Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Latest Posts

The Last Zombie Conversion: A Final Look At Paper Medicine And Some Advice For EMR Vendors

The digital revolution in healthcare has transformed most hospitals into EMR-dependent worksites, dotted with computer terminals that receive more attention than the patients themselves. I admit that my own yearning for the “good old days” was beginning to wane, as my memory of paper charting and a patient-focused culture was becoming a distant memory. That is, until I filled in for a physician at a rural hospital where digital mandates, like a bad zombie movie, had bitten their victim but his full conversion to undead status had not been completed. At this hospital in its “incubation period,” electronic records consisted of collated scans of hand-written notes, rather than auto-populated templates. I’m not necessarily recommending the return of the microfiche, but what I experienced in this environment surprised me.

1. Everyone read my notes. Because everything I wrote was relevant (not just a re-hash of data from another part of the medical record), reading became high-yield. Just as people have adapted to ignoring internet advertising (Does anyone even look at the right hand rails of web pages anymore?), EMR-users have become accustomed to skimming and ignoring notes because the “nuggets” of useful input are so sparse and difficult to find that no has time to do so. The entire team was more informed and up to date with my treatment plan because they could easily read what I was thinking.

2. I was able to draw diagrams again. Sometimes a picture is worth 1000 words – and when given a pen and paper, it is great to have the chance to quickly draw a wound site, or visually capture the anatomical concerns a patient may have, or even add an arrow, underline, or circle for emphasis. Thorough neuro exams are so much easier to document with stick figures and motor scores/reflexes added.

3. I could see at a glance if a consultant had stopped by to see a patient. It used to be customary for specialists to leave a note in the paper record immediately after examining a patient. If they didn’t have time to jot down a full consult, they would at least leave me their summary statement – with critical conclusions and next steps. It was a real time-saver to know when a consulting physician had evaluated a patient and get their key feedback if you missed them in person.

Nowadays consultants often see patients and order tests and medications in the EMR without speaking to the requesting attending physician. It may take days for their notes or dictation to show up in the electronic medical record, and depending on the complexity of the system, they may be nearly impossible to find. The result is redundant phone calling (asking the consultant’s admin, NP, PA etc. if they know if he’s seen the patient and what the plan is), and sometimes missed steps in the timely ordering of tests and procedures. At times I simply resort to asking the patient if Dr. So-And-So has stopped by, and if they know what he was planning to do. This doesn’t inspire confidence on the patient’s part, I can tell you.

4. I could order anything I wanted. EMR order entry systems force you to select from drop down menus that may not reflect your intentions. When you have a pen and paper – imagine this – you can very clearly and accurately capture what you’d like to order for the patient! There is no confusion about drug taper schedules, wound care instructions, weight bearing status, exercise precautions. It’s all as clear as free text. You can even explain why substitutes are not acceptable, thus heading off a follow up pharmacist call.

5. The patient became the focus. Since I didn’t need to spend all my time entering data into a computer system in real time, I was able to focus more carefully and clearly on the patients. My attention was not constantly being distracted by EMR alerts, unimportant drug interaction warnings, or forced entry of irrelevant information in order to complete a task. I felt more relaxed, I had more time to think, and I got more important work done.

In conclusion, it is obvious to me that we have a long way to go in making EMRs fit our natural pre-zombification hospital workflow. At the very least, we should be developing the following tools:

1. We need better ways to separate the signal from the noise. Even something as simple as a different font color for the new information that we doctors enter (in a given progress note) would help the eye latch on to what’s important. There should be a simple, visual way to distinguish between template and free text.

2. We need a pen feature that allows authors to signify emphasis. Wouldn’t it be nice if there could be an overlay that allowed us to circle words or add arrows or underlines? If the TV weather man can do this on his digital map, why can’t EMRs allow this layer? For example, physicians would like to circle lab values that are changing, and indicate the direction of change.

3. We need boxes where we can draw diagrams. A simple tablet function would be easy enough to enable. Sure it would be nice to have a stylus, but I’d settle for mouse or track pad entry. This is not a feature of most EMRs I’ve used, but could easily become one. Perhaps not everyone will want to use this feature, but for the artistic among us, it would be a god-send.

4. We need a Four-Square check in type feature so that physicians immediately know if their patient has been seen by the requested consultants. Their impressions should be quickly accessible (perhaps with a voice text to the ordering MD) while their formal consultation notes are grinding their way through the system days later.

5. We need to pare down the unnecessary EMR alerts, and off load data entry required to meet billing requirements to non-clinical staff. Physicians need to focus on their patient care, not spin their wheels figuring out coding subtleties and CMS documentation requirements that could be completed by others.

