Rhonda Cole has worked for ETSU Physicians for 34 years. Hard to imagine, huh? And for most our pre-EHR employees, when the computer programs screwed up, bit the dust, or became inoperable by some other clichéd demise, Rhonda was a phone call away. She still is the go-to for many of our practice management computer programs, but with the implementation of the Allscripts EHR, a whole new team, with a dedicated line just for EHR issues, was formed.

Now, when someone has computer problems, they usually aren’t singing “Help Me, Rhonda,” more like “Help, I Need Somebody … who will help me with this #?!*&%^ EHR.”   It’s not that they prefer the Beatles over The Beach Boys, or that they don’t like talking to Rhonda. It’s just the tune we have to play now. Rhonda’s computer program issues may be a nuisance to many that have to call her, but most of the issues don't keep providers from seeing patients. More often than not, though, when someone calls the EHR Helpdesk, they can’t continue to work because they are frozen or have received an error message. Without access to the chart, they feel powerless to help the patient.

So, I probably just validated all of the negative thoughts you’ve been having about using an EHR, but what about the positive aspects of the system? What makes it better than all that paper? What makes it meaningful?

For a while, Rhonda was one of the few people who could pull data for ETSU. She was the person to see for reports on codes and charges, or else, clinic personnel would have to take the time to manually pull data—a very time consuming and expensive task. Now, a call or task to the EHR Helpdesk can provide users with meaningful data that we could never easily gather before. For instance, we regularly run reports on Controlled Drugs that are prescribed in some of our clinics for quality assurance. We are also currently generating a report on patients with HIV and CAD for providers heading up a research study. We can also generate patient lists by request for providers wanting to keep track of a specific patient demographic or diagnosis.

There is also the convenience to the patient of providers being able to send prescriptions electronically so that the medications are waiting at the pharmacy, or the quick access to last week’s or last month’s or last year’s labs. 

The patient’s accessibility to results and medical data is also greatly improved. As they leave the clinic, a clinical summary is easily generated if desired, and very soon, an electronic portal will be available to the patient. 

And what about provider accessibility? The patient’s record is now accessible from home, from the hospital, even from a smart phone. That kind of convenient accessibility has never been a option—on-call providers had to fly blind.  

Obviously, EHR isn’t perfect and probably never will be. Ask Rhonda. She’s been working with computers and software that still need buggy problems fixed. She’s heard the song before: “And I can give you lotsa reasons why/ You gotta help me, Rhonda.”  (The Beach Boys, Help Me, Rhonda)

But since we have a new program, and a new team, a new number to dial, how about we try singing a new song: 

“(Now) But now these days are gone (These days are gone), I'm not so self assured/
(I know I've found) Now I find I've changed my mind and opened up the doors.”  (The Beatles, “Help!”)

I’ve never been a huge rap music fan. Some of it I like, especially the “old-school” hits from my high school days, but for the most part, I can’t really name that many hits...or tell you much about one of the most well-known rappers—Notorious B.I.G.—whose murder in 1997 still has L.A. police stumped. 

As little as I know about him, there are many times I think about him...or at least make an association with his name. A matter of fact, it happens more often than I like, or any of us using our EHR. It’s that moment … when our patients are filling the lobby… and exam rooms...and backing up at the check out line. It’s the exact moment when we are about to click the yellow COMMIT button ….and then—NOTHING. The system has frozen up , maybe an hour glass is staring you in the face. And you feel helpless, stuck, and above all—FRUSTRATED.

On my end, it’s the constant ringing of the phone, the rush to contact our system support at Blue Ridge, and the  back log of Help Desk tickets notifying us that the system is locked. 

It’s that moment I think of Notorious...more specifically, the Notorious E.H.R.

But maybe we should all take a moment to reflect (and I include myself here) on life before the Notorious E.H.R.  I would love to see a report on how many hours each of our offices spent tracking down paper charts for the next day’s clinic (especially the “lost” ones), and how many times we got frustrated trying to dig through especially large paper charts looking for the last year’s lab results. Or perhaps the hours spent dictating, transcribing, and faxing referral letters...and the money spent doing so. And have you ever tried to gather data tracked on paper? I’m sure the manpower, time, and money spent on major research projects was barely covered by the grant money applied for by the office staff. I don’t think any of you will be rapping a verse from Notorious B.I.G.’s track “Want That Old Thing Back.” 

I say all of this because, as I read through the piles of literature on Meaningful Use, and as I hear the woes of so many Notorious E.H.R. users, and as I try to brainstorm better ways to support our excellent providers and clinic staff, I realize that we have come a long way. . . .and didn’t mama say “they’ll be days like this”?  (Okay, so that’s not a Notorious B.I.G. song, but I’m sure his mama probably told him the same thing.)

Just the other day, one of my son’s teachers, after noticing my name badge,  said to me, “I never thought I’d say ‘I love my doctors’, but I really do love my doctors.” She was referring to our providers at OB/GYN. She didn’t complain about the wait, she didn’t complain about the computers….all she saw was a great group of physicians providing the best of care. 

So the next time the system freezes up, or the computer crashes, or whatever may bring to mind that Notorious E.H.R., try taking a deep breath, and maybe even rap a tune: 

Sky is the limit and you know that you keep on/
Just keep on pressin on  (Notorious B.I.G., 1997)

According to the TennCare website, the definition of Meaningful Use involves using certified EHR technology to

· Improve quality, safety, efficiency, and reduce health disparities,
· Engage patients and families in their healthcare,
· Improve care coordination,
· Improve population and public health, and
· Maintain privacy and security.

Remarkably, we have already seen first-hand examples of Quillen ETSU providers and clinical staff using our EHR to each of these ends. 

Addressing health disparities has been the primary  focus of the patient lists generated for each provider. Many of the family medicine and internal medicine providers now have access to a list of all their diabetic patients with records in the EHR. 

These lists help providers and clinics manage this patient population, who, in Tennessee, had a 19% higher risk of dying from diabetes than the national average.  The Tennessee diabetes death rate of 30.2 per 100,000 was ranked 10th highest in the nation in 2002. In 2004, the age-adjusted diabetes death rate for black Tennesseans (61.1 per 100,000) was over twice the rate for whites (27.8 per 100,000).* 

*Information from tn.gov. 

Each of the Quillen clinics has also been offering  Clinical Summaries to patients and/or their family members at check out.. While not every patient asks for the summary, some patients have found these summaries very beneficial, such as parents wanting the most up-to-date immunization record, or simply patients who are on multiple medications.  

As we look toward adding a patient portal, patients will gain even more access to their health records, and, hopefully, this will prompt many of them to become more engaged in their own healthcare.

Improving care coordination has been one of the biggest benefits of using the system. With multiple providers and specialties having quick access to the patient’s chart, duplicate labs and medications have significantly decreased, saving patients money and time.

The referral process to providers within ETSU clinics has also  been significantly improved. Faxing records is no longer necessary, and clinics can use tasking rather than phones and faxing to make the referral.

With the system’s ability to track and report data, we are now able to run reports on various population and public health initiatives. In the Department of Pediatrics, data has been requested to track abnormal labs, the Read N Play initiative, and reflux diagnoses. In the Department of Family Medicine, various information is being tracked for improvement of their Patient-Centered Medical Home designation, as well as monthly reports on Controlled Substance prescriptions.

The system is also designed to generate reminders based on either input from individual providers or as system-generated reminders based on recommended screening and diagnostic guidelines, such as colorectal cancer and mammography screenings. Recently, reminders have been set up for CSMD checking  for patients on controlled substance prescriptions.

Maintaining privacy and security has always been a top concern for EHR users, no matter what the system. With retail electronic security breaches being reported regularly, many healthcare providers questioned the security of electronic health records when EHR systems were first introduced into practices. However, with quickly evolving technologies, and the stringent requirements on systems in order to be certified for Stage 1 of Meaningful Use, EHR systems are exceptionally secure. Eligible providers need to “attest” that they have met certain measures or requirements regarding the use of the EHR for patient care. 

