ICD-10 Can Be Poetry

Last Thursday the United States made the long-anticipated switch to ICD-10.  At UCSF it has so far been smooth, although we won’t be declaring victory until the revenue cycle is complete for several turns.

On cutover night, our resident EHR poet laurate and revenue cycle analyst, the multitalented Sam Marcus, commemorated the event with the following poem.  Read it aloud for rhythm and meter, your ICD-10 fellow travelers will surely appreciate it.

Sam Marcus, UCSF Revenue Cycle Analyst and Guest Poet

Sam Marcus, UCSF Revenue Cycle Analyst and Guest Poet

‘Twas the night of cutover, and all through the house
Not so much as a W53.01 (bit by mouse)
The code sets were loaded; the build was all done
(an aside: Carpal Tunnel’s G56.01)
The toddler was nestled all snug in his bed
To avoid W06.1-ing his head
And I was asleep, though I’d be up at three
To kick stage two conversions off in P-R-D
I was thrust from my slumber by noise like a bomb
H93.19? No- my iPhone; time to log on.


Away! To my laptop I slunk like molasses!
All bleary-eyed (not H52.1; don’t need glasses)
And what ‘fore my sleep-sagging face did appear
But a huge system update- this could take all year!
Please wait while the drivers, the message explained
Resolve digital M84.3’s (fracture, strain)
“Now, @#$&er ! *Now*, #*@&!er!” I raised cry and hue,
Briefly presenting F95.2
To the top of the stairs! (where the rail meets the wall)
I Y01’d my computer (assault, method: fall)
It quickly contracted S00.33
And I threatened to append to the end an “XD”
The long-story-short is the laptop complied
I logged in, ran conversions, then sat back and sighed
Our dual coding’s finished; cutover’s begun
We’ll see how things look when our first claim run’s done
As visions of PTO danced through my head
I R53.82’d back to bed.

Leaving the Past Medical History actually to the past

In the original format of an Admission History and Physical, the “History of Present Illness” spoke to the single problem for which the patient needed to be hospitalized. The “Past Medical History” described problems the patient might have had in the past, but by definition, were behind them. In the days when patients were admitted for a single acute illness, the distinction was clean.

The 'Edwin Smith Papyrus', an ancient Egyptian text on the surgical management of trauma.

The Edwin Smith Papyrus, an ancient Egyptian text on the surgical management of trauma.

As medicine became progressively more successful turning once-fatal conditions in to manageable chronic diseases, the distinction between “Past Medical History” and the patient’s current problems became fuzzy. When a patient with type 2 diabetes mellitus is admitted to the hospital with urosepsis (excuse me, sepsis of urinary origin), is the diabetes part of the “history of present illness” or the “past medical history”?  The patient isn’t being admitted because of their diabetes, and yet, it’s wrong to say it’s part of their past medical history because its an ongoing, usually lifelong problem requiring active management. In practice chronic medical illnesses started to show up in both places – the HPI would begin “Ms X is a 75 year-old female with type 2 diabetes admitted for urosepsis”, but the diabetes would appear again in the PMHx. For patients with multiple chronic medical illnesses, the HPI one-liner got packed with a comma-separated list of ongoing conditions, which then line up duplicatively in the PMHx, there joined by medical problems truly in the past.

In an electronic health record this fuzziness becomes obvious because a problem-based EHR (Epic for example) forces the physician to put their nickel down. Is the Past Medical History really in the past? The actively managed Problem List is integrated in to documentation, order writing, signout, and many other clinical functions. The diabetes belongs on the “Problem List”, not the Past Medical History, because it is an ongoing, not past, condition.

I just finished discussing this at UCLA as the Medicine housestaff are building up their inpatients’ problem lists for the first time. At UCSF we’ve tried to move the culture towards using the Problem List for all the patient’s active medical issues, including chronic issues, and reserving the Past Medical History for items actually in past. I remember pitching this for the first time to our Medicine residency program leadership, who looked at me like I had two heads. (in the most friendly and collegial way) Today’s patient is likely to have more present problems than just one. It’s a culture change, but it’s more accurate, more concise, and consistent with the original distinction between the HPI problem(s) in the present and past medical problems in the actual past.