6. We need more flexibility in data order entry – so that treatment intentions are captured, not forced into an ill-fitting box. Currently, physicians are finding ways to free text their orders in bizarre “work arounds” just to get them on the record somewhere. This is a recipe for disaster, as lost orders are fairly commonplace when staff aren’t on the same page regarding where to look for free text orders. I feel badly for the nurses, since “note to nurse” seems to be the favored way to enter a complicated pharmacy order.

I am grateful that I got one last look at hospital care as it used to be – so that I can put my finger on why our new digital system is not working well. I just hope that my suggestions help to make processes better for all of us medical zombies in the new digital world.


More advice for EMR Vendors here.

Pluses and minuses of EMRs.

American Academy Of Pediatrics Endorses Guidelines For Checking LDL Cholesterol Levels In Kids

Why would a pediatrician draw blood from your 9-, 10-, or 11-year-old at his or her next annual wellness visit? Because the American Academy of Pediatrics (AAP) recently endorsed updated guidelines that call for checking LDL (bad) cholesterol levels in all kids between the ages of 9 and 11.

The cholesterol-test recommendation created quite a stir. But wait, there’s more. The guidelines also call for annual blood pressure checks beginning at age 3, and periodic blood sugar measurements starting between ages 9 to 11. There’s also a strong recommendation for kids and adolescents to limit sedentary screen time to two hours or less per day, and to get at least an hour a day of moderate physical activity.

The biological basis for these guidelines is that atherosclerosis (the fatty gunk in arteries that causes heart attacks, strokes, and other serious problems) starts during youth. In many cases, Read more »

*This blog post was originally published at Harvard Health Blog*

It’s Not Too Late for You AND Your Patients to Get a Flu Vaccine

Getting a flu vaccine is on many “to do” lists in the fall, but for those who still haven’t checked it off their list, it’s not too late to get vaccinated. Many people don’t realize that flu activity usually peaks in the United States in January or February, and flu viruses can circulate as late as May. As long as there’s flu around, it isn’t too late to get vaccinated.

Getting a yearly flu vaccine is the first and most important step in protecting against the flu, and CDC recommends influenza vaccination for everyone age 6 months and older. We urge you and all health care professionals to get vaccinated yourselves and offer flu vaccine at every opportunity to every patient—except infants younger than 6 months and the very few people for whom flu vaccination is contraindicated.

Studies show that your recommendation makes the difference in your patients’ decision to get a flu vaccine. You should continue to emphasize the importance of flu vaccination for your patients. And, if you don’t already do so, consider offering flu vaccines to patients in your own practice, even if yours is a sub-specialty practice and you don’t see yourself as a vaccine provider. Even if you don’t offer flu vaccines, you can still recommend and emphasize the importance of flu vaccination as a way to keep your patients—and their families—protected throughout the season.

As promising as it is sounds that flu vaccination rates are increasing among children and healthcare personnel, Read more »

*This blog post was originally published at Safe Healthcare*

Guidelines For The Treatment And Prevention Of Frostbite

Led by Scott McIntosh, MD and his colleagues, the Wilderness Medical Society has published “Practice Guidelines for the Prevention and Treatment of Frostbite” (Wild Environ Med 2011:22;156-166). These guidelines are intended to provide clinicians about best evidence-based practices, and were derived from the deliberations of an expert panel, of which I was a member. The guidelines present the main prophylactic and therapeutic modalities for frostbite and provide recommendations for their roles in patient management. The guidelines also provide suggested approaches to prevention and management of each disorder that incorporate the recommendations.

In outline format, here is what can be found in these guidelines: Read more »

This post, Guidelines For The Treatment And Prevention Of Frostbite, was originally published on by Paul Auerbach, M.D..

Will Doctors Actually Change Their Recommendations Given The New Cancer Screening Guidelines?

Cancer. Just the word is scary. Actually, that’s the problem. Once you say that word, the average American will do anything — ANYTHING! — to just get it out of my body!!! Whether or not they have it, whatever the actual numerical chances of their ever developing it, no chance for detecting or treating it should ever be neglected. EVER! Ask any Med-mal lawyer. Better, ask any twelve average people off the street (i.e., the ones who are going to wind up on a jury). “The doctor didn’t do every possible test/procedure, and now the patient has CANCER? String him up!”

Hence we have the new guidelines for PSA testing. (Given that many patients with prostate cancer have normal PSAs and lots of patients with high PSAs don’t have prostate cancer, it doesn’t seem semantically correct to call it “prostate cancer screening”.) Surprise! Turns out that not only does PSA testing not save lives, but that urologists don’t really care. Certainly not enough to stop recommending PSAs to just about everyone they can get their hands on.

Nor do breast surgeons have any intention of modifying their recommendations, not only in light of new understandings of the limitations of mammography, but even as Read more »

*This blog post was originally published at Musings of a Dinosaur*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »