An Electronic Health Record misAdventure

We thought we were ready. We had all our training. The staff was pumped. The doctors were apprehensive but willing. Tuesday morning "GO LIVE" began. Fortunately the hardware folks just happened to be in the office installing our dual monitors, so there were two techs present when none of our medical assistants (MAs) could access their tablets. Uh oh...

Shortly into the day our office manager discovered that the stand-alone electronic prescribing software we'd been using for years had been turned off since Friday and prescriptions sent electronically since then had never made it to their destinations. Patients were calling. They weren't happy. And we had no way of knowing who they were because our workflow is to fill the prescriptions, document in the chart and file. Uh oh...

Meanwhile, my MA was still unable to use her laptop to triage my first patient. I was waiting...Dr. K had seen a patient, documented most of her note but she could not put in the plan for some reason. This was a problem that went on all day until it was determined that her 'profile' was corrupted. IT promised a fix by the next day. Uh oh...

Remember being told to "save, save, save"? Dr. I, not big on computers to start with, was humming along only to find out that one of her electronic notes, on a complicated patient, had vanished into the ether due to a Citrix glitch, never to be found again. She was nearly in tears. Uh oh...

Finally, my MA had a patient ready for me to see. Only an hour behind. It was a young man, a new patient in for what the scheduling staff was told was an uncomplicated physical. I remember being told that this patient was perfect for the first day on EHR "He's young and healthy, a great start to using the Health Maintenance Template". Except that he was drinking a pint of bourbon daily with a blood pressure through the roof, a urination issue, chest pain and was anxiously depressed. Uh oh...

It is very difficult to have one's attention divided by electronics when it needs to be concentrating on a real person's medical issues. If I had to grade myself with how well that first patient was treated by me, it would be close to failing. It felt like a return to medical school--working blind, feeling incompetent, trying to speak two different languages at once (electronic and paper) and never quite sure anything was being done well.

Rumor has it our skills will improve over the next year. My hope, as one of the first primary care offices to go live in our organization, the technical support staff and the doctors can help other offices begin this journey with a refined send off.

This is a hospital "go live" but still hilariously hit close to home:

Dangerous 18 Hours Shifts in Nursing Homes

A nurse friend of my husband's was recently let go from a Kentucky nursing home for medication mistakes made while working two back-to-back, weekend, eighteen-hour shifts. I didn't believe that was possible under labor laws but I can find no maximum labor law covering how long people can be asked to work.

I'd be curious to know if this is a common practice in other places. I found this document, put out by the  Department of Health and Human services, that described nursing homes using 16 hours shifts as non-traditional, flexible hours for employees. By the time you add in breaks and lunch, I assume this is the same scheduling my husband's friend was talking about working. There is no suggestion in this document that these hours might be dangerous to patient health. There are well documented studies illustrating the increasing errors that occur when nurses work more than 12 hour shifts[1].

Even if an individual conscientiously gets enough sleep prior to one 16-18 hour shift, there is not sufficient time to sleep enough when shifts are back-to-back on a weekend. The nurse described here found her abilities slipping, particularly as she entered the end of the second shift.

This kind of care is unconscionable and has no place in the care of our elderly population.

1. Roger,Ann. The Effects of Fatigue and Sleepiness on Nurse Performance and Patient Safety. 2008, Apr.
http://www.ncbi.nlm.nih.gov/books/NBK2645/

22 Days into Implementing KY's "Emergency" Narcotic Regulations

(This is the second of my blog series on KY's "Pill Mill Bill". Please access the first blog post here)
At some point in the discussion of the perfect storm created by Kentucky's new narcotic-prescribing bill someone asked "How can regulations that aren't going to be enforced until October be considered emergent?" I have no clue what the answer to that is but I can give an update into my office's attempt at implementing the regs. Let me start by describing it as chaotic, confusing, time-consuming, and utterly frustrating.

We have patients calling from other doctors' offices who want to switch their care because those physicians have thrown their hands up in frustration and are simply refusing to prescribe any controlled substances. We are not accepting any new patients on controlled substances until the dust settles. I spoke with an ER doctor a couple of days ago who told me it is taking 15 more minutes per patient who needs a controlled substance prescription. I was unable to find any statistics on how many patients leave an ER needing a narcotic or other scheduled medication, but given that it is an acute care environment, one could assume at least 25%. Emergency Departments are already over-crowded, so imagine the issue with increasing the waiting time due to these ill-conceived, burdensome regulations added to a law already over-reaching in its original form, now with many more medications than originally intended.

I try to explain the regulations to patients, including the need to have urine drug testing because of their Ambien (a sleep aid of mild abuse potential) or testosterone prescriptions. Their expressions and questions are of disbelief and frustration.

• Question: Will my insurance pay for the drug tests?  Answer: I have no clue. 
• Question: Why am I being treated like a drug abuser? Answer: Call your governor. 
• Question: Am I going to have to be seen every three months? Answer: As long as I have to run a KASPER report on you every three months--yes.
• Question: Will my insurance pay for those visits? Answer: I have no clue.
• Question: Who thought this up? Answer: I'm not sure but I'd recommend asking Governor Beshear that one too.
• Question: I've heard some doctors are just not prescribing controlled substances. Are you going to do that too? Answer: No, uh, let me qualify that. I don't think so.

Despite Governor Beshear's reassuring words "For doctors who worry their ability to prescribe will be compromised, you have nothing to fear", it is taking my associates and me an average of twenty minutes per patient to explain the regulations, have patients sign informed consent papers, obtain drug tests, and run KASPERS. We only have fifteen minutes slots for patients so this is, of course, making us run behind all day long. And we are about average in the number of patients we have who take a controlled substance. The bill in its original form, covering only Schedule II meds (drugs like Oxycontin, morphine, amphetamines) and Schedule IIIs with hydrocodone would only have been an inconvenience during flu season with cough meds. But with the medications added in the emergency regulations, it's a nightmare).

So far I have run maybe fifty KASPER reports. How many have had any surprises on them? ZERO. Let me repeat that number--ZERO. Not one of my patients have had any controlled substances that they have obtained in this state over the last year that I didn't know about. Let me repeat that number--not one. When I asked the ER doctor what he thought of the law, he said, "This is a waste of time. None of the KASPERs we are running have anything of significance on them. The people that come in here who are drug-seekers we know about and we don't get KASPER reports on them because we don't give them controlled substances. Everyone else have clean reports. And the people from out-of-town we can't get a report on anyway." Then he said, "Oh here's your patient's KASPER. It has one entry." I guessed, "The 20 Valiums I gave her last February?" His response? "Yep. That's it. A real abuser, this one." She's 75 years old and her family begged me to prescribe something to help when she is completely overwrought with caring for her demented, terminally-ill husband. So far she's taken two of them. Yep, a real abuser there! 

Followup on the Healthy Uninsurable Patient

As a quick follow up to The Healthy Uninsurable Patient, a few weeks after the blog was posted my daughter received her COBRA (Consolidated Omnibus Budget Reconciliation Act) papers. By this time she had obtained individual health insurance with a high deductible, but a reasonable cost. The COBRA quote came in at $569.04 per month. This is, by the way, more than I pay for my family plan that covered four people. This is also more than she makes in a month. How many 26 year olds can afford $569.04 monthly for health insurance? Of course I have a cadillac plan as an employed physician at a hospital but there are no other options offered. There is not even any information on how she might obtain other coverage included with the papers.

As a side note, it turns out that she was covered by my insurance when she had the CT scan done. Despite the fact that the letter received from Humana stated that her insurance would terminate when she turned 26, she actually was covered until the end of her birth month. She is a post-graduate student and I'm a doctor who deals with insurance issues every day and we still got it wrong. No one at the hospital where she had the tests, including the financial aid people, realized she was still covered. And this is where I work!!! Nor did the upper management in my office or the office staff at the surgeon's office understand that she had continued coverage until June 30 (and the surgeon is employed by the same hospital I am).

Of course payment for the scans will be denied because pre-authorization was not obtained for them and we will have to appeal and cross our fingers. What a mess.

When she saw the premium amount on the COBRA papers my daughter asked, "How can they send this stuff out with a straight face?" Of course we don't know that they do, since we don't know the people at Ceridian in Florida who mailed the papers. More surprising to me is the number of patients in my office who keep a straight face when they say "But there is nothing wrong with our healthcare system. It's the best in the world!" No. It's not.