Virtual Perfection

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My new electronic health record (EHR) likes to be helpful. Very helpful. It is full of all sorts of suggestions to ensure that my care is better than best.

For instance:

When I prescribe a birth control pill, a warning flashes up in the form of a red and yellow pop-up to remind me that it is contraindicated in pregnancy. Um. Duh? The patient isn’t pregnant. Not yet anyway. 

Similarly it wants me to know that metoprolol, a medication used for blood pressure and the heart, is contraindicated in chest pain. Well, Ok…

Dozens of commonly used medications have absurd warnings. What I am most afraid of is getting to the point where my brain blocks out all warning pop-ups because at some point I am going to get alerted about an allergy that I forgot about. I don’t want to automatically click through that alert. It would help if the medication allergies were listed on the same screen as the order entry screen. Wishful thinking, I guess.

The EHR wants me to add “Morbid Obesity” to everyone with a BMI over 30 and “Overweight” to everyone with a BMI over 25. For many of my patients, rubbing their noses in their weight is counter productive AND the bigger question would be is being overweight by BMI standards really a medical condition? I don’t think so. THEN it wants to suggest that I send the patient for nutrition guidance. That would be all well and good but when was that ever covered by a patient’s insurance company? Almost never. Even for diabetics, thank you very much. I have yet to have a patient volunteer to pay $1,500 for nutritional guidance with a dietician. I sure as hell wouldn’t.

Are you coming in for strep? Well, the computer wants to remind me that you also need your tetanus booster. Except that I already gave you a tetanus booster two years ago. You are good for another eight years, technically. In fact, the computer has that immunization in the shot record, it just isn’t giving you credit for it. Or me credit for it, apparently. I have to go through a complicated series of maneuvers to “properly” record that you had the vaccination. It cannot be easy. Oh, no.

Oh! I have patients that are finding their records merged with old records from when they saw an unrelated doctor in another part of the state over fifteen years ago. Kinda fun, except that their name is now reverting back to their maiden name or some other nonsense and I have to delete those ancient meds off of their current med list before anyone gets confused.

Speaking of the magical appearance of meds, do you have something you don’t want your PCP to find out about? TOO BAD! If you fill an antibiotic or any other medication at a pharmacy from another provider, I’m gonna find out. That has made for some awkward conversations with patients about their over utilization of teledoc services… I hate it when they cheat on me with another physician!

The EHR fills in quantity and refills on many of the meds I order automatically, except it often isn’t correct. For instance, a Z-pack (azithromycin) that it says to take two pills on the first day and then one pill every day thereafter, auto fills a quantity of two rather than six. Or amoxicillin three times a day for ten days sometimes auto fills a quantity of 20 rather than 30.

It is still early. We will see how this continues to shape up as I get more proficient.

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101 thoughts on “Virtual Perfection

  1. What a nightmare! Sounds like you got the beta testing version of the program instead of the final version after all the comments, critiques, and bugs were worked out. It sounds like no actual doctors were invited to be involved in the creation of it. It’s definitely filling someone’s agenda; too bad it isn’t practicing physicians’.

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  2. Funny! Now I know when I told my internist yesterday that I already had
    my flu shot, when he asked me where? It was in another MD’s office who
    was clearing me for the knee surgery that I postponed?? He knew!! Ha!

    Liked by 1 person

  3. My husband works on EHRs and he gets so aggravated by things they make him put in there. How they try to make it work with the wrong operating systems…. oh there’s so many problems.
    My sympathies are with all: The programmer, the medical personnel, and the patients. In a perfect world it could help. Maybe it will get there. Good luck.

    Liked by 1 person

  4. Having spent the past 40 years designing and writing systems for a living, I can almost see a mental image of the code that is causing these problems. I’m not defending the system, but I know how seemingly intelligent requirements are translated into software that makes these kinds of mistakes. For instance, the developer not being aware that prescription dosage can change during the prescribed period.

    The other issue (guessing now) is that the developers were serving multiple masters. Healthcare providers want requirements A through M, insurance companies want N through W and large Pharma wants X, Y and Z. The poor slob developer doesn’t realize that O is a different version of F and that Y reduces B, H and P to never being able to work.

