been able to get the powers-that-be to understand that I am getting fried here with their insistence that I do things their way. It's just not working.

The worst to me is that I have stopped to say "thank you" nearly as much as I used to when anybody really does try to do something nice for me. Our office manager took time out to write me a very lovely personal card to sympathize with me and to let me know she would try to do anything possible to help me. I should have been in her office first thing after receiving this card but I just couldn't say anything to her right away because I did not want to break down and bawl (which I would have) when I had a full afternoon of patients to see and labs and xrays to sign off and a stack of mail to go through and phone calls to return. I tried to find her at the end of the day but she was already gone and I know she is feeling unappreciated for her nice gesture as though I brushed it off. I've been considering calling her at home this weekend. If I cry, so I cry, but I don't have office duties this weekend so I don't have to keep holding it together. (Though I am on call this evening.)

Blech. This has to go one way or the other. You are SO RIGHT about that rock and thanks again for your deeply appreciated words of support.

xraymd
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xraymd,

There is a lot of stuff I found on google about your problem. Here are the results of one search:

http://makeashorterlink.com/?A27335DFB

You should note that some of the articles listed here discuss how to get physicians on board with an EMR and I liked some of these:

Lesson 12: Dictation is an effective way of bringing nontypers into the EMR fold. Although few physicians lack the computer skills to use a modern EMR, some cannot type quickly enough to efficiently document patient care, so we use an outside dictation service that interfaces with our EMR. Currently, about one-third of our outpatient documentation is generated by dictation rather than direct note entry. Although dictation increases costs and slows the availability of documentation, it ensures that physicians do not seize upon a lack of typing skills as an excuse for nonparticipation.

http://www.healthcare-informatics.com/issues/2002/10_02/commentary.htm

They need to get someone to input the information for you. Period.

-b-
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Greetings, blkmagwom, thanks so much for your input. As it turns out, I am a fast typist (I was actually a PROGRAMMER prior to leaving for medical school in 1994!). What is much harder for me is the wending through a byzantine set of modules, each of which has its own little rules for data input, many of which have checkboxes or radio buttons, and many of which require clicks to shut off pop-up boxes requesting more detail. And the WORST of which is that I am now required not just to type what I used to handwrite (that's not so very hard for me) BUT that I must, at the end of the patient encounter, be prepared to SEARCH over a specific database whose search terms are different in many cases from common medical parlance to try to find codes to assign to each of the diagnoses that I arrive at that I used to be able to handwrite without those codes (we have a professional coder on staff who assigns the codes). And that impacts my accustomed thoroughness - one of the things my patients say they most appreciate about me - because for every code *I* now have to hunt down and assign, that's yet another entire branch of modules I have to make my way through even when I already KNOW the code. Heaven help me if I DON'T already know it, because it's about a 50-50 chance it will be in the database. And again, I still have to spend extra time processing this info electronically even when I find it. The big kick in the head is that the program will literally NOT MOVE FORWARD unless all codes are resolved - so I end up with sessions that don't close and patients stacking up waiting to be seen because I am fighting with the computer. Thus I have taken to saving all my documentation for the end of the day, and that's why I've been in the office night after night after night until well after 9pm. I've been asked to be not just a physician anymore. I've been asked to become a data entry expert and a coding expert. And adding further insult to injury, if I manage to match a code to a diagnosis and wish to write prescriptions based on it, I have to continually re-enter my password for every single prescription I print off from the computer - and sometimes I can't even find the desired medication in the Rx database! Is it any wonder I throw up my hands and revert to paper and written Rx's? And then I have to record what I've done for later transcription into the computer.

Can you hear the screaming from Tucson yet? :-)

The equivalent to what you proposed, regarding dictation as a form of one level of indirection of data entry into the computer, would be simply to let me do what I have DONE SUCCESSFULLY TO DATE. That is, allow me to continue paper charting and have someone else input my patient encounters on paper into the computer asynchronously, rather than MY doing it. My handwriting is perfectly legible (so I am told). I have always written down in duplicate what Rx's I've written and I have always put all of my diagnoses on the checkout ticket as well as on my assessment and plan on paper - I just never before had to find codes for every single stinking one of them (many of the codes I do know and do put). The other docs who have adapted are simply shortcutting how much information they used to capture, because they can't afford to get bogged down by the limits of the system. And they are online in front of their patients so they don't have to spend an additional half-day at the end of the day encoding the encounters. On paper, I could get the work done simultaneous with a patient visit. Online, I can either choose to spend X amount of time wrestling with the system while the poor patient in front of me grows weary of the interruption this causes - or I can choose not to cause delays in patient throughput and save the whole battle for later, which I've ended up doing. But there are just not that many hours in the day to get it all done and still have me thrive. And the management is recalcitrant - they are just not going to allow me to go back to paper charting. So it's become something of a standoff and I am going to drop over from sheer exhaustion. I am being scrutinized to see where I can "streamline" what I've already learned to do in documenting, and that's fine, but it just DOES NOT ADDRESS the issue that I don't want to be doing this in front of patients, nor does it address the issue that it still takes me 3-5 times as long to input the data than it did to write by hand my progress notes. I used to get home by 7 or 7:30pm (still a long day but way better than now). Now if I try to stay till all the work is done, I never leave before 9pm and often not even before 10pm. Something I have not even mentioned yet is that I am walking out to my car in a deserted parking lot night after night in the dark - and there is no security to call to escort me. Of course the "answer" to that is perhaps I should take all the work home with me since I can get online from home. But clearly, the real answer is to separate me from this crazy requirement to keep fighting with this system and let me get back to my prior level of productivity as I've been accustomed to operating at, with tremedous reduction in stress level.

The bottom line is that there is going to be a cost, one way or the other. The practice will lose me (and will have to find another physician to take on the work I've been doing - and they haven't been getting great bites so far) or they will have to spend money to get someone to code my encounters. The price paid, so far, is that I am thoroughly burned out and am quickly getting bitter. Not every physician is going to adapt equally to this system and I have long said that they have erred in not planning for failure. And this is a failure of colossal proportions. I miss feeling like I am both productive and rested. I miss feeling like I am an asset to the organization. I am coming dangerously close to saying "take this job and shove it" which would be a tragic outcome but is a very likely one given the degree of stress this has created, and in my view, unnecessarily. But it is what it is and I must make my decisions in light of the constraints I am placed under.

xraymd
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The newest doc in the practice who has already adapted to EMR freely admits that he does not record info for future reference. He says he will just "reconstruct" the history from hearing about how the patient is doing weeks to months later. I don't think I want to rely on my memory to be able to do this, nor do I believe I would be any faster at trying to do this than if I'd written it down timely and in full. Yet he is easily seeing his 23 patients a day and encoding at least 14 of them and leaving the office by 6:30pm - so however imperfectly, he is apparently doing it. He acknowledges that even if he shows me HOW he does, that I might not opt to mimic him if I would prefer to capture a greater level of detail. He is in no way a better, nor worse, physician than I am, but he has been able to record less because it suits his comfort level. It does not suit mine. And that fact alone may indeed spell the end of my present job.

xraymd


Good grief! This practice is begging to lose a medical malpractice suit. Jeez, whoever is making these decisions must have their head so far up their @ss that it echoes when they talk.