Oroville Hospital Implements VistA, part 2

by guest author Matthew N. Fine, MD

This is the second in Dr Fine’s two-part series describing Oroville Hospital‘s implementation of VistAthe open-source EHR developed by the Veterans’ Administration. In his first post, he discussed their strategic approach and initial experiences with electronic documentation. Here, he picks up with Oroville Hospital’s CPOE go-live. – RC

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

After a whole year of hybrid charts the staff was chomping at the bit to go live and the anticipation outweighed the fear. Turning on CPOE was almost a welcomed event – watch out what you wish for. I think the (unintentional) strategy of having hybrid charts may be a good way to make full conversion to EHR more palatable.  CPOE was turned on October 15, and by the end of the first week nearly 70% of the orders were electronic and it’s now about 80%. There are holdouts among some of the physicians, notably surgeons and OB/Gynes.  Does anyone else have this problem? The hospitalists have a co-management arrangement with the surgeons, so most of their patients’ orders are electronic. This situation has actually give the EHR staff a little breather, enabling them to clean up many of the minor problems, including building a number of new orders sets – everything on VistA is easier with an order set.  We expect that CPOE will be mandatory within two months.  The pharmacy has created weight-based medication orders for pediatrics.  We don’t have a neonatal ICU, but it’s felt that the CP Flowsheet module could be adapted for this function. We are still working on a better medication reconciliation system.

Now, three weeks after the “go live” it’s still somewhat hectic and there are numerous minor and a number of major refinements required.  Dr. Singh our CMIO wondered when he would be able to go back to doing more clinical work – never!  Most of the problems have been delay in care, but a lot of the orders are carried out more quickly since they are sent directly to the appropriate department. There was a wrong medication entered by a pharmacist due to our still partly paper medication reconciliation system. Despite the challenges, some of our nurses and physicians, who also work in other area hospitals with proprietary systems, already prefer VistA.

Stage I meaningful use was achieved in 2011 and 2012 for the hospital and some of the clinics.  We are working on Stage II.

The EHR staff has participated extensively in the WorldVistA and, recently, OSEHRA, VistA’s non-governmental arm.   Oroville Hospital’s efforts are well known to the VistA community.  More than 100 patches to FOIA version of VistA have been created and some are being used by the VA in general.  The hospital is continuing to build additional enhancements and modules with the open source community.  Oroville Hospital made the necessary modifications and financed some other products through WorldVistA to get VistA certified by CCHIT. These upgrades include the ePrescribe system, which allows prescriptions to be sent to retail pharmacies through a clearing house, and has just been released to open source by WorldVistA.

Web based products were developed with collaborators in London. Enterprise Web Developer (EWD) was used as a framework to rapidly build rich web applications over a MUMPS database.  It allows us to deliver content to any device regardless of operating system, including iOS, Mac, Linux, Android and Windows based clients, eliminating device constraints. A number of our providers use an iPad to access information, but prefer mouse based computers for entering orders and writing notes. Also using EWD, Oroville has developed a real-time dashboard to monitor orders and other patient activity.  A patient portal for access to records from home will be rolled out next month.

For the last two years a number of clinics have been sharing health information. Last week Narinder and Denise participated in a regional HIE meeting in Sacramento that will allow for the trading of records with our SacValley MedShare HIE, of which Oroville Hospital is one of four core members.

Being from the clinical (the light) side of the project, I know I’ve given short shrift to the technological accomplishment of the team.  The usual progression of my requests for a new function is “the system can’t do that” to “it’s hard and will take a long time” to “I’ve got something to show you.” I also want to acknowledge the hard work done by many members of our staff.  Our HIT department is relatively small, so each department played a large part in developing their specific components.  Pharmacy, nursing and nutrition deserve special mention.

