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Friday, May 15, 2009

Training the EMR: A Case-Based Perspective

Part One of a Four-Part Series

I have had some interesting and intensive encounters with hospitals in the past six months. I am currently sitting in the rarified atmosphere of the Johns Hopkins Hospital in Baltimore, MD. My family and I are in the Family Surgery Waiting Area while my brother is two hours into a craniotomy for removal of a brain tumor. Only last December I spent about ten days on the East coast hanging around the Neuro ICU at Fairfax Inova Hospital in Virginia. In between I briefly worked as a trainer for a Electronic Medical Record System at a brand new hospital built by a local outpatient care organization in our community.
While I did work in a university student health center for two years in the 90's, my exposure to hospital acronyms was limited mainly to those we hear on television shows like ER, Scrubs, and Grey's Anatomy - ones like, well, ER and Code. Now I can add the acronyms that didn't sink in: PACU, Pre-Op, Peri-Op, NICU, NCCU, PICU, PCU, ED, etc - as well as sort out the ones that are unique from the ones that are interchangeable.

I'm still trying to sort out what purpose all this exposure to the medical field serves - what are the lessons I'm meant to learn, what tools are meant to accompany me in service down the road. I have a feeling I'll be discovering the answers to those questions for some time to come.

The timing was perfect, in certain respects, for the job opportunity I got at the new hospital. Last fall's historic presidential election has moved healthcare reform back to the front of the line, and along with it, the potential of the EMR to improve patient safety, provide better medical care, and to provide efficiencies that will help us in our quest for affordable health care.

The new hospital raised the banner high with their EMR - even though their quest to go paperless has, in actuality, resulted in their being "paper light" (to quote a colleague). However, they are still closer to a completely electronic medical record than any other hospital in their network, including some of the larger ones. Healers also raised the banner high in terms of patient-centered care. Over their past 50 some years of existence, the health care organization started a system of outpatient and urgent care and specialty clinics in our community. Building a new hospital to go along with those clinics represents a bold vision of providing integrated outpatient/inpatient healthcare for the community. The hospital itself provides a lovely healing space that includes private rooms with beds for family members to spend the night, accessible bathrooms complete with roll-in showers and toilets with bidgets, full time supervision by a clinician rather than use of restraints, and a cafeteria system where both patient and family can order from a menu and have meals delivered to the room. In mid January my husband spent a relatively comfortable night there (under the circumstances) after his hemorrhoid surgery and he loved it. The hospital still sits at this point in the middle of a cornfield where the winds blow across the prairie.

The hospital also raised the banner high in terms of management philosophy - they wrote a unique "healer's compact," in which all employees are considered practicing healers in every interaction they have with one another and with the patients they serve. It makes sense to me - even though my previous IT role at the university student health center wasn't clinical, it seemed natural to view ourselves as an extension of the clinical arm, subject to the same rigorous performance expectations requisite in so critical a field. Some of my favorite parts of the healer's compact are "practicing forgiveness, always assuming the best of intentions on the part of your colleagues, and embracing the healer - including being patient with yourself." It's an enlightened, inspiring, and holistic management philosophy that sadly has been somewhat trumped by the the parent organization's "Quest for Excellence" initiative that was rolled out shortly after I started. Our CEO told us that in essence, it was the same thing. It wasn't. However, our orientation package fortunately included a copy of the compact and our orientation class covered it in some detail. I was disappointed that I didn't get to cosign it with my supervisor and departmental colleagues for my personnel file as the orientation materials stated. Or that some of my colleagues, particularly the hired consultants, hadn't been introduced to it as well.

Ah, ideals and the process of translating them into reality - we tend to forget it's a pioneering thing that involves a lot of blood, sweat, and tears. And sacrifice, life, and death. We all hope to reach California, but some will inevitably die along the way. But, whether we reach our final destination, or our journey ends along the path, in the end we can count ourselves among those who helped break new ground for others to follow.

So before we continue, let me make very clear that I am not a health professional. I have only served a bit over two years providing technical services in support of that profession. This post on the EMR does not represent expert medical opinion. I just wanted to reflect on this exciting new development in the light of my recent encounters with the medical field and my cumulative thirty some years of experience and study in the fields of education, systems analysis, and instructional design. With a masters in educational technology, an A.A.S. in computer programming technology, a bachelor's in education, and experience helping various departments and organizations, including health organizations, pioneer and leverage technology, I feel I have reached a stage in my professional life where I am able to have an informed opinion and perspective about instructional and systems design.