The more I hear about this, the more I think you're better off somewhere else--working at this place sounds like it presents an unacceptable risk to your own career's well-being. :-( You will the be the one held accountable if you miss entering something because of this ridiculous EMR thing, in a lawsuit, and even if your place of employment also got sued, it wouldn't impact them nearly as much as it would you.

xraymd, get out get out get out. I am extremely fond of you, and this place sounds like it's being run by inflexible idiots that don't have the self-preservation instincts that God gave little furry animals. I don't want their stupidity to hurt you. :-(


--Booa
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(((((((xraymd)))))

I am a frequent lurker here and you are one of my favorite posters to this board. I am so sorry to hear about your career challenge!! I agree so much with most everyone who has posted to you. It sounds as if your work situation values procedures over people. When your values clash with this, your colleagues will not bend.

I agree that it is time for you to move on. Your values are not aligned with this place, because you value people and good practice over procedure. They do not value you as a person or a healer and they do not value their patients to the extent that no one is willing to stand up and address the flaws in their EMR system. Except you.


Please listen to your own inner wisdom on this. You know what the right thing to do is and posting to this board was the first step in making a change. You have done some amazing things with your life already, I can't wait to hear what you will do next! I am sure you will be a winner. DB
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Seeing your response to Chris --

(I replied once on the physicians board already, but here's more!)

1. It sounds like revenue is going to go down in the office if people aren't coding their visits with all diagnoses, etc. Did the practice ever employ a coder/billing specialist? Many practices find a dedicated trained coder increases revenue dramatically even if doctors *are* listing all the diagnoses. In this case, though, if people aren't putting in the odd stuff, collectibles are going to drop.

2. If the doctors aren't noting all the pertinent observations, the first malpractice suit your practice faces could end up being proof of the pudding. After all, if you didn't write it, it didn't happen, despite the 12-inch surgical scar, right?

3. (Yeah, this doesn't help, but) Wow, that sounds like an obnoxious interface!

-- Laura
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http://www.useit.com/

Pretty much everyone I know worships at the altar of Jakob Nielsen, but his website isn't anything that would stir the loins of someone wanting shining examples of how-to-do-it and willing to sign the checks for it.

It's okay on a lot of levels for me. Neither Bob Dylan nor Willie Nelson can sing worth a damn. They're both fine songwriters, though, and both excellent performers and good people in their own right. They just can't sing. UseIt.com is a fine site for what it is and does and says. It just doesn't sing the way Zeldman's or Meyer's or some of others' do.

I had one of those bosses that looked at the site and figured it was something his secretary could do in an afternoon, and so there must not be anything there worth spending hundreds of dollars to learn. He's gone now and we're probably both happier.
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in fact, the system designer offered our practice a free two-hour solutions session to see how the modules could be customized for easier face-to-face use, and the management DECLINED to take him up on his offer (too busy to spend time customizing the modules!)

If this is the general attitude about the transition....

AAAAAAAAAAAAARRRRRRRRRRRRRGGGGGGGGGGGGGGGGHHHHHHHHHHHHHHHHHH!

If that's the general attitude about making life easier for the doctors, double that! Maybe the $DEITY is giving you a really loud hint about going someplace that would be a better fit.

If you don't mind the cold, there are a lot of places in Maine that would love more doctors! :-)

-- Laura
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What makes me so mad is that none of this has ANYTHING to do with your skills as a physician.

I have to disagree. My qualifications are that my dad was a doctor, which means I have none. However, the ability to accurately document diagnosis and treatment is every bit a part of being a doctor as is the ability to tell the knee bone connected to the thigh bone. This is not to say that xray is not good at that on paper. Technology has made digital records more reliable (no chance for a nurse being unable to read the dr's writing).

It is not easy to adapt to. I remember when DF's practice bought it's first computer insurance system. The Office Manager hated it, and DF just took what the turnkey company offered, despite my telling him he was overpaying for technology already obsolete. He eventually caught on and became more and more computer literate, and today he is doing digital video editing. I have no idea if this is applicable or not, but just consider the possibility that it is a resitance to change that makes adapting so difficult.

In every other aspect of your profession, you are expected to keep up with new treatments, new medical discoveries, even new technologies and diagnosis tools. Consider this digital diagnosis tracking system as one of those things. Anywhere you go, you will probably come across the same trend. Even worse, unless you come to terms with the issue, you may turn down a great opportunity because they will expect you to walk down the same path as the current employer.

It may be that you do need a fresh start, that the pressure of change in the current environment will be lessened in a brand new situation where expectations are fresh. When I left the FEWMNBN™ I felt a lot of pressure to conform to a process that held a higher priority with management than my 11 years worth of experience and success. It mattered more that you followed the process than if you complete the task correctly.

In my two contract positions since then, I have had to work in environments with very different processes, neither of which is how I would have done it if anyone had asked (which of course, they never do). I found that without the 11 years of baggage, I was able to adapt with less stress. The important thing to me was the product, and even if it took longer to complete there way, I could live with that.

In your case, keep in mind the priority is the patients care, and whatever hoops you have to jump through to provide it, the end product is the important thing. You have to find a way to adapt, just like I had to find a way to adapt. It is not easy - I am in my 3rd year of career recovery - but it is a necessary part of getting older, getting wiser, and getting on with life.

Fuskie
Who wishes you the best of luck, and is reminded that being a doctor is nothing like it was when DF was practicing...
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Greetings, Fuskie and everybody, I actually AGREE that it is high time (past time) for computers to enter medicine, including even a computer interface for entering data. I just don't agree that how it is being done where I work is working for me.

The docs who have adapted are able to sit with their patients, both facing the computer, and they talk and type at the same time, I can talk and WRITE at the same time but when I try to fuss with the current user interface, it's either that or pay attention to my patient but in the present environment, NOT BOTH. I've tried for months to become more fluent but it is not happening with sufficient rapidity to keep me as productive as I'd been before.