The total cost of the system, from soup to nuts, has been about $14 million.  Compared to proprietary systems, this amount contains a significantly higher proportion of hardware expenditures, including servers to support VMware.  This decision allowed the hospital to provide enough devices for all users, including dummy devices, and to let them use their preferred device.  Even though the system is open source, there will probably be some return on investment such as fees for use of the clearing house function for ePrescribe, consultation charges, and licensing for the order sets.  A detailed breakdown of the costs is covered in an upcoming article in the Open Health News.  If another non-VA hospital choses to use the use the system, it is felt their costs would be considerably less since they would not have the development expenses.

Bob Wentz said that he has been asked a number of times how a small hospital ended up developing an e-prescription system; he tells them – and I think his answer applies to the system as a whole – “Because we needed to.”

Oroville Hospital Implements VistA

by guest author Matthew N. Fine, MD

Several years ago I had the pleasure of meeting Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety at Oroville Hospital, at UCSF’s annual CME course Management of the Hospitalized Patient.  When Dr Fine attended the course again this year, he told me Oroville Hospital had recently gone live with CPOE on VistA, the EHR developed by the Veterans’ Administration. I’ve invited Dr Fine to post a two-part series here on Oroville Hospital’s experience. In this first part, he discusses their strategic approach and their initial experiences with electronic documentation, and in the second, their CPOE go-live. — RC

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

Guest blogger Dr Matthew Fine, Chief Medical Officer and Director of Patient Safety, Oroville Hospital

On October 16, 2012, Oroville Hospital turned on the CPOE component of its EHR, becoming the first individual US hospital to successfully adapt the Veterans’ Administration’s highly regarded electronic medical records system. How did a small, 153 bed semirural California hospital serving a mostly Medicare and MediCal population arrive at this place?

Almost exactly six years before, in October 2006, I attended the EMR and CPOE workshop with Drs. Russ Cucina and Michael Blum at the UCSF Hospital Medicine conference chaired by Dr. Bob Wachter.  The last thing Dr Cucina mentioned was the VistA system, which he said had barriers to its use at a non-VA hospital. At Oroville Hospital we had been discussing what do about EHR. We found that the proprietary systems were expensive, less than functionally ideal, and we didn’t want the tail wagging the dog. At one of our meetings in early 2007 I remembered I’d heard about the VA system and that “it’s free.” That night our CEO, Bob Wentz, downloaded the program.

We explored working with private companies that were marketing VistA with some embellishments and impressive consulting fees. They also retained proprietary rights to the system, restricting or charging for modification and thereby closing the open source. The hospital leadership decided to see if we could do it ourselves. The CIO retired and moved to Mexico.

We visited several VA hospitals to see the system in operation.  Whenever we spoke with residents, who also work at their university hospital, we found they preferred the VA system.  A team was assembled including Dr. Narinder Singh, a techy internist who had helped implement an outpatient system, Denise LeFevre, the new CIO who had started working at Oroville Hospital about 25 years ago while still in high school, the CEO Robert (we can do this) Wentz, CEO and Zach (the ex-pizza guy) Gonzales, now Director of VistA Development.

Initially, they chose Linux over Windows and a non-proprietary data base GT.M was used instead of Cache to complete the open-source stack. The EHR team took classes from consultants to learn the functionality of the system. They learned what they could do on their own and for what they needed VistA clinical application coordinators from various disciplines. They traded ideas with the country of Jordan, which is also implementing VistA. Some of the consultants worked in both places.

In April of 2009 I started using the system in my office practice.  I insisted on a small mobile cart with a small device – I got a notebook, so I could look at the patient no matter where they were in the room.  At first we had “flat templates” which were soon replaced with ones that were more flexible and interactive. The mental work of learning a new system while taking care of patients was a real challenge, which I’m sure is the case for many physicians “of a certain age.” After about six months, I felt comfortable with the system and after about a year and half you couldn’t take it away from me.  Having known that the system would be trialed in my office, I did a time utilization study before and after EHR.  Before EHR, a routine follow-up encounter took about 10 minutes of which total clinical time (including multitasking) was 8:57 and undivided clinical time was 6:22.  Six weeks into EHR a visit took about 16 minutes and total clinical time was almost the same at 8:12, but undivided clinical time had fallen to 3:02. Follow-up visits are now taking about 12 minutes, but I feel the clinical only time has gone up considerably.  My long time patients often say something like “Wow, your typing has improved.”  While the EHR team was working on the inpatient side, over the next two years we added about twenty other clinics including pediatrics.