That being said, I believe the EMR is still in the pioneering stage of development. And pioneering is the operative word when we consider ideals versus actuality. When I was growing up we couldn't imagine ever having the capabilities we have today. Calculators, desk top computers, and cell phones seemed a school child's pipe dream. Back then (I was born in the exact middle of the 20th century) we couldn't even imagine what to do with these things. But being born in 1950 put me in that fortunate position called the catbird's seat, inasmuch as it enabled me to watch a whole field evolve and "grow up". As a (relatively) young adult, I was able to ride the wave of the desktop revolution - from the very first isolated Dos (desktop) machines all the way to today's ubiquitous and inter-connected Windows, Macintosh, and Linux workstations, cell phones, palm tops, ipods, mp3 players, televisions, land lines, and even automobiles.

So it's only natural that I should see similarities in where the EMR is today with where we were at the eve of the Desktop Revolution. Remember those good ol' days (if you were there)? Remember when we had Word Star and Word Perfect and Word to mention only a few of the available word processors? Remember VisiCalc, Quattro Pro, Excel, and Lotus 123 to mention a few of the spreadsheets? Remember dBase, Fox Pro, Borland, Oracle, Double Helix, and FileMaker being among the various database packages from which to choose? All with different interfaces, all from different vendors? Remember when we started to get DOS and Windows machines talking to Macs - and when we had to find ways to share documents between Word and Word Perfect? Remember what a crap shoot it was trying to figure out which software to invest in - which one would have the staying power and dominate the market share? Remember the days before standards and shared objects and usability studies and common interfaces? Remember the days when uploading PC data to legacy mainframe applications represented a big step forward, second only to downsizing mainframe applications to PC-Based applications?

To me the EMR is very much in the same place as the desktop revolution through the 80's and 90's. Only 5% of hospitals across the country even have an EMR. And it is not the same EMR. So in the iterative process of design, I look for lots of changes to occur in the EMR as it evolves over the next ten to twenty years. Based on the past we can assume and almost predict the direction it will take with the development of common medical objects, languages, and interfaces - and degrees, jobs, curriculums, and training programs.

A case in the EMR's current state of complexity is the new hospital where I was recently employed. Before the out-patient organization in our local community built their new hospital, they joined a larger network of hospitals based in our state capitol, a large metropolitan area. Standardization and hierarchy become important matters in such mergers - even with, or perhaps even more so with Joint Commission. Standardization resulted in the new hospital going with the parent organization's EMR software, (Cerner), while the outpatient clinics stayed with their EMR software (Epic). And that's the story of how our local organization with its bold new integrated inpatient/outpatient healthcare system ended up split down the middle with their EMR. One integrated inpatient/outpatient healthcare system. Two, count 'em, TWO different electronic medical records - from two different vendors - two different systems - two different interfaces - trying to share data about the same patient ... no wonder it feels like a rendezvous with the 80's.

Another complexity is that it's difficult to convince people to pioneer and Clinicians are people. When the new hospital started in October, Benny and I received letters from our doctors stating that they were going to practice only at the new hospital. Well, no wonder. There are two hospital systems in our county, and more in outlying areas. If you have to pioneer, albeit kicking and screaming, then at least try to simplify the challenge. Who wants to go to five different hospitals and have to learn five different systems just to be able to look at a patient's chart? In a way, access to medical information has become (at least temporarily) more complicated via electronic charting, even though everyone recognizes the long term potential of the EMR to make medical information more instantaneously and widely accessible.

In April, our new hospital had to back off some of its Computerized Physician Order Entry policies and requirements because the facility was not operating at capacity and was losing money. Part of the problem? Locums (local physicians) were reluctant to bring in patients and to practice at the new hospital because of the "perceived difficulty" of learning / using the unfamiliar EMR.

Multiply this scenario by similar birthing pains across all the cities, counties, and states in the country and around the world, and we can begin to surmise how profoundly the medical field and profession is being affected by change. Add to that the mix of new employees needing training that I observed at the new hospital - lifelong practitioners who are not conversant with computerized systems versus newer clinicians who have had previous experience with them. You might want to ask yourself, as a patient, who would I rather have - an experienced and compassionate clinician or a clinician who is computer savvy? (yes I realize there are variations in between - just answer the question.) What about technology dependence? Would you rather have the clinician who is computer savvy or one who chooses to exercise their critical thinking skills in a technological setting? And you may want to ask yourself - who and what is driving the hiring decisions that prizes the one above the other?

And so it just goes to show the complexity of implementing the reality versus the simplicity of the ideal. It also hints of the opportunities and possibilities and pitfalls created in the new frontier of the EMR. Which brings me back to my brother's surgery - which in the end turned out very well amidst all the other families sitting around us in shared crisis. While I can step away from this article and then return to "word smith" it to my heart's content, that brain surgeon who operated on my brother had only one chance to get it right.

JuneBug's Blog

On to Part Two in the series on Training the EMR: A Case-Based Perspective - Drilling Down

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