EHRs are more secure than most paper charts ever were, especially within organizations where chart audits are frequently performed. In the paper world,  if an employee wanted to access a health record without reason, most likely, no one would ever know if he or she  had been in the record. With electronic records, anyone who accesses a chart is trackable, resulting in a more secure health record.

As we all become better users, the possibilities for how the system can be used in more meaningful ways will be illuminated.

What makes a medication meaningful? I suppose that ANY medication that is prescribed to a patient should be meaningful, but what happens when a patient’s medication list is maintained on the EHR, but the list isn’t accurate? Would an incomplete or inaccurate list be meaningful to anyone?

Let’s for a moment suspend the idea of a medication’s “usefulness” to the patient and examine the “meaningfulness” of the medication’s inclusion on the medication list. Perhaps the best way is to present a few patient scenarios:

Patient Scenario One

Patient One, “Mary Meaningful,” visits a clinic because she has allergy symptoms. She currently takes an over-the-counter decongestant, as well as a few vitamins and supplements. She also takes an anti-anxiety medication that she asks not be included on her medication list. Not wanting to cause Mary any distress, the nurse records her medications in the system (absent the anxiety medication) and sends her on to see the provider. Mary doesn’t mention anything about the anxiety medication to the provider because she feels embarrassed that she is taking it. The provider feels sure the medication list is accurate because it has been reconciled by the nurse and prescribes Mary an antihistamine.

Do you see the potential hazard here?

Dangerous interactions can occur when antihistamines and anti-anxiety drugs are taken together.

Patient Scenario Two

Patient Two, “Mike Meaningful,” shows up for his annual Medicare visit. He reports to the nurse that he has been seeing one of the cardiologists for some heart-related issues and that he was prescribed some medications a few months ago. She pulls up his chart and doesn’t see any medications on the list. When she questions Mike, he tells her that the doctor was too busy at his appointment and didn’t have time to put them in the system.  He just wrote them out on prescription paper.

How meaningful is the medication list now?

One provider’s responsibility has now been pushed off to another provider’s clinical staff, and, consequently, takes more time and is potentially less accurate than using the system the way it was designed.

Patient Scenario Three

Patient Three, “Misty Meaningful,” was originally prescribed 25mg of a blood pressure medication by her primary care physician, which was ordered through the system correctly. A few weeks later, Misty’s blood pressure hasn’t improved so the clinic calls in a higher dosage—50mg—but doesn’t record the change in the patient’s chart. Misty visits her specialist, who sees the dosage is 25mg but knows she is taking 50mg, as she reported to him. He decides she needs to take 100mg, and renews the medication at the higher dose. Unfortunately, Misty has a bad reaction and files a malpractice suit. When the defense attorney reads the specialist’s note, it appears that he upped her dosage by 75 mg because no one recorded the 50mg.

Where does the fault lie? 

Obviously, no one could have predicted the bad reaction, but how can we rely on the accuracy of a medication list and the system’s ability to accurately reflect a provider’s plan when no one takes the time to document in the EHR?

Meaningful Medications = Better Patient Care

I could describe many more patient scenarios in which the lack of accurate medication documentation has caused problems, but I think you get the point. Even when clinics were on paper, keeping an up-to-date medication list was very important for good patient care, but now, with the transition to an electronic health record, and with multiple providers using the same chart, each user must be particularly careful to accurately document. If we strive to make the medication list truly meaningful, the end result can only mean better patient care.
 

Perhaps an analogy to cycling and Lance Armstrong may not seem the most appropriate of comparisons, considering the recent news of his steroid abuse, but for some providers, making sense of the different rules, requirements, and stages—and having to manage these in clinics—may seem just as deflating as Armstrong’s stripping of his accolades, and just as tough as having to compete in the Tour de France.

As a multi-specialty, multi-provider practice, Quillen ETSU Physicians will be pursuing stages of meaningful use in various years, and the criteria that must be met is determined by the stage of  the eligible provider’s (EP’s) participation (either Stage 1, Stage 2, or Stage 3). EP’s progress through six years of the program—two payment years in each stage.