Slowly our homegrown and consulting geeks, many of whom had vast VistA experience began designing, building and arranging for the necessary components of the system. An interface was constructed for our Sunquest lab system which serves the hospital and many affiliated and independent clinics.  A McKesson PACS system for imaging was installed and integrated with VistA using HL7.  An electronic prescription system was developed from scratch.

Billing was a major issue. The hospital had a well-functioning financial management system and we did not want to interrupt the cash flow, so it was decided it should not be disturbed. Instead, an interface with the billing system was created that sends the needed pieces for billing to a proprietary system.

Even before the EHR was contemplated, the medical staff had been developing paper order sets. By 2011 there were almost 100. They had been designed using a systematic format, so they could be converted with few changes to CPOE. Since the providers were very familiar with them and had participated in their creation, acceptance has not been a significant problem.

Gradually the medical information was linked to VistA so the system would be “VistA-centric”. By the summer of this year the process was almost complete including lab, imaging, and dictated reports. Most recently ECGs, echocardiograms, and ABGs were added. All the nursing notes and most of the progress notes were being documented on the computer. The ICU flow sheet was created using the VA’s CP Flowsheet module and implemented at the same time as CPOE.  It’s complex and slow, but is being improved almost daily and will be used as the basis for anesthesia, obstetrical, and infusion center flow sheets.

UCSF Launches Electronic Exchange of Health Information

On September 1st UCSF Medical Center turned on electronic health information exchange with our Epic electronic health record. It’s an important step forward and one of the features of electronic health records I’m most enthusiastic about. It has the power to improve health not just at our own institution but wherever our patients go. We had hoped to enable this as part of our June 2nd inpatient big-bang go-live, but decided to wait 90 days to make sure some final details were fully hammered out.

Epic has two levels of electronic health information exchange, “CareEverywhere” for exchanging information between Epic customers, and “CareElsewhere” for more limited exchange with a non-Epic EHR. For now we’ve turned on CareEverywhere, connecting us with participating northern California providers like UC DavisStanford, and Palo Alto Medical Foundation, although there’s no geographic limit within the United States for where records can be shared. (With their particular sense of humor, Epic presented this week at their annual meeting on the future “Intergalactic” sharing of health records, emphasizing the point with photos of the Curiosity Rover and The Netherlands)  Our first exchange was at 10am on the 1st when we electronically received records for an ill youth hospitalized at UCSF who had previously received care at Stanford, and we had a dozen exchanges in the first 7 days.

Like always, we only share health information between institutions after getting written permission from our patient.  The large majority of patients want their health information shared electronically with other physicians and hospitals when we need it to provide safe and appropriate care, as long as we are sharing securely. In my experience, my patients are surprised to learn even major hospitals have largely remained isolated islands of information. When I collect permission from a patient to obtain their records from a hospital across town, patients are usually surprised and discomforted to learn I didn’t have access to it already.  Health care is far behind other industries in this kind of information integration, and fixing this in a hurry is a centerpiece of the federal government’s standards for health IT implementation.

For the last few decades health records have been shared primarily by telephone and fax. We call the primary physician’s office (for example) and if we actually reach the physician immediately, we usually get their best recollection of the patient off the top of their head, followed by more complete information by fax hours or days later if at all. If the patient was recently hospitalized, getting that hospital record requires work from that hospital’s medical records department, seldom a 24/7 operation, and it arrives as a thick, grainy, often disordered, fax-of-a-copy-of-a-scan of the original record. This helps, but the information has to be manually transcribed in to our own record, which is only as accurate and complete as any 10-fingered process.