Some of the patients hate it, and they've left. Other patients are happy enough with it if their doc happens to be a maestro. On paper I am a maestro. On this computer system, I am a clumsy oaf who constantly forgets things and who has to ask the patient aspects of past medical history that on paper I would have ALREADY KNOWN and who causes delays when trying to print out Rx's. This interface and I are not seeing eye to eye. One of the bigger issues all summer is that we had a dearth of medical records staff so the xray reports and lab reports and notes from consultants were not getting scanned into the system - so when I went online to look for data to keep the patient informed, it was not there. My medical assistant and I took to separately photocopying important results and, in effect, running a parallel file system because trying to look for a document awaiting scanning meant, literally, searching through a huge, unsorted, photocopy-paper-sized box of documents on dozens of patients. In the 15 minutes alloted for a patient appointment, WHO HAS THAT KIND OF TIME? And this was becoming a daily event. And the parallel filing system, while allowing us to at least put our hands on pertinent data, was causing its own kind of time hit. I am told that the medical records staff are now replete and that scanning documents is back on track, but if we are in the midst of switching off of paper charting and onto electronic documentation and records storage/retrieval, one would think that we'd be right in line with how we at least USED to track and access patient records. Can you imagine having YOUR xray report buried at the bottom of a box? So it became a real challenge to be able to tell patients their results during their appointments. And even if it is improved, it is still not trouble-free, for the dates on the scan system are known to be buggy and I have to sometimes hunt through multiple electronic documents to find the one I am looking for - can't rely on the datestamp.

I actually cheer advances in technology that truly make a task easier and if it takes a learning curve then so be it. Certainly there was a learning curve involved in getting onto a personal computer and getting online. What I fault here is that I've been treated like I have to keep going at this like a battering ram and it's my tough luck that it takes me till past 9pm to finish the work. It's depleted me and that has sent up no alarm signals to the powers-that-be, despite my objecting to the schedule it was causing me to keep as long ago as last spring when I was 2-3 months into having gone live. I've been drowning and have not found a lifeline. That's what I consider to be the real issue underlying all of this: I am supposed to float and if I am sinking, then what message I've been receiving amounts to buh-bye. As I've said already, the management has not planned for failure. There has been no plan B. I've just been left to work this cockamamie schedule for months, even having said that it is taking me into the night to get the work done. And, trust me, I have said it more than once. What finally caught someone's attention is when the senior partner called me at home one of the nights he was on call to tell me about an admission of a patient I'd need to be seeing the next day in the hospital. He called at 10pm and I was STILL not home from work. My fiance answered and told him this and point-blank asked him "When are you going to get her some help? It's like this night after night." And I had already told the senior partner this weeks before.

The way I am going to find to adapt is most likely going to be outside this present position. I completely concur that needing to get electronic is the coming wave in medicine. But it feels like I've been pancaked by the present system and the present management attitude. If any of the other partners were struggling, alarm bells would be going off. But since I am the only one NOT adapting (in certain ways for some very good reasons) then the culture and I have a clash. For those who used to read the Ladies Home Journal magazine series on "Can This Marriage Be Saved?", the position I am now in is "Can This Job Be Saved?" and it's looking decreasingly likely and that is such a shame.

xraymd
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Greetings, Fuskie, some further thoughts:

Technology has made digital records more reliable (no chance for a nurse being unable to read the dr's writing).

I think I would actually say here that technology has made digital records more LEGIBLE. If the data capture is incomplete, it is no better than an incomplete handwritten record. It's just prettier.

In every other aspect of your profession, you are expected to keep up with new treatments, new medical discoveries, even new technologies and diagnosis tools. Consider this digital diagnosis tracking system as one of those things. Anywhere you go, you will probably come across the same trend. Even worse, unless you come to terms with the issue, you may turn down a great opportunity because they will expect you to walk down the same path as the current employer.

Absolutely true. I am required to have no fewer than 20 hours of CME (continuing medical education) per year to continue to validate my medical license. I certainly agree that electronic documentation is not just coming; it is here to stay. But what I'd like to see is the development of systems that are more sensitive to how to input and process information in a way that truly helps, not fights, a busy physician. What I've said before is that we need the medical equivalent of Xerox PARC - that old think tank from the 1970s which resulted in some of the more innovative of computer userface solutions, many of which found their way into Apple technologies. The guys who staffed PARC really took usability seriously. On the Physicians and Other Professionals board, I read of a homegrown user interface that Adenovir touted which was customized to his requirements for caring for preemies and critcally ill neonates. I am CERTAIN that a similar system could be invented that is customized to the needs of an internist who sees 25-40 patients a day which would enhance the capture of crucial information. But that's not the system I am working under. If relocation were no barrier, I would literally LOVE to go to work on the problem of user interface design and usability testing (I just don't think this effort is taking place in Tucson but I am looking into it). One of the quotes I remember from Xerox PARC was the idea of a software "appliance" - much like one's toaster or telephone is an appliance. It is a technology that so much SIMPLIFIES a task that one hardly knows that there is in fact an interface involved. Get me that level of ease of use and I am so there!

xraymd



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I have to disagree. My qualifications are that my dad was a doctor, which means I have none. However, the ability to accurately document diagnosis and treatment is every bit a part of being a doctor as is the ability to tell the knee bone connected to the thigh bone. This is not to say that xray is not good at that on paper. Technology has made digital records more reliable (no chance for a nurse being unable to read the dr's writing).


Fuskie -

I have to respectfully disagree with your disagreement. I currently work in the technology field as a technical writer and I've worked in training and support at a small company that made crappy software.

From what I've read EMR is the wave of the future - and it does make sense that entering medical info into a large database could be enormously helpful in many ways. I haven't seen any posts from xaymd implying the data shouldn't somehow go into a database. The problem is the particular EMR she is being forced to use.

I can tell you from my old job that there are many small companies making crappy software. The software we sold was designed by the guy who originally was the salesman and "figured out" how to program. The interface was awful, the database design was atrocious. Support and training was a nightmare.

It sounds like xraymd is trying to be a good doctor - she is trying to document in a system that sounds like no thought was given to how a doctor might actually use the software. Worse, the database is not fully populated and ready for use.

The other doctors who are being "successful" with this particular EMR are essentially *not* doing their job - through documentation.

The real problem is in all probability that the practice has sunk and continues to sink mucho dinero into this system. I'm guessing that they don't have the money for a new system, they don't want the upheaval that goes with a new system, and worst of all they don't want to admit to making a bad choice.

xraymd - I don't know what to say, other than start thinking of yourself as a short timer. If the situation is what you describe - please remember that there's nothing wrong with *you* - it is everyone else is having serious issues. (There is no sane reaction to an insane world...) Get your smile back soon...

JustSilly
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Hi again xraymd,
If you found an EMR device or software that you liked better,
would you be able to use it, or does the hospital require
everyone to use the same program and hardware?
I'm asking because when I Googled "emr medical software"
there seemed to be a boatload of choices.
Any chance that there's a newer one that is more
user-friendly?
Just a thought. . .
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Greetings, PineLevel, the EMR that the practice uses is tied into the patient database of the practice. If there were an alternative interface to collecting the information and transferring it to the patient database, it would theoretically be okay IF

1) there were seamless support to linking up outside software to the patient database and other ancillary databases (lab module, coding module, etc)

2) it did not violate the constraints of HIPAA (the new regulations regarding patient privacy rights and restrictions on how their information can be coded, stored and distributed)

There are a boatload of choices and I am totally persuaded that there will be newer and better options all the time (this is a moving target). JustSilly nailed it when she said that the EMR I am presently on is the software our practice has committed to. I don't see any departure from it anytime soon.