Each month, in our newsletter and here on our blog, we provide information and updates  on the EHR Incentive Program, as a “roadmap,” so to speak, as we make this journey together.

The Centers for Medicare and Medicaid Services (CMS) recently updated the criteria for Stage 1 Meaningful Use (MU) for 2013 and beyond. For most of our EPs, these changes will not affect their 2012 attestations.  If an EP is pursuing his or her first or second payment year of Stage 1 in 2013, respectively, the following updates do apply.

Minor Updates
Core Measure 1: More than 30 percent of all unique patients with at least one medication in their medication list seen by the EP have at least one medication order entered using CPOE.

The Update: This particular update (in the form of an alternative measure) took effect in September 2012. EPs have the option to use the alternate measure with a denominator of all medication orders created by the EP during the EHR reporting period.  EPs should choose whichever measure (the original or alternative) works best for them.

How this effects you: As a multi-specialty organization, we often share patients among our providers. Being able to choose the alternate will help the percentages of many of our specialists.

Core Measure 4: More than 40 percent of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.

The Update: A new exclusion has been added for EPs who qualify. Along with the previous exclusion of  “any EP who writes fewer than 100 prescriptions during the EHR reporting period,” now “any EP who does not have a pharmacy within their organization and there are no pharmacies that accept electronic prescriptions within 10 miles of the EP’s practice location at the start of his/her reporting period” can also be excluded.

How this effects you:  This update will not affect us. We have several pharmacies near our offices.

Core Measure 8: For more than 50 percent of all unique patients age 2 and over seen by the EP, height, weight, and blood pressure are recorded as structured data/ More than 50 percent of all unique patients seen by the EP during the EHR reporting period have blood pressure (for patients age 3 and over) and height and weight (for all ages) recorded as structured data.

The Update: Even Tenncare describes this change as complicated, but basically, in 2013, EPs will have a choice to separate the measure and exclusions. Blood pressure can be separated from height and weight, and EPs can specify an age range of 3 and up for blood pressure.

How this effects you: This change will be particularly welcomed by our pediatricians, as well as specialty providers, for whom these vitals are not applicable to their scope of practice.

Core Measure 10: Successfully report to CMS ambulatory clinical quality measures selected by CMS in the manner specified by CMS.

How this effects you: Core Measure 10 will no longer be listed as a measure. In 2013, providers will simply report the clinical quality measures rather than attest to a separate measure.

Menu Measure 9: Performed at least one test of certified EHR technology’s capacity to submit electronic data to immunization registries and follow up submissions if the test is successful (unless none of the immunization registries to which the EP submits such information has the capacity to receive the information electronically).

The Update:  The verbiage “except where prohibited” was added by CMS for understanding that if EPs are “authorized to submit the data, they should do so even if it is not required by either law or practice.” Technically, this update is not a change but a clarification

How this effects you:  It doesn’t. We are NOT prohibited to submit data and are working with the state of Tennessee to have our immunizations sent directly to their registry.

Menu Measure 10: Performed at least one test of the certifies EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which an EP submits such information has the capacity to receive the information electronically)

How this effects you:  It doesn’t. The change is the same as in Menu Measure 9; however, the Tennessee Office of E-Health Initiatives (TDOH )is not currently participating in testing Syndromic Surveillance messages for Meaningful Use.

Major Update

Core Measure 14: Performed at least one test of certified EHR technology’s capacity to electronically exchange key clinical information.

The Update: Beginning in 2013 and beyond, this objective and measure will not be required for 2013 and beyond. This objective and measure will still be a part of the core set for anyone attesting to Stage 1 MU for 2012, but CMS felt that preparing for Stage 2’s emphasis on exchanging data was incentive enough for EPs to start testing this capability.

How this effects you:  Look for updates and improvements on Quillen’s ability to exchange data, as the beginning of Stage 2 begins in 2014.

A recent survey conducted for the American College of Physicians and Doctors Helping Doctors Transform Health Care (published October 2012 ) in collaboration with the Bipartisan Policy Center (BPC) revealed some interesting findings concerning physician views about the adoption of electronic health records (EHR).