With electronic health information exchange, sharing patient records is more secure and more accurate. The electronic point-to-point connection between institutions is encrypted and the identity of the patient is confirmed electronically between the EHRs. The patient’s health information arrives immediately in our EHR instead of on the tray of a fax machine some unknown number of hours later.  A physician on our receiving end reads and validates the electronically exchanged information before incorporating it in to our own record. The exchange is at the level of data instead of pieces of paper, and so discrete information like medication lists, drug allergies, problem lists, and other pieces of history can be synchronized between the institutions.

Unfortunately we’re still not able to exchange information with San Francisco General Hospital or Kaiser Northern California, two providers with whom we share many patients.  Kaiser Northern California has been on Epic for years, but does not to participate in electronic health information exchange. San Francisco General is moving fast on implementing its own electronic health record, and we look forward to connecting with them when the capability on both sides is ready.

Seven tips to prevent medical technology from ruining the doctor-patient relationship

Does this sound like something that has happened to you?  You are driving, you stop at a red light, and all of a sudden you find that your iPhone has migrated its way from your pocket or the passenger seat of the car into your hands.  You push an elevator button and pull the phone out of your pocket to glance at it in that split second while waiting for the door to open.  You eat dinner with a group of six friends and everyone is buried in Facebook rather than making eye contact.  In all facets of life, we are quickly becoming more entangled with our machines, allowing them to become extensions of ourselves.  The hallowed walls of the doctor’s office have not shielded out this rising tide.  This “Piece of my Mind” by Elizabeth Toll in the June 20th JAMA eloquently captures what so many of us have been feeling and seeing over the last few months and years.  Here is an excerpt of her opening paragraph and the drawing she discusses:

Dr. Toll goes on to discuss how this particular physician is someone overflowing with empathy for patients and enthusiasm for medicine.  Unfortunately, the computer has now demanded his attention, which he can no longer fully devote to his patient.  I agree wholeheartedly with Dr. Toll and I hope that her article will spark a dialogue about this issue in the medical community.

Part of the problem is the current generation of electronic health record (EHR) systems.  They demand too much cognitive effort to use.  In fact, Horsky et al showed that users of a CPOE system used twice as much cognitive effort on system operation as on patient-centered clinical reasoning.  This balance has to shift.  Nobody wants her physician wasting his energy and focus like this.

This improvement in EHRs will happen.  As was pointed out on Twitter this morning by @ReasObBob: “#EHRs will get better. Poor EHRs are not the problem but the symptom. New approach needed. We’re working on it.”  Bob is right.  The current generation of EHRs has been built to meet the demands of a healthcare system that is focused on compliance and billing.  We got what we asked for.  This time around, let’s ask for what we really want.  Let’s ask for EHRs that are sleek and streamlined, easy to use, and that augment the high-quality and high-empathy medical care we want to provide.

What are physicians to do in the meantime?  I have spent some time in the last few years thinking and reading about this.  How can we best maintain the doctor-patient relationship in the age of the EHR?  I offer you seven tips:

1) Set-up your office properly, with placement of the chairs, monitor, and keyboard to best support good eye contact between you and the patient.  Don’t allow your office to become like this drawing, where your chair could put your back to the patient.  This is common sense, not Feng Shui.  (I will post some photos of exam rooms at the bottom of this blog piece to allow you to start to think about what works and what does not work)

2) Get a quiet keyboard.  If you think this sounds trivial, try this: Spend one day in your clinic using a loud keyboard and then switch to a quiet one.  You’ll see.

3) If you can, spend thirty seconds preparing the electronic visit before you walk in to see the patient so that you are ready to hit the ground running.  You want to be immediately ready to let a patient start talking to you without interruption to start the visit.  Visits get off to a bad start when they go like this: “So, what brought you in here?”  “Well, my thyroid…” “Hold on a minute, I have to log-on and get a new progress note open so I can write down what you say.”

4) Let the patient see your screen.  Hopefully you are not reading ESPN.com when you are talking to your patient.  Let them share the experience with you, and share the fact that you are populating their medical record.  I have on many occasions had this lead to bonding moments with my patients when we are both hunting through the CPOE (computerized provider order entry) system for a particular type of glucose test strip prescription or some other seemingly hidden or obscure task.

