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.

Go Bruins – UCLA Goes Live Tonight with its “CareConnect” Epic Electronic Health Record

Big BruinAt midnight tonight UCLA Medical Center will go live with CareConnect, their name for their implementation of the Epic electronic health record. With this, four of the five University of California Medical Centers (Davis, San Diego, San Francisco, and Los Angeles) will have the same EHR infrastructure.
A handful of us from San Francisco, including my colleagues Carolyn Jasik, Ellen Weber, David Robinowitz, and I, are spending four days here helping support their clinicians and their go-live team. The two institutions have a lot in common, and several physicians from UCLA visited UCSF during our go-live to provide support and meet with our leadership team. It will be fascinating to see the similarities and differences in our respective builds and in how the clinicians work through their first days with the system.

UCSF Goes Live with Teen Patient Portal

by guest author Carolyn Jasik, MD

A major ambition of health care informatics is to enable patients to be more engaged in their own care. One avenue to give them online access to their electronic health record. At UCSF, our adult patients have had access to their EHR using UCSF MyChart since April 2011. Parents can also use MyChart to access the health records of their children aged 11 and under.

Access to the EHR of a minor age 12 through 17 gets more complicated.  I’ve invited a member of our informatics leadership team, Dr. Carolyn Jasik, to post about these issues and describe UCSF’s solution that goes live today. Dr Jasik is an Assistant Professor of Pediatrics specializing in adolescent health behavior change. She publishes in preventive health and confidential care for teens, and led the development of inpatient pediatric provider content for our EHR.  Dr Jasik has been the driving force for UCSF’s Teen Patient Portal.  – RC

Starting this morning, teens who receive primary care at UCSF can sign up for private access to their electronic health record through UCSF’s patient portal, based on Epic’s MyChart.  This is a remarkable achievement for an institution that is still adjusting to the changes in daily work throughout the hospital after our Epic inpatient “big bang” 7 months ago.  As institutions across the country race to implement EHRs to take advantage of federal incentives such as Meaningful Use, innovative features often take a back burner to keeping the lights on.

Guest blogger Dr Carolyn Jasik, Assistant Professor of Pediatrics at UCSF

Guest blogger Dr Carolyn Jasik, Assistant Professor of Pediatrics at UCSF

In California, and many states across the country, a teen can consent for confidential medical care for certain medical needs such as contraception, testing for sexually transmitted diseases, and pregnancy care.  This means that, under the law, their parent cannot have access to these records.  Traditional patient portal implementations for pediatrics have parent-only access, where the parent sees the child-patient’s entire record. However, because of the legal requirements for confidential care of teens, most healthcare providers either severely limit parents’ access when their child reaches adolescence, or they turn off the portal completely.  Only a few institutions have allowed teens access, but usually this access is limited to messaging only.  These limited versions still meet meaningful use requirements, but they deny teens and their parents access to the full potential of the EHR.  This is in conflict with recommendations by both the American Academy of Pediatrics and the Society for Adolescent Health and Medicine about the importance of the EHR advancing adolescent health.

At UCSF, our patient portal now allows the teen and parent to have separate access to messaging, lab results, diagnostic imaging results, appointment requests, and immunizations, but only the teen can see medications, request refills, appointments, and their health summary.  The separate access is to protect the privacy of adolescent confidential care as required under California law.  We look forward to leveraging our teen portal for educating teens about their chronic disease, improving our no show rates (highest in our teen patients), and assisting them in their transition to adult care.  So how did we make it happen?  The real answer is it just makes sense when you consider the clientele.  But the back story is a combination of a geography lesson, federal incentives, passion, and timing.

The MyChart configuration started with standard proxy settings, plus a little custom build.  The table below summarizes the patient portal functions available by user.

Content Parent Proxy
0-11 yrs
Parent Proxy
12-17 yrs
12-17 yrs
Immunizations YES YES YES
Allergies YES YES YES
Growth Chart YES YES YES
Messaging to and from provider* YES YES YES
Appointment Request YES YES YES
Appointment View YES NO YES
Problem List/Summary YES NO YES
Medications/refill request YES NO YES

* Parent and teen can send private messages to the provider.

The teen and parent lab view is shared, but we withhold certain lab results, such as pregnancy testing, OB ultrasound, and a few others, from displaying for patients ages 12 to 17.  We allow parents to send appointment requests, but not to view current appointments.  We investigated defaulting only one recipient (the adolescent) for messages from the provider to the patient, but this was not possible due to limitations of the software.  Finally, we turned off online appointment requests for clinics that provide exclusively confidential care for teens, since the appointment request field is shared between patient and parent and includes the clinic name.

Perhaps the most important step was extensive provider training – including in-services, webinars, and email notifications – on how to properly send messages to patients and parents.  We also completed an extensive internal review with our legal, privacy, and risk management departments to make sure we identified all potential areas of risk for violation of confidentiality.  The Adolescent MyChart build at UCSF would not have been possible without the expertise of our lead portal analyst, Kathy Lehto, project manager Alisa Armstrong, and Sacheen Drucker and Deborah Yano-Fong from our Privacy Office.

Teens are pros at sharing and receiving information virtually.  Any parent of a teen knows that sharing personal information via text or Facebook is, for a teen, on par with an in-person conversation.  So why not also virtually connect with their medical provider?  To provide patient-centered care for adolescents, we will need to be more flexible in how we interact with them.  In addition, their health status is linked to decisions, behaviors, and environmental influences that occur way beyond the clinic walls.  To extend our reach only strengthens our ability to improve health.

We made the decision to give teens their own access, and to make them able to see their full record, because we think it’s the right thing to do and it’s where we see patient-centered health information technology going.  Our teen patients are already thriving in a rapidly changing virtual landscape.  As we envision a future with these kids as our adult patients, we don’t want them to be left behind.  Stay tuned, we are just getting started.

If you are a parent or teen and want access to the UCSF Adolescent MyChart, please contact your provider’s office for details.

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. ]

Go-Live Day 7 – A power outage, just because

Its our 7th day live on Epic in our inpatient areas, and at 1522 we lost commercial power. The rumor so far is that PG&E has had a substation go down and power is out for several blocks at least. Our clinical areas are equipped with multiple layers of emergency power and are fine, as is our phone bank for supporting clinicians, but here at the Command Center in UC Hall we’re in the dark for now.

Update – the word on Twitter is that power is out all the way to 19th Avenue (we are at 3rd Avenue) with 11,000 customers blacked out.

Update #2 – San Francisco Chronicle confirming.

Update #3 – power is back on after 55 minutes.

Photo of the Epic (Apex) Command Center at UCSF during blackout