    Unfortunately, the best I can say is that some of these things will be easy to fix, some won’t. Ironically, I enjoyed reading this post for a very different reason than the one I think prompted you to write it – Good luck.

    Liked by 1 person

    • Ha! I wanted to give a peek to people of what happens on the other side of the computer screen. The company that made this EHR is HUGE. Tons of people. Lots of feedback from physicians. Crazy amounts of money. They have the best system on the market, I think, but why stop there? They could drown the competition. I would help them, too, if they’d just listen… ๐Ÿ˜‰

      Liked by 2 people

      • Systems are constantly evolving. They’re never perfect, and they are usually released for use when they meet the basic demands. I would think that they would want feedback to help them make the system better.

        I did enjoy the view from your side of the screen.

        Liked by 1 person

  5. It seems a physician will have to spend more time with the EHR than with the patient. Now we have a behind the scene view of what physicians go through. I just remember the days when it was all paper but I guess we can’t go back. Good luck!

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  6. EPIC….arggghhhh we cannot get our meds reconciliation process to work at all and now we just added the AVS or discharge paper work as a new source on input for meds. So now we are writing IMOs like they are going out of style because we have to have signed orders… and the doctors hate us because they have to sign multiple orders and so they don’t and on and on and on… it will never work and really WHO CARES? “Ya got this here drug..ya taking it? check! We’re done.” I had one of those days too.

    Liked by 1 person

    • It doesn’t tell me who, just that a medication was filled at a pharmacy. When I reconcile the meds, it is clear it didn’t come from me. Then I have to ask…. Apparently it is connected to large retail pharmacies across the country.

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  7. Does that mean that if I go to the Pharmacy and buy Cortisone Cream, which I have to sign for, that this goes on your list even although I thought it was not serious enough to bother you? Or is it more complicated than that?

    Liked by 1 person

  8. Oh my. I don’t envy your learning curve. Whoa.
    Also, thank you for telling me what a Z pack is. You’d think I’d know more than ‘antibiotics’ as many as I’ve had, but I did not. Never even wondered… Hopefully that’s not a side-effect, hah!
    I know it may sound crazy, but I sorta expect my doctor to know what meds I’m takin, and not to prescribe me any that are conflicting. My husband and I are particularly alarmed by the commercials that say, “Make sure your doctor knows you have X condition.” If my doctor doesn’t know I have X, then is my doctor a real doctor? Who else would tell me I have X?
    Sorry, anyway, I enjoy stories of Beyond the White Coat. It’s fascinating.

    Liked by 1 person

    • There are so many gosh darn drugs out there and so many “new” ways those things interact that staying on top of it while managing to navigate a distracting and confusing EHR makes it downright dangerous. This is even more of an issue as you get NPs and PAs prescribing who have had a very watered down education. For them, computer alerts are critical.
      Those commercials crack me up… ๐Ÿ˜‰

      Liked by 1 person

  9. Just had my yearly “physical” and the doctor didn’t even have me undress. I’m a retired dietitian/diabetes educator and non-reimbursement from insurance companies was the biggest frustration I faced in my practice. Sorry for both doctors and patients that we are going down this road.

    Liked by 1 person

    • Guidelines say clinical breast exams are probably not necessary and PAPs/ pelvic exams are routine now every 3-5 years rather than yearly and if you’ve had a hysterectomy you don’t even need that. Considering prostate exams are no longer considered to be routine screening anymore, getting undressed is really not as necessary as it used to be. These things are changing so rapidly, it is dizzying for providers, too.

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      • Saw my gyn to day and he did a breast exam, pelvic and checked my skin for moles. He also spends a lot of time talking to me. I know he doesn’t have to do all that, but it makes me feel like a person rather than a “digital file”.

        Liked by 1 person

  10. After about a month on our newest EHR….. I finally can say we probably will survive. The husband hasn’t killed himself or retired. We’re getting used to sending all the meds while in the room with the patient, talking to them and listening as I frantically type in doses and refills. We also have to add a diagnosis code for everyone’s BMI, and must print out educational material for 10% of all patients. Before training, they already had it rigged to “fake print” because no one really gives that stuff out, but you have to say you did…. right…….