One of the most encouraging findings is that 80% of physicians surveyed believe that the adoption of EHR is having a positive impact on the quality of patient care. Additionally,

· 80% see EHR as improving the ability to coordinate care;
· 69% believe EHR is improving efficiencies in their practice setting;  and
· 57 % see EHR as reducing health care costs.

The same survey was fielded by the American Academy of Pediatrics in September 2012 with similar results. A majority (80 percent) of those surveyed believed that the electronic exchange of health information across care settings will have a positive impact on improving the quality of patient care as well as the ability to coordinate care.

While these percentages suggest an optimistic attitude about the EHR implementation, other findings reveal that there are still areas that need improvement, namely in the ability to exchange patient information among providers. 71% of the physicians surveyed said that the inability of the EHR to communicate electronically with other systems (or lack of inoperability) was a major barrier preventing them from exchanging information, as well as the lack of an exchange infrastructure (71%) and the cost associated with exchanging information (69%).

Fortunately, Stage One of Meaningful Use includes measures for tracking transition of care information exchange, and Stage Two emphasizes the clinical exchange of information electronically. According to CMS, “the Stage 2 criteria place an emphasis on health information exchange between providers to improve care coordination for patients. One of the core objectives for both EPs ... requires providers who transition or refer a patient to another setting of care or provider of care to provide a summary of care record for more than 50% of those transitions of care and referrals.”

Other changes to Stage 2 that demonstrate this objective include: 

· EPs that transition or refer their patient to another setting of care or provider of care must provide a summary of care record electronically (>10%)

· EPs that transition care must either a) conduct one or more successful electronic exchanges of a summary of care record with a recipient using technology that was designed by a different EHR developer than the sender's, or b) conduct one or more successful tests with the CMS-designated Test System during the EHR reporting period.

Although the extra documentation may seem time consuming at first, the more familiar systems become and with more feedback from users and providers, the future of EHR looks promising.

We admit it...for some providers, it may take a little extra time to see a patient using an EHR.  
Just the other day, one of our physicians quoted a random stat about how much more time it was taking him now to do what he used to do when he was on paper. 
That may be true, but EHR is still a work in progress, and what should 
the ultimate goal be?
Improved patient care, right? 
The PATIENT is who matters.
Patient care is why the federal government is investing up to $29 billion in the Meaningful Use incentive program, but EHR users, understandably so, want to know if it’s working. 
One recent study released in the Journal of General Internal Medicine (J Gen Intern Med, Pub. Online Oct. 3, 20011 DOI: 10.1007/s11606-012-2237-8) set out to gather data  on ambulatory quality  in community based settings using EHR.  
The study, which included 466 physicians; 204 using EHR, 262 using paper) and 74,618 unique patients, compared nine measures within the group. The results showed significantly higher quality of care for four of the 
measures:

1. Hemoglobin A1c testing in diabetes,
2. Breast cancer screening,
3. Chlamydia screening, and 
4. Colorectal cancer screening

When all  nine measures were combined into a composite, EHR use was associated with higher quality of care.  The authors do list several limitations, such as the inclusion of self-reported adoption of EHR in its predictor variable, as well as the small number of pediatric measures (although consistent with the call for development of more 
pediatric measures). 
But even with such limitations, this study is significant in that EHR now can be qualified. In this “multi-payer community with concerted efforts to  support EHR implementation,”  EHR was found to indeed be meaningful. If Quillen, as an organization, can work together to improve the current system, the patient is the one who will 
reap the benefits. 

In a recent JAMA issue (2012;307(23):2497-2498), author Elizabeth Toll, MD, shares a poignant patient example of the “Cost of Technology.” Illustrated by a pediatric patient’s colorful drawing for her doctor, the patient is on the exam table with her parent seated nearby, and the physician is pictured behind her, back toward her, and head buried in a computer.