Of note, I just had a phone conversation with our office manager this afternoon, away from the office. She understands fully that we are at an impasse and she recognizes fully that I am completely burned out. She is not in charge of making decisions on behalf of the practice what they will or will not support in the way of offloading me by having someone input my paper documentation and freeing me from doing it. But she definitely understands that we are at that point, and it has been pointed out to her that it is a cost to the practice either way - they will need to pay to offload me or they will need to find another physician to do my work. This was said calmly and factually by both of us, no threat, no ultimatum. For the time being, she will oversee what I do spend my time on apart from documentation and try to determine how much more help I can get with it (who else could do the reporting of lab results, for instance - do I need to write out every detail for the medical assistant or does saying "normal labs - go over numbers" convey sufficient information to get the right report in the right detail to the patient). She has told me that the most senior doc has his medical assistants pre-prepare all of his lab results (he gets nothing raw) so that he can quickly see what has changed based on what therapies he's tried for a patient and it saves him time looking this up. It might help if I had the same processed information provided to me.

Anyway, at least there are some short-term efforts to streamline that will get started right away. The long-term questions remain to be addressed, and there is not yet a solution for having to continue to document patient encounters myself. But I will accept any efforts made to help lighten my load and will allow time to tell whether it is sufficient or not. Even if I left the practice, I would very much rather NOT do so in frustration and heat - I am very willing to say dispassionately that it did not work out as envisioned, should it come to that. Today's out-of-office conversation was a start.

xraymd
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Hi I am a lurker on this board so am familiar with many of you while my name is new to most of you. This board has been very helpful in making me keep my priorities and finances straight. And help me to live below my means.

For xraymd - I was in a similar circumstance just over 2 years ago. Not an EMR system (I'm a nurse by the way in the workers comp system) but I was in a job where I was being asked to do things that were unreasonable and impossible. The details don't matter. I was under very high stress and keeping very long hours to try to do a good job. I was exhausted and miserable, and I cried at the drop of a hat.

And I left. I left before I had another job. Not something I'd normally do- and have never done before. It was the very best use of my e-fund. Must say it's likely due to this board that I had an e-fund. I had no energy to look for a job while I was there. I was starting to fall apart and simply had to leave

This may sound silly but a few days before I left I had a dream. I dreamt I was driving my car on a glass highway miles above the city. There were no siderails on the highway and I was slowed to an almost-stop afraid I'd drive off the road into space. I was just creeping carefully along so I'd stay on the road. Meanwhile there was someone in a car behind me urging me to go faster. It was pretty clear to me what it meant when I woke up.

Could be you're on the same highway.

I'd leave. Immediately. At the very least I'd tell them that you plan to leave unless things change and change quickly. I'd give them days only to make the change. The way they are having you use the EMR sounds completely unreasonable. And the fact that you are unwilling to sacrifice your standards makes it an impossibile situation for you. And it sounds like to do the system you have to ignore patients and cut corners in what you input. That appears to be okay with those that run the practice you are in. But finding a way to make this system work for you and would still allow you to practice good medicine does not appear to be a priortiy or even on the list. Who wants to be part of that kind of practice? You are an excellent physician and a wonderful ethical human being. I've read many, many of your posts and those things shine through. You will find another place where you can practice good medicine, a place where you will thrive. And then you'll wonder how you ever lasted as long as you did at your current job.

My best-- Susan
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Greetings, Susan, thank you for sharing your experienceand for offering your support. So much of it strikes a chord with me and I am really glad you are out of your own pressure-cooker circumstance.

I have a bit of breathing space as of today, having spoken with the office manager. We're going to try some short-term strategies to offload me. I've already decided to request a cutoff. If I am not done signing off labs/studies AND documenting on the system by 7pm, I want to switch to paper and have someone else put in the rest of what is left over. I have not proposed this yet but I have no doubt that I could handwrite even 8-10 visits in a half hour and still be out by 7:30pm. To me, that seems fair and would give me some instant relief. This will be raised tomorrow. I have also acknowledged that the long-term outcome is still uncertain, since the practice may not wish to invest in what it takes to cover me. But I can't fret long-term now. All I can do is work within the current constraints while making an effort to set limits that will prevent me from being totally drained.

Interesting about your dream. Last night I dreamt that my fiance and I were in a boat or on a dock connected to a large body of water. We were watching an American Airlines 747 approaching as though it were supposed to make a water landing but horrifyingly, instead, we watched it start to sink below the surface on touchdown. We were close enough to see the pilots and all the passengers and could feel the abject terror within the plane while simultaneously feeling paralyzingly helpless to stop it from happening or fix it once it did. I am not enough of a dream analyst to suggest why it was a particular airline - nor even this particular scenario - and on relating this to my fiance he went straight online to be sure there were no such events overnight (no there were not, thank heavens, but in another round of posts, ask me sometime about the dread dreams both my fiance and I had independently 2 days before 9/11). But all the emotions of fear, terror, helplessness and drowning are all pretty self-explanatory, n'est-ce pas?

xraymd
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I'm glad you are getting some relief. Your situation resonated with me as well- that's why I posted.

Dreams are very interesting. There's a radio show that does dream interpretation where I live and it's quite amazing what it can tell about someone's life. I do know that water oftentimes represents emotion. I needed no one to interpret the dream I had about the highway though.

One thing I'd encourage you to do is not to think of yourself as the problem. Practicing good medicine within the system as they now have it is the problem. You'll find out soon if they are bendable enough allow you work as you need to within it, to do your work and leave for home at a reasonable hour. I hope it works for you. Sound like you liked the practice before they started using the system so if there can be a work-around for it, that would be a good solution.

In my case I worked in a office where there were 5-6 other nurses. Every single one of them left within 2 months of when I did.

Sometime I'd love to hear about the dreams you had pre-9/11/05. I hope you will post them. I once had a very vivid dream then had an almost identical experience to what had happened in the dream occur while awake about a week later-- enough that I could predict what was going to happen next.

I hope it all works out for you. But if not there are certainly other opportunities that will open up.

Susan
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xraymd: "This system was selected 2 years ago on the basis of a single site visit by the CEO and only one of the partner doctors."

I am a day late and have not read the entire thread, so forgive me, but

---1. Was that the parner doctor who is still not on the system?

Also, with one doctor not on the system, how can the practice ethically claim to be 100% EMR?

---2. Is the CEO a doctor? To whom at your EMR vendor is the CEO related? Or what else is the CEO getting in return?

---3. Who runs risk management at the practice? A discussion with your risk manager/professional liability issuer might straighten out some of the problems (or make things much worse for you, at least until you leave). Spotholder codes that are never replaced; less than adequate records lacking detail. I hope you get out before the big malpractice hit that is inevitable occurs.

Best wishes, JAFO
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Zeldman's or Meyer's or some of others' do

links, please?

b
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Greetings, JAFO, let me answer your questions one by one:

---1. Was that the parner doctor who is still not on the system?

Also, with one doctor not on the system, how can the practice ethically claim to be 100% EMR?


The partner doctor still not on the system was not the partner who participated in the site visit. The one who did is thought to be one of the computer-savvier of the practice. And I don't think the claim that we are 100% EMR is meant to be final yet - it represents the INTENTION for the practice. I, too, am waiting to see what happens when the senior partner is supposed to go live next March. Perhaps he will take to it better than he thinks but I am predicitng that he lasts a week, hurls the interface through the window and insists that someone else do his documentation while he continues to do on paper what he has excelled at doing for 30 years now. I could be wrong, but that's what I'd wager. He's at least as much a perfectionist as I am.

---2. Is the CEO a doctor? To whom at your EMR vendor is the CEO related? Or what else is the CEO getting in return?

How ironic you should ask this. I have on occasion wondered the same thing. The CEO is definitely not a doctor. He is a businessman. I would believe that he could easily have cut a side deal but I have not a shred of proof of that and it would be ugly to suggest it, though it is not hard to think it. I will say this, though: the email I sent him on the system last January has gone unanswered because he does not know how to sign on. So how can he profess to know whether it is easy enough to use or not? He pretty much goes by what the young maestro doc succeeds in doing. Heck, if I could succeed in doing what the maestro does, this thread would not exist! (and I LOVE this doc but realize he is in a category by himself, and I think everyone who works with him also realizes it).

---3. Who runs risk management at the practice? A discussion with your risk manager/professional liability issuer might straighten out some of the problems (or make things much worse for you, at least until you leave). Spotholder codes that are never replaced; less than adequate records lacking detail. I hope you get out before the big malpractice hit that is inevitable occurs.

Risk management is masterminded by the office manager. She is pretty astute. One of the first things that came up in the conversation we had this afternoon related precisely to issues of incompleteness of documentation and the liability it confers, and that was not initiated by me. So she gets it. She also completely gets that despite all the talk about my needing counseling and needing to streamline what I've done successfully before (wrong on both counts), it simply may never come to pass that I get synchronous on this system. It is finally dawning that since they did not plan for failure (leaving aside how badly they have burned me out over this), that there is going to be a latter-day cost. They are simply going to have to either spend money on offloading me - or on unloading me. In the latter case, they wouldn't be paying a doctor's salary to me anymore but they would have to find a way to cover all the patients I DO see daily in the hospital as well as the patients I have seen in the afternoons. And since the schedule of the other docs has filled up to the brim, there is no-one else presently available at the practice to pick up the load. So they will have to go out and hire someone, which they've been trying to do for over a year without any success. The next most likely candidate does not graduate until next June. One never knows; perhaps they will get a good resume tomorrow, but the fact remains that there would be a ramp-up cost to replacing me that would not be any smaller than to hire a coder to give me a break and let me get productive again as I had been, which in turn would bring in even more revenue than has dried up since March and my going live. It's fairly simple math, really. And if I had to state it in human terms, it seems outrageous that they would ever have let this go on for so long. Does the idea of hubris seem out of place here? I am no longer the darling of the CEO given that I have not performed according to his plans. But nobody seems to be listening to me what it would take to get me back to that level of performace. We are 100% EMR, you see, so what I need to have to get my work done timely and completely has been taken away from me. I've felt far more like a yoked ox than I have a respected colleague and the office manager definitely knows this. But the decision rests with the partners and with the CEO. It rests with me, too, and I am as willing as I've ever been to simply walk away from the paycheck and reclaim my life and my sense of internal equilibrium. There will be changes made this week, even if they are not the final solutions. And forward progress started with posting here and laying it out for consideration and feedback. Thank you so much for yours.

xraymd
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I have to respectfully disagree with your disagreement. I currently work in the technology field as a technical writer and I've worked in training and support at a small company that made crappy software.

From what I've read EMR is the wave of the future - and it does make sense that entering medical info into a large database could be enormously helpful in many ways. I haven't seen any posts from xaymd implying the data shouldn't somehow go into a database. The problem is the particular EMR she is being forced to use.


I have to reiterate what JustSilly said. What I think got somewhat buried in the thread is that this software is *NOT* designed to be used this way--it is not designed to be used while seeing a patient, it is supposed to be used to enter the data after the patient visit. The designers of the software even said so, and they were *appalled* that xraymd was being asked to use it that way. And when she tried to get the software designers to talk to her bosses about it, and get some orientation on how the software was meant to be used, they "didn't have time."

A shovel is great if you use it as a shovel. If someone tries to flip pancakes with it, well, it's not going to be quite as useful. And some people might be able to make it sort of work, but that doesn't mean the person who can't use a shovel to flip pancakes is against learning to make pancakes *or* the use of shovels--just against the misapplication of a tool.


--Booa
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that the system was NOT designed for real-time capture of information in the way my practice intends for it to be done - in fact, the system designer offered our practice a free two-hour solutions session to see how the modules could be customized for easier face-to-face use, and the management DECLINED to take him up on his offer (too busy to spend time customizing the modules!).

xraymd,

I just wanted to offer my warmest regards for your situation and a huge hug. {{{{{{{{xraymd}}}}}} I can't think of a *worst* feeling than that of failing when you're working your tail off to succeed. I'm supremely confident that you're a fabulous doctor and this practice is out of their collective minds to alienate you in this way. I haven't read the entire thread yet, but the detail I italiced above struck a chord with me. If the designers of the program quite clearly explained that this system was not intended for real-time capture of information then there are several important things you must realize go hand-in-hand with that. Probably most importantly of these is that this problem is NOT your fault! You cannot possibly make lemonade with absolutely no sugar, and it seems there is a definite lack of sugar coming from management. Forget that the other doctors have adapted, especially if they're abbreviating their notes at the risk of malpractice and their patients' long-term benefit. If the system wasn't designed to be used in this manner than your struggles are far more than simply understandable. If management are not technically savvy enough to take full advantage of the benefits this program DOES offer, or better yet, have selected a program that suits what their ultimate goal is (100% EMR with real-time functionality) then you simply cannot blame yourself. Period. Do try and remember that as this all plays out.

Personally I find it hard, if not impossible, to work in an environment where I don't feel encouraged and supported. It sounds like your present practice is a long way from that standard. It's just my assumption, but I imagine if the management is this blind and difficult on one topic that bleeds into other areas. Simply put, you deserve better. I think it would be best for you to look for another job. If they won't work with you to determine a solution then move on.

Even if you decide to stick it out a while longer, one way or another, you need to take the power back. I wish you the best of luck with this.

Lots of love,
Smurfette

((((((((xraymd)))))))))
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xraymd:

<<<<---1. Was that the parner doctor who is still not on the system?

Also, with one doctor not on the system, how can the practice ethically claim to be 100% EMR?>>>>

"The partner doctor still not on the system was not the partner who participated in the site visit. The one who did is thought to be one of the computer-savvier of the practice. And I don't think the claim that we are 100% EMR is meant to be final yet - it represents the INTENTION for the practice."

If it is merely intent, then you ought to be able to get some relief. Your being "offline" so to speak does not affect the truthfulness of the claim while another partner doctor is also offline.

"I, too, am waiting to see what happens when the senior partner is supposed to go live next March. Perhaps he will take to it better than he thinks but I am predicitng that he lasts a week, hurls the interface through the window and insists that someone else do his documentation while he continues to do on paper what he has excelled at doing for 30 years now. I could be wrong, but that's what I'd wager. He's at least as much a perfectionist as I am."

Any chance the partner doctor's timeline could be accelerated or your delayed to match his/hers?

<<<<---2. Is the CEO a doctor? To whom at your EMR vendor is the CEO related? Or what else is the CEO getting in return?>>>>

"How ironic you should ask this. I have on occasion wondered the same thing. The CEO is definitely not a doctor. He is a businessman."

That is unfortunate, especially if this is his first experience running a medical practice. Providing medical services is not exactly like producing widgets.

"I would believe that he could easily have cut a side deal but I have not a shred of proof of that and it would be ugly to suggest it, though it is not hard to think it."

I was thinking more along the lines of shunting business to a friend or relative rather than a cash "kickback".

"I will say this, though: the email I sent him on the system last January has gone unanswered because he does not know how to sign on. So how can he profess to know whether it is easy enough to use or not? He pretty much goes by what the young maestro doc succeeds in doing. Heck, if I could succeed in doing what the maestro does, this thread would not exist! (and I LOVE this doc but realize he is in a category by himself, and I think everyone who works with him also realizes it)."

Setting the standard at the "superstar" level makes it largely impractical, and the CEO sounds like a tachnological idiot.

<<<<---3. Who runs risk management at the practice? A discussion with your risk manager/professional liability issuer might straighten out some of the problems (or make things much worse for you, at least until you leave). Spotholder codes that are never replaced; less than adequate records lacking detail. I hope you get out before the big malpractice hit that is inevitable occurs.>>>>

"Risk management is masterminded by the office manager. She is pretty astute. One of the first things that came up in the conversation we had this afternoon related precisely to issues of incompleteness of documentation and the liability it confers, and that was not initiated by me. So she gets it."

If she is also willing take some action, she could pull a few files (possibly with your help) and let your regular defense counsel conduct a mock deposition of a few of the doctors who are skimping notes and see whether being made to look like not good and be told about the exposure scares the partner doctors and CEO into some sense.

"She also completely gets that despite all the talk about my needing counseling and needing to streamline what I've done successfully before (wrong on both counts), it simply may never come to pass that I get synchronous on this system. It is finally dawning that since they did not plan for failure (leaving aside how badly they have burned me out over this), that there is going to be a latter-day cost."

Dawning on whom?

"They are simply going to have to either spend money on offloading me - or on unloading me. In the latter case, they wouldn't be paying a doctor's salary to me anymore but they would have to find a way to cover all the patients I DO see daily in the hospital as well as the patients I have seen in the afternoons. And since the schedule of the other docs has filled up to the brim, there is no-one else presently available at the practice to pick up the load. So they will have to go out and hire someone, which they've been trying to do for over a year without any success. The next most likely candidate does not graduate until next June. One never knows; perhaps they will get a good resume tomorrow, but the fact remains that there would be a ramp-up cost to replacing me that would not be any smaller than to hire a coder to give me a break and let me get productive again as I had been, which in turn would bring in even more revenue than has dried up since March and my going live. It's fairly simple math, really. And if I had to state it in human terms, it seems outrageous that they would ever have let this go on for so long. Does the idea of hubris seem out of place here? I am no longer the darling of the CEO given that I have not performed according to his plans. But nobody seems to be listening to me what it would take to get me back to that level of performace. We are 100% EMR, you see, so what I need to have to get my work done timely and completely has been taken away from me. I've felt far more like a yoked ox than I have a respected colleague and the office manager definitely knows this. But the decision rests with the partners and with the CEO. It rests with me, too, and I am as willing as I've ever been to simply walk away from the paycheck and reclaim my life and my sense of internal equilibrium."

Unless there are significant changes, you probably need to review your options. Anyplace that put me through such a wringer is not likely a place with which I would like to remain associated.

"Thank you so much for yours."

Your welcome.

Best Wishes, JAFO


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Hi xraymd,

I really feel for you. I think I ranted a bit before on the "Physicians" board about my frustrations with our EMR, but I think I'd go nuts if I had to deal with yours. A password for each prescription? WTH?

I'd second the opinions that suggest that you move on. I'm sure that you could adapt with time, and with sacrifices, but this practice doesn't seem to deserve it. There are simple steps that they could take to help you through this process, but they refuse to. What's so bad about having you "transition" from all-paper to all-electronic? Nothing. Their inflexibility speaks volumes about their priorities. Physicians and patients don't seem to be high on their list.

In the meantime, how can you make the EMR process less painless? You mention that a big part of the problem is searching for the proper ICD code. Would an online ICD-finder help? http://icd9cm.chrisendres.com/

In my case, I try to remember that the EMR should serve 2 purposes - to document the patient's condition well enough that it is helpful to the care provider, and to document my activity so someone can bill for what I've done. My EMR has a lot of free-form fields, so I enter as much data into those as I can and I avoid the checkbox/extra-module stuff. In the end, the same information gets entered in the patient chart, but it's easier for me to enter free-form and it's easier for me to find it. The downside is that it's more difficult for the billing people to find it, but I figure that's their job :-) Maybe it will be incentive to get software that's easier for us to use (doubt it, though)

Anyway, keep us updated and I hope things get better!
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WARNING--LONG POST

On the EMR, I must open the patient visit, go to the specific module intended to capture chief complaint/history of medical illness, put the individual complaints into their individual boxes (the medical assistant does some of this), put the vitals into a different module into their individual boxes, go to the review of systems module and click off each little box regarding Normal or have to open yet another module to detail any abnormal review of systems, go to the physical exam module and click on each little box similarly to the review of systems module - and every time I answer that something is not Normal, yet ANOTHER box pops up asking me to further detail the degree of abnormality which I have to answer or close, then I have to go to the Assessment module to search the ICD-9 database for every single diagnosis I wish to document (when I know the codes it's easier but when I can't find them it's a showstopper because the program WILL NOT PROCEED without ICD-9 codes for everything). Having spent time to find the codes, I then have to go to the Plan module to say what I am doing for each diagnosis, then I have to go to the Rx module to put in every single prescription (each time having to re-enter my password because it is not set up to allow me to input it once per session or even per patient) that I wish to print out - sometimes I can't even find the desired med when I search for it - then I have to go to the printer to collect all my scripts to sign. Then I have to go to the lab module to enter lab requests that I used to simply circle. Then I have to go to the imaging module to detail requests I have for imaging - xrays, CTs, mammograms, bone density scans. Then I have to encode the results of any EKGs I've done (can't just write it anymore on the EKG itself - have to ALSO do this). And this is just for urgent care visits. For Establish Care visits, I have not even mentioned what needs to be done to capture past medical history, social history or family history on this system - each with their own modules with multipart steps for each, and none of the modules passes information forward to the payoff Assessment module which, if not completed, causes a block to closing off the patient visit.

For the love of all that is important....no piece of computer software should be that hard to use. Shoot, the more important the software, the easier it should be to use. Dare I ask what EMR software that you are running? Please don't tell me it's made by GE and has the initials CPO....... :)

For the record, I am an ex-healthcare IT employee that helped drive the implementation of EMR software through out about 60 outpatient facilities, and I have seen a number of the same issues you talk about. It definately sounds like the folks who chose that EMR software didn't do much to test the workflow and make sure it fit in with the mechanics of your practice.

The EMR we used to use was much simpler to work with, in that the data entry was much more workflow-oriented. For example, if your patient complained of sinusitus-like symptoms, you had a form built based on that that already had a lot of the commom codes related to those symptoms built into the form in a drop-down box. You only had to go searching if you needed something you weren't expecting. Also, the obs were based on standard obs for that type of visit, with a big free-form area at the bottom of the screen for other things that were not related to the primary form.

The true strength of the system was the fact we involved the doctors in the system design, and used their input to help develop these new forms for the types of visits the office normally had. That way, the OB docs weren't bogged down going through forms designed for Family Practice docs, and vice versa. I would wonder if your software has this capability, and if so, maybe you could suggest that?

And, unless you were born with a computer in your hand, people shouldn't expect EMR software to be an instantaneous boost to productivity. We actually took over two years to get back to our inital level of productivity, and an additional 6 months after that to improve. Now, the providers love the system. (But, believe you me, they had a lot of similar complaints as you have now in the beginning.)

While I certainly understand your frustration, I hope that this doesn't color your option of EMR in general, it just sounds like to me you have crappy or poorly implemented EMR software. I firmly believe that EMR is a huge step towards eliminating medical errors, and providing a consistent interface to your medical information.

The nice thing about our local healthcare providers is that our EMR is accessible from all providers that work for the company. So, if I have been to my FP doctor twice for a problem, and then end up in the ER of an affiliated hospital, my entire medical record is there for access by the ED staff.

Hang in there, hopefully you can find a happy medium in there that works for both you and your practice. :)

RkeFool
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No. of Recommendations: 17
Hello, XRaymd---


I'm very sorry to hear about the difficulties you are facing in your profession. I've read the thread on the other board, and this one to this point.

You have addressed the attempts people have made to help, but no good solution seems to have presented itself.

The best paragraph from my blue collar point of view is that by rozina:

<<In the meantime, make a committment to yourself. You will do the EMR with the patient in the office. If that means having to have a 30 minute or 45 minute block per patient instead of 15 minutes, then that's the way it will have to be for awhile. With you taking the work home with you, only you feel the pain. The pain has to be felt by your collegues before their best interest becomes your best interest.

>>


You have a system that doesn't really doesn't work. Your senior doc doesn't use it and recognizes that he can't do the high quality work if he uses it. Other doctors wind up making unprofessional compromises that will eventually come back to harm them and the practice.

One doctor has devised methods that work.

So what to do? Well, I'm no professional. I was once a union business agent who sometimes sometimes problems with management imposing unreasonable conditions on employees. The paragraph quoted above appeals to my sense of holding the MANAGEMENT responsible for the decisions they have made.

Management is perfectly capable of imposing lousy systems on employees and making it stick if employees make enough compromises to keep a bad system limping along. But eventually a bad system's faults can't be glossed over: someone dies or is seriously injured because the system didn't work right. You get sued. Too many people quit. When management feels the pain, things will change. As long as only employees are feeling the pain, everything is ducky.

Unions can protect people from unreasonable demands by employers, and employees can't be forced into making unsafe compromises to enable a bad system unless they choose to do so. If enough employees cooperate to make the faults of a bad system or policy painful for management, it will be changed.

Unfortunately, you don't have that kind of protection. The doctors who are making compromises in their documentation are exposing themselves and the practice to liability, but that fact is hidden or glossed over for the present. You are reacting to the situation by killing yourself with overwork and still not meeting the production expectations of the practice management. The top doc recognizes that the system is badly flawed, but uses the power he has to escape from the system by not using it himself.

A true professional practice is quite special. It involves colleaques who trust and respect each other, and are committed to excellence rather than merely paying the bills. In such a practice, your concerns and those of your colleaques would not be ignored, but would be confronted and resolved in a way that promoted excellence for both patient care and physicians. Instead, you are being treated as the object of management power plays as they attempt to prove that square pegs do fit in round holes, if you have a big enough hammer.

Long term, I very much doubt that they have a big enough hammer. Their only real hope is a new edition of the software that solves many of the problems you describe (any hope for that?).

Your other options appear to be making the same compromises your other colleagues do, which you do not want to do. Or finding a new job. Or soldiering on in hopes that the system will be seen to fail before they hand you your hat.

You make a great case for unionizing physicians in your post, but I suppose the practice is too small for that to be especially practical.


Sorry I can't offer any good solutions. But perhaps your situation illustrates why we blue collars have formed and joined unions from time to time.



Seattle Pioneer
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No. of Recommendations: 5
I haven't read through all of the responses yet - the thread has gotten pretty long - but I thought I'd share a few thoughts.

I'm not in medicine, but am a professional (a CPA). Especially during tax season, I see clients, have to document files, prepare reports, and communicate it all back to clients. In a sense, it's not too different from a physician. Except, of course, that if I mess up, people don't die. They just have to pay money. (Which, for some, is not too different. <grin>)

As a patient, I like the concept of EMR. It makes a lot of sense. No confusion about the doctor's handwriting or dictation, either in the records or on the communications with others in the health care process (like prescriptions, orders, and the like). Conceptually, there can be a double-checking for potential problems (drug interactions, diagnosis that is inconsistent with the symptoms, prescriptions that are inconsistent with the diagnosis). From that standpoint, I would think that EMR could be a good thing.

But for it to be actually work in practice, it has to be a system that the physician can work with. Some learning curve should be expected with any new system. But if you're not getting up the learning curve, there is probably something wrong with the system. OR the system is not designed to work the way you work. Example:

I've taken the bulk of my individual tax preparation practice paperless. I interview clients, scan documents, create backup documentation, and produce a tax return with only the final product typically being on paper. It works because I designed the process to work the way I work. My business partner likes the idea as well. But he has been basically unable to implement my process. Why?