5) For part of your visit with the patient, stop typing, take your hands away from the mouse and keyboard, and use the body language we learned how to use as first year medical students in Introduction to Clinical Medicine.  Every visit has at least one natural moment when the patient has to be certain that one-hundred percent of your attention is focused on her.

6) Practice.  Seeing patients while using an EHR is a learned skill.  None of us were able to handwrite a perfect note while talking to a patient the first day of medical school.  The new generation of medical students will learn how to talk to patients while typing from day one.  At UCSF, the new Kanbar Teaching and Learning Center has simulated exam rooms to help medical students learn this (although, embarrassingly, you’ll notice in the photos on their website that the computer monitors are buried in the corner of each exam room, assuring the “back-to-patient” syndrome).

7) Remember that this is our chance to take back the medical record.  Let us not forget that, even with paper charts, the medical chart has increasingly become about legal protection, billing, and reimbursement.  The EHR gives us a clean slate, a new opportunity that brings us legible notes and notes that are immediately visible to colleagues.  Take advantage of this.  Write good narratives.  Tell your patients’ stories.  Make the medical record useful again.

Sample photos of exam rooms

                     

Epic Go-Live at 1 Month

We’ve been live on Epic now for a little over 1 month. Our newly-minted interns started work on June 21st and a flock of new upper-year resident physicians and fellows began July 1st.  One of the most enjoyable aspects of practice at UCSF is the phenomenal quality of students and trainees we attract, and as hoped, our new trainees have taken to the EHR and computerized provider order entry especially smoothly. In some respects they are more comfortable with the workflows than the senior trainees who directly supervise them because the new arrivals have no prior expectations from how things at UCSF used to work. We also have the advantage that something like one-third of our new trainees come from a hospital system that was itself an Epic customer.

Total call volume to our “provider” (physician, NP, and PA) and general help desks, starting with the go-live date.

The interaction between Epic CPOE and our lab and radiology systems continue to have some challenging wrinkles. Epic offers an integrated laboratory system called “Beaker” and a radiology system called “Radiant”. (Epic likes to give cute names to its software components) For reasons of project scope among others, we chose to stay with Sunquest and IDX/Rad for lab and radiology (respectively) for the time being. Although these are each leading systems and widely used elsewhere, the workflow integration between Epic and these ‘outside’ systems remains a work in progress in edge-case scenarios.

The only workflow to date we’ve backed out of is using Epic to satisfy the CMS requirement for an attending physician to document their face-to-face evaluation of an inpatient to qualify them for home care. We built this in Epic as an ‘order’ with all the required elements, and the Case Manager could tee this up (‘pend’ it in Epic jargon) for the attending’s review and signature. For reasons of workflow and the competition for attention, we’ve backed off on having this be electronic for now and reverted to the paper form.

The next piece of functionality we aim to turn on is health information exchange. Epic calls this “CareEverywere” for data-level exchange between Epic customers and “CareElsewhere” for the exchange of CCD documents with non-Epic EHRs.  Once we throw the switch on CareEverywhere we’ll be able to exchange data with other Epic customers, including our fellow University of California Medical Centers in Sacramento (UC Davis), Los Angeles, and San Diego, and with our respected colleague-competitors at Stanford. Health information exchange will be a signature advance in our service to the community, but at first the clinical impact will be modest because we share relatively few patients with these sites.  Of the main regional health care systems, we share the most patients with Kaiser-Permanente, San Francisco General Hospital, and the City-operated Department of Public Health clinics. However, although Kaiser-Permanente is also an Epic customer and participated in health information exchange in Colorado, their northern California region opts against health information exchange outside the Kaiser system. San Francisco General Hospital and the DPH clinics are underway with their own (non-Epic) EHR projects, and I hope to see us sharing CCD documents with them once the technical ability on both sides is in place.