Revealed is the fear most providers have about adopting an electronic health record (EHR)–the loss of patient interaction. Dr. Toll makes some very valid arguments in her essay: first, that the connection between and physician and his or her patient is established best by face-to-face interaction; second, “picking and clicking” has replaced internalized learning; and third, written notes are easily corrected after the patient leaves, but documenting in a computer seems more unforgiving. Thus, physicians tend to focus more on the computer than the patient in order to prevent a wrong click from becoming an irreversible mistake.

As an electronic health record analyst, I would like to disagree with Dr. Toll’s points, but I can’t. There are certainly some drawbacks to having an EHR; specifically, the loss of connection between patient and physician. However, there are numerous advantages, and as Toll goes on to write in her essay, there is no use fighting the system. In fact, she challenges her fellow physicians to “embrace technology to help us consolidate and organize data and communicate with colleagues for the benefit of patients and ourselves” (2498). 

While it may seem defeating, even daunting, resistance is futile. Fighting a system that could (will?) eventually get better can only cause more anguish for the resistor and further delays in improving EHR design.

Toll concludes with reminders–of how lucky healthcare providers are to care for patients like the young artist and to work with physicians like the young provider she describes within her essay. Of how human we all are and how important the human connection is when facing new challenges, including the electronic health record.  She states, “If we take time to connect with one another and draw strength from listening, learning, teaching, and caring we can join together to find ways to take on new challenges” (2498). Meaningful use, in theory, was put into place to help improve patient care, not deter it. Of course, it’s a work in progress, and the way I see providers taking on Dr. Toll’s challenge is not to refuse to participate (because patients still need care), or to complain or grumble (because complaining and grumbling makes everyone miserable), but to start voicing thoughts, ideas, and opinions on how to improve system.

From an analyst’s perspective, we appreciate ideas and feedback. When something isn’t working, tell us. When you have an idea that could make the system more user-friendly, tell us. If a meaningful use requirement doesn’t really make sense for your scope of practice, get involved in government policy.

Obviously, a challenge is never easy, but if providers, administrators, analysts, and policymakers can work together, perhaps one day the EHR truly will be meaningful.

How many times have you found yourself “clicking through” alerts in order to get through a busy clinic?  Or, have you found yourself ignoring big red triangles, frowning faces, or bright yellow reminders?

Unfortunately, providers across the specialties are notorious for this behavior, relying on their own clinical judgment to deliver care and ignoring clinical alerts, such as drug-drug interactions or overdue order reminders...and why not?

That’s why you have a license to practice medicine, right?

The Human Condition

But aren’t we all human? We all make mistakes, forget things. EHR adoption is supposed to be an aid to help support us, to remind us when we may forget something —or even if a patient forgets. Mistakes, forgotten orders, or ignored orders were almost impossible to track on paper, or were too time consuming for those “keepers of the charts” who were responsible for tracking  all the orders, medication lists, and the like.

A great example of the tracking efficiency EHR offers is the email I received the other day from my daughter’s provider. “Bridget, Allscripts is telling me that Leah hasn’t had the urine culture that I ordered.” I hate to admit it, but he was right, and the next day I had her urine sample at the lab, along with my son, who still hadn’t had his blood drawn (his doctor had sent me a reminder, too!). Although an EHR system can be cumbersome and time consuming (especially at first), the reality is that in the end, providers are delivering better care….that is, unless they start ignoring the system.

An EHR Casualty

The phenomenon is known as “alert fatigue.” Providers see so many alerts , notices, and reminders that they tend to ignore them, including alerts for meaningful use: reconciling meds, documenting smoking status, recording vitals, etc.  According to accessmedicine.com, “Studies within and outside health care show that the beneficial effect of an alert, such as a pop-up box in a software system, is rapidly extinguished if the alert becomes a routine part of using the system. . .If a clinical decision support system provides an ‘alert’ to the drug-drug interaction of two medications routinely used together safely, such as enoxaparin and warfarin, in the same way as to unfamiliar but dangerous interactions, such as theophylline and fluoroquinolones, clinicians become desensitized to the alerts and dismiss critically important guidance when it does appear.”

In the next few weeks, another alert will have to be implemented in order to attest to Core Measure 11: “Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance with that rule.”