Two reasons, really. Mainly, we work differently. I like to gather the information, input it directly into our tax software, and do the documentation of our files as I go. All of this is done while the client is sitting with me. He prefers to get the documentation from the client, review it with the client, and then pass it all off to someone else to do the data entry. My system won't work for him, because he uses a different process. Secondarily, I'm not really sure he wants to go paperless.

I suspect there are some of the same issues working for you. If you had an EMR system that worked the way you worked, my guess is that you'd be all over it. The problem is that this system and you have different ways of working. Unfortunately, there are only two resolutions - the EMR system goes, or you do.

As a professional, I'd prioritize things this way:

1. Patients. Don't do anything that would jepordize the patients. As someone suggested, perhaps you greatly increase the time with each patient so you can (slowly) work through the EMR system. Or maybe you engage in outright rebellion and go back to paper. Whatever it takes to keep from making a mistake with the patient care.

2. Yourself. You have invested a great deal of time and money to get your professional license. Don't do anything that would endanger that license or your professional reputation. I suspect this is closely tied with number 1. Malpractice cases just can't be good for anyone. But it also includes handling the professional dispute with your managing MD's professionally. I imagine that would involve everything from consulting with them about the difficulties you're having to resigning your position rather than let yourself get fired. (PS - if you resign, you'll have a whole lot more time to job hunt! And a good quality professional like yourself WILL find another position. So don't let the illegitimate children get you down.)

3. The practice. The profitability and health of the practice need to come last. If the management of the practice has made a bad business decision, they need to suffer the consequences. That undoubtedly means some kind of loss - loss of the investment in the EMR system, loss of profitability, loss of good quality staff, and perhaps the loss of face. The last loss is likely the hardest for them to face. Most entrepreneurial doctors I've met are very egotistical. They don't like to admit mistakes. And they can behave very irrationally when faced with the possibility of losing face.

That's a lot of rambling to say this: you're a good doctor and a good person. It's tough right now, but in the end it will work out. It may get tougher, but you WILL get through whatever needs to be done to improve the situation. I have faith in you.

--Peter
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So sorry to hear about the unreasonable expectations at work, xraymd!!! I'm a big believer of "voting with my feet", so I'd take Chris's advice and start filling out the necessary forms / resumes for a potential move.

Working in that sort of environment, where you happen to have a single geek who can actually make it work is just bad luck. It sounds like if he wasn't there, they'd take the rest of y'all's (hey, look at that, there's two apostrophe's in y'all's!!! Never knew that! Anyway, back to the sentence...) input seriously.

The facts, as I see it:

1. You're being asked to use a computer system that was not designed for your actual use.
2. There happens to be a single geeky physician, a fluke, who can make it work.
3. Others are compromising their work, opening some liability to the entire practice. (!!!!!!!!!)
4. You are unwilling to compromise your work until being told directly by Management to do just that (don't hold your breath).

Your options, as I see it:

1. Continue pounding on Management until they see this system is a bad thing. They're spending a dollar of your time to save a penny for a sheet of paper. Penny-wise, pound-foolish and all that. I'd go to the EMR software's website and print out anything that confirms what the actual programmer told you. I'd even go as far as asking the actual programmer for a letter or e-mail verifying what he told you in the conversation.

I'd really hammer them with the liability issue. These Managers seem to think only inside their books rather than in the real world.

This will keep your days stressful, potentially with no

2. Compromise your work. I wouldn't, but I'm single and unattached, and could move fairly easily. Your situation is considerably different.
At my work, we document everything. Our culture is that everything is documented sufficiently so that if I were to die tonight, someone could pick it up and continue the work without retracing steps. And I'm only in air conditioning!!! If I screw up, someone is a little uncomfortable. If you screw up, it could be life or death. (!!!!!!!)

3. Quit. This is the option I would pick. But again, we're in different circumstances.

Don't really know what to say beyond that. Just realize that not all managers are this incompetent. There is a better place out there that will actually realize that not all people are created equally geeky.

Oh, and (((((((((((((((((((((xraymd))))))))))))))))))))))))))))).

-Agg97
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((((((xraymd))))))

I wish ya luck. That program sounds horrible.
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You make a great case for unionizing physicians in your post, but I suppose the practice is too small for that to be especially practical.

Physicians are unionized - they mostly belong to the AMA.

Unfortunately, trying to get doctors to work together to resist something, is like trying to herd cats.

Which also explains their lamentable showing when it comes to medmal reform. Herding lawyers is NOT like herding cats...
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Oh dear, oh dear xraymed! What is the stumbling block in doing the EMR? I feel like I'm part of the problem (as opposed to solution) as I've been trying to work with military MDs to push so that they capture everything electronically so that we can better understand, statistically, war injuries. Transcribing records from the docs written notes to electronic format is so terribly expensive that it becomes a huge pit in which potientially valuable (collective) information is lost because there is no money to put it into electronic format.

In theory, EMR is suppose to be simpler. What is making it not so? EMR is the future. Medical data will be put on medical dog tags to speed up the ability to help patients better and more effectively.

You sound like you need a breather, a break. I'm sorry that the only thing that I can offer you is a

{{{{{{{{{{{{hug}}}}}}}}}}}}}

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No. of Recommendations: 5
rosietomato: "Oh dear, oh dear xraymed! What is the stumbling block in doing the EMR? I feel like I'm part of the problem (as opposed to solution) as I've been trying to work with military MDs to push so that they capture everything electronically so that we can better understand, statistically, war injuries."

For xraymd it is the particular software her employer has chosen.

It is all about the interface? Why did Windows GUI replace DOS?

In order to make EMR work, the software designers need to meet with doctors (probably from each speciality) in order to design an interface that works in the way that most doctors work. What is a very elegant inteface from a designer's/coder's perspective may be useless if makes the docs struggle to enter information in the maner and form it is collected.

I see this in my legal practice, where software designed for litigators often has no used for transactional lawyers; in addition, even within the transactional world, I have seen software for corporate lawyers that is not particularly useful for real estate attorneys or trust & estates attorneys, because the practices are so different.

Really well written softwares conforms to the practices of the end users and makes their life easier. Poorly written software not only does not conform, but trys to force the end user into changes its practices to what the software designer decides is appropriate, regardless of what the end user thinks or wants.

One of my former employers paid a not insignificant amount (low 5 figures) to have some custom software written when it could not find any commercial software that readily accomplished what we wished to accomplish. All the end users were interviewed and allowed to describe required fields and functions, which were then integrated. Even after several years of use, complaints were minimal except for the cheap calendar function which counted calendar days well, but could not calculate business days.

Just my $0.02.

Regards, JAFO





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I am late jumping on this thread and I admit to not reading all the posts before commenting, but...

I think you need your own data entry assistant. Sounds like some of the other docs do too. Perhaps one assistant for every two or three docs to enter data in from your handwritten notes. I do not think it is unreasonable that a doctor should not have to enter in all their own data.

I wish you well..
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