    Liked by 1 person

    • I don’t give it out, those loooong print outs. I don’t even print them. I also don’t add weight diagnosis for the majority of my patients. Patients need a concise print out of the important points not dozens of pages of fluff that I don’t even read myself. As it is, I hate the three page things I give at checkout. Two pages. Max. I will probably get “disappeared” and sent to reeducation “camp” at some point….

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      • Still difficult to customise, time wise. I’m guessing the defaults are really intrusive because it’s easier to have users look for options to turn off, rather than have it turned off as the default and have someone say they didn’t get a warning.

        Development for a judiciary program where I work was a nightmare because people are so different, and it’s terribly tough to come up with default settings and workflows and the user interface. I used to be someone trying to design EHR interfaces, and gawd, it’s tough!

        Plus with doctors being swamped, I can see why the EHR is a real pain right now! โค

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  11. Sounds like a nightmare! Technology gotta love it. I have a question regarding a diagnosis error on my mother’s EHR and I was told it’s going to be extremely difficult to get it removed. She never had what’s been reported and I can’t tell who put it there but it’s a big deal because while some of the effects of her condition mimic the error they are two entirely different conditions. Obviously I have to have the misdiagnosis deleted but is there a way I can find out how it got there in the first place? I’m concerned with her continued care and medications.

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  12. It’s a shame a that common sense cannot be used in programming the EHR, but sense isn’t common and as much as hospitals, and insurance companies want to save every penny at the expense of their patients’ health and their doctors’ sanity, it would behoove them to create a system that doesn’t needlessly waste time either.

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  13. sounds awful ..Amoxycillin comes in packs of 20 that may be why our PBS over here is 20 and 1 repeat we can’t give 30 as it’s over so the doctor have to specify reg 24 which means supply the whole lot at once then the patient get 40 ..

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  14. Over here electronic health is just starting out..you’ve got to opt in and as a patient you can hide your history from your doctors which defeats the purpose..so if you go to doctor A for herpes and you don’t want doctor B to know of that herpes episode you can hide it away if I understand it correctly ..privacy issues

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    • Fascinating! I am not sure how I feel about it. Does the presence of genital herpes have any bearing on my treatment of diabetes? Nah. But there are other instances of things that do matter. Like coming in for a bladder infection when you have taken three rounds of antibiotics over the past six weeks. That really increases the risk of resistance and is important to know. Unfortunately, patients don’t always know what is important to share or not. Still, I believe patients should have control of their health records and their privacy. My getting access to their medical history in some ways is a privilege that should be earned, not a God given right. It is a sticky thing.

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  15. EHR sucks Monkey balls, complicating more than helping. 26 boxes of loose papers are now to be scanned into our EHR…which means a new encounter…For. Every. Single. Piece. Of. Fucking. Paper. And all within the Indiana DOC system. FML… I feel your pain, doc. I feel your pain.

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  16. To me it seems that it’s not that you (and your colleagues) must become “more proficient”, but rather the system itself. More fine tuned in a way that it supports without overloading. I often wonder if pilots don’t have a similar issue, sitting in front of that huge board with control lamps and indicators. At what point do you stop seeing, or thinking?

    Liked by 1 person

  17. Oh, and the Chenonceaux picture is great. An unusual view. “Now go straight ahead to visit the kitchens. Hurry. The visit should not take more than 22 minutes. Are you running put of breath? Check your healh app. Now. The next recommended stop is Chaumond castle, then you must see the night animation at Amboise. If you fail to do so, your trip will be charged additional costs…” Tut. Tut.Tut.

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  18. Yep. This happened when my primary merged with the company that my allergist uses. The allergist had my weight at 357. More than 100 pounds my actual weight. My primary was like “What the hell?” You’ve never weighed that much. I told him that I know. Their information is incorrect. I get tired of correcting systems that they can’t seem to get straight. He has seen me for the last 16 years so he has more accurate information. Aww, the perils of technology.

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