“Another alert?” you may be thinking. “Isn’t your point that we’re already tired of them?”

Patient-Centered Data

True, you may be tired of them, but the reality is that they do improve patient care….if used correctly. CMS requires that the clinical decision support rule be based on “general and person-specific information, intelligently filtered and organized, at appropriate times, to enhance health and health care.” Our system, as a certified EHR product, generates alerts based on patient-specific data. An example of this would be an alert reminding the provider to ask the patient if he/she has had his/her Pneumovax, driven by individual patient immunization status and patient demographics (such as age or problem list information). For users, this means that information needs to be entered correctly and updated regularly.

Accurate Data

As we have been looking over charts the past few months for quality improvement, there have been numerous instances where patient records have not been updated (i.e. a patient with an active pregnancy who aborted three months previously). Using our Pneumovax example, if the administration of a previously given Pneumovax was not documented, then the number of false alerts could hinder rather than help.

Steps to Follow

The following are some steps to help avoid alert fatigue and ensure that Meaningful Use data is reported accurately.

1. When an alert pops up, don’t just click out of it. Read the alert and make sure that what is being “alerted” should be. If the alert shouldn’t be generated, question why.

2. If the alert was generated based on incorrect information entered in the system, correct that data. For example, if medications are still on the current medication list that shouldn’t be, then fix it.

3. If an alert generates that shouldn’t based on information you know to be clinically incorrect, let your support team know. Alerts are supposed to generate on evidence-based medicine and the latest national standards of care.

If all of our users in our clinics work together to make sure that data is accurate in the patients’ chart and that the system is functioning correctly, then the alerts that generate should be less frequent and clinically relevant. 

 

I have a “To Do” list of EHR requests, as well as a “To Do” list for all the stuff that needs to be done at home (and both lists can get quite long –with approximately 1200 EHR users and three busy kids!). I’m sure that you also have similar lists.

So, when it comes time to maintain more lists (problem lists, allergy lists, medication lists, etc), I can imagine your response is less than enthusiastic. But lists tend to be generated for a purpose. I know without mine, I would forget many of the things I put on them (and my kids would probably go hungry because I would forget to pay their lunch money). Lists in the EHR, obviously, help us keep up with our patients’ current diagnoses, medical histories, medications, and allergies. With the patient volume many of our clinics handle, keeping lists is essential for providing quality patient care.

That’s why maintaining and reconciling lists is part of the core objectives for Meaningful Use.


Maintain an up-to-date problem list of current and active diagnoses.

Maintain active medication list.

Maintain active medication allergy list.

According to the TennCare website, the up-to-date problem list measure requires that “MORE THAN 80 percent of all unique patients seen by the EP have at least one entry or an indication that no problems are known for the patient as structured data.” So what exactly does this mean? Simply put, active problems need to be entered on the Clinical Desktop (i.e. electronic chart) for your patients, and if by chance they have no active problems? That needs to be recorded as well (For our Allscripst users, ‘No Active Problems’ should be a quick list item in the ACI). And take note of the word CURRENT. If the patient comes back to see you for a follow up or office visit, and the rash associated with poison ivy from the last visit is still listed as an active problem, then resolve it. If the patient is pregnant—and delivers— then resolve it.

Additionally, “more than 80 percent of all unique patients seen by the EP must have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data.” The same requirement is true for allergies.

The Allscripts system makes it easy enough to reconcile these lists, but when you click on Reconcile, remember that you are stamping the list as up-to-date. You must take the time to review the lists with the patient and make sure that all medications and allergies are accurate. Otherwise, when you click on reconcile and you have not truly “reconciled" it, you are falsely documenting in the chart. We have seen time and time again where duplicate meds and expired meds are still on a list that has been stamped as reconciled.

As I mentioned in my last post, clinics must work on office workflows to ensure that someone is going over these lists with the patient at each visit, whether it’s the nurse or the provider.  We encourage spot checking daily schedules and lists to ensure accuracy. And if you can’t remember this recommendation, how about adding it to your “To-Do” list?