Go-live Week 2 – good numbers, and the triple intersection of complexity

We’ve been live on Epic in inpatient now for two weeks and we’re cautiously very happy with our results. Direct entry of orders by physicians is stable at just over 90%, with the balance being orders written on paper in settings we planned for (chemotherapy and pediatric TPN) and verbal or telephone orders.  We’re digging in to our live data on verbal and telephone orders to see how they cluster and how we can continue to reduce them. Revenues remain within the margin of variation, and our near-term clinical metrics (door-to-floor, average length of stay, etc) are unchanged to slightly improved. The very interesting clinical outcomes, like rates of medication error or risk-adjusted mortality, await more data.

Our knottiest workflows in the system are what Epic calls (a little strangely) “Hospital Outpatient Departments”. These are facilities that serve both inpatients and outpatients, like interventional radiology and the endoscopy suite, and so require a mix of inpatient and outpatient workflow and software. If the patient needs full anesthesia for the procedure, as is often the case with child patients, you have a triple-intersection of complexity. In our paper-based prior existence this was all smoothed over by smart people with lots of institutional knowledge and the right relationships. They knew how to get anything done. In preparing for an integrated EHR we put a great deal of effort in to analyzing this work prospectively, but the magnitude of change brought by automation has had unintended effects. No surprise, and we’re crunching through all those processes again with the benefit of experiencing the system in real life, and the problems continue to look solvable.

Meanwhile our clinicians continue to ask deeper and more interesting questions about the system, moving from “How do I get my job done?”, to “How do I manage this complex discharge?”, and on to “Our Division wants to start publishing custom packages of SmartLinks and we want to send people to Wisconsin. Whom do we talk to?”

[ Special welcome to the Twitter followers of UCSF Division of Hospital Medicine chief Bob Wachter, physician-leader extraordinaire and blogger at Wachter’s World. ]

Charting on the Problem List

Still in its early stages at UCSF, one week old as of today, is inpatient documentation centered heavily around the Problem List.  This has been used by some providers in the ambulatory setting over the last year, but is now being used nearly universally on hospitalized patients.  Rather than writing an assessment and plan as free text at the bottom of an admission, progress, or consult note, each relevant item on the hospital Problem List will now have a unique assessment and plan note written specifically about that item.

This has several potential beneficial effects:

1) Sharpening a physician’s diagnostic thinking.

2) Improved continuity-of-care and ability to review a patient’s chart.  Currently, if a patient named Bob has COPD and you want to find out what has been done over the last ten years for his COPD, you have to sift back through every old note in the chart, looking for the ones where COPD was discussed.  Very time-consuming.  With the Problem List approach, Epic allows you to “View All Notes” for any given item on the Problem List.  This means that with a single click, you can conjure up every assessment and plan note written specifically about Bob’s COPD, whether from the ED, ambulatory clinic, or inpatient setting, going back through time.

We think this is a very powerful tool and are excited to see it begin to improve care.

Go-Live Day 5 – the Complexity of Security and the Madness of Printers

We’re five days in to our go-live and continuing to maintain all our expected workflows on the system. Our CPOE rate hit 90% today, the balance being orders written on paper for expected reasons (Pediatric TPN and Chemotherapy) and telephone or verbal orders. Our ED door-to-floor time is about expected, neither better (yet) nor measurably worse. Revenues are within the margin of variation.

Below are the trouble tickets called in to our service desk broken out by category.  As anticipated the large majority of issues are users whose security is not set up perfectly for their role.  Security settings in Epic are very customizable and, it has to be said, enormously complicated. When I took the Epic security class in Madison it reminded me of the nephron.

Next in the stack is “optimization” which for now doesn’t count as trouble, and third on the list is printing.  With the incredibly powerful things we can do with technology, like order and document extracorporal membrane oxygenation on a premature infant clinging to life, I find it remarkable that printers everywhere continue to be such a pain. No amount of rigor and testing (and we did a lot of testing) here or elsewhere can seem to entirely decomplexify them.

Graph of the Trouble Ticket categories for UCSF's Epic go-live

Trouble Tickets by Category