Home Forums Discussions General Discussion I Hate Change!

OK, this is just me ranting a bit but it is apropos to AC in a couple of ways. I have been using Intuit's online payroll service. It was fantastic, intuitive, cheap and virtually bugless. A few months ago they notified us that they were increasing the price over 3 times what I was paying (still cheaper than a payroll service like Paychex). Then a few weeks ago they changed the entire program. The site looks different, works differently and is not nearly as intuitive. Some features to which I had been accustomed are no longer there and others, which I will never use take their places. Sound familiar? One favorable thing though is that after I sent an email with my complaints I received a reply THE SAME DAY!! And to top it off, yesterday THEY CALLED ME to discuss the problems I was having with the changes!! Although I am pretty sure I will never see my beloved old payroll program again, it definitely impressed me with their concerns about my concerns.

Leslie and I are obviously of the same breed of mammal. I hate change as well. Well actually, I don't mind change if it makes things better. I hate change for the sake of change.

I use QuickBooks software but not their online service. I do find QuickBooks to be very simple and the payroll to be quite easy on the software. No clue about online stuff.

I guess, at least with AC, you could keep it like it was (v4) but with an online service, your stuck with the change.

I feel your pain. v4 was so good.

Travis,

I am still on V4 . I just cannot seem to make myself make the change although I would be interested in eprescribing. The fact that I am using an EMR says that I too am not afraid of change but when something is good, why does someone think they have to make it "new and improved". The improvements rarely are.

Ah, Leslie, How well I know what you mean!!

We have not yet stopped feeling that way about the switch to the EHR in the first place. Although things are getting easier, upon polling our staff there is not a clear consensus that we are better off. We can only trust that those who continue to extoll its virtues know we something we don't and are not in denial about having made a ghastly mistake.

Old and improved would be good. But, I would never go back to paper.

Agreed that old and improved would be great. I'm not sure v5 is that.

I'm strongly debating reverting my entire office back to v4 until v5 is better. I understand the supposed benefits of v5 but I'm getting nothing from it. I'm really waiting to see what 5.1 has or even 6.0. I'm kicking myself because I worked with v5 for many months before converting the office. You just never know until you take the plunge.

That being said, you couldn't get me to go back to paper. No way. Never ever.

I'm fine with v5. It's just that I have to open a one-hour slot to make up time I have to spend on the orders.

I HATE the orders! HATE them.

Like Bert, I too am fairly critical at times of AC on the boards. But, when I talk with other docs looking for EMRs I am always very positive and give a good sales pitch. I was at a board meeting last night at the new hospital with which I am affiliated. Granted, it has been open less than a year but the medical records suck!! They are using a Cerner system which is just horrible. It cannot even make a page break between radiology, lab and dictated admission reports!! I was talking to one of the docs about it and remarked that my $500/year office EMR could out shine this Cerner system hands down. We then had a nice discussion about AC and this doc is exited about looking into it for his own office use. So, Jon, if you are sneaking peeks on the boards, it is kind of like we are one big family. It is ok for us to talk down about our siblings or parents but no one else better call you a son-of-a-#$%@*

RE: Quickbooks / Intuit

Leslie, Oh yes, Intuit is all about change, but not always for the better. Intuit's "sunset" policy on their software is 3 years. So just when you understand the flow well, the software changes.

Leslie,

Cerner is what kept me out of the EHR for years, It was the shining example I had to use at our hospital of how bad it could be.

As to Quickbooks, for years we ran our office on just Quicken, and it worked great. I changed accountants, and the new one insisted on Quickbooks. It is now 4 years later, and I still can't create a report that shows if we have collected more or less this year to date vs. last year to date. I have to keep a separate Excel file for that. She is happy, and I hate it.

And, Bert; tell me why you hate the orders? Maybe we just use them differently, but I really don't mind them. In fact, they are one of the good things about AC for me. I click a few buttons during the patient visit, I walk out of the room, and the lab slip is clipped to the door and the nurse has the vaccinations, imaging studies and procedures all waiting.

@Leslie Great post

David,

I probably am doing everything wrong. So, I am in a progress note. I dread it, because I have to order a coagulopathy panel which contains about six labs. Or a thyroid panel. So, I click on Write Orders. Fortunately, I have deleted everything out of nursing, patient education and follow-up, although we tried to do follow-ups from there.

I have yet to figure out how to click on "Thyroid Profile" and have the TFTs show up. I guess I could add them to the comments, but our lab won't take them that way. In v4, I just pulled up the lab writer (which was for everything -- no decisions), and right clicked and chose from a list, which then gave me one or ten labs.

Then, since I would generally be the one printing the lab slip (it makes little sense TO ME -- not commenting on your method) to send it to my nurse to do when I may as well click on it and print it, I have to print it then click on the Send Orders button, which used to be automatic. Of course, now I simply just use the Other tab, where I can at least do everything the way I used to by right clicking and choosing labs and x-rays, etc.

Then there is the diagnosis, where I used to just type it in. Now, I write Hyperaldosteronism, and there is no ICD-9 code. Some times it will show up with Google, but half the time I have to go to a separate website. Now this may be where I am missing something. If I get the code, I find no way to add it to the database from within that window. So, I have to go out of that window, go to the main screen, choose the diagnosis window and add it from there. Then, I can go back to the lab window and enter it. Now everything is a go unless I forget to unclick all of the other diagnoses.

If the lab isn't on the list, I have to use the Add Lab feature. Once I enter it, I then have to go hunt for it, because it is not selected by default (which makes absolutely no sense).

Obviously, the x-rays are the same.

The referrals tab is the only helpful one. But, of course, I have to choose the people it is going to, because A) it changes and B) it never seems to stay the way I set it.

In fairness, I suppose the nursing section is helpful for some. We don't use it, because my MA is rarely sitting at her desk, and there is also no auto-refresh. My nurse also figures out all of the shots. I look at them in the room. If I am really busy, I may just tell her by IM or verbally or just give her the chart on the way down to do the lab slip. Most of the time, I do them on my own.

I forget if you used v4. I don't want to come across as condescending if you did. But, basically, there was just:

The equivalent of the other
You typed in the diagnosis (maybe some places require ICD-9 codes) If so, since the site I use pulls up every ICD-9 code for every diagnosis, ours should as well.
You didn't send it to anyone.

I suppose that those who like it must send a lot of things to their nurses. But, we simply don't. And, we use Superbills, which have the F/Us on them.

Even Jon told the ACUC committee that he has to work on the orders section.

Any tips or advice you can give me to help me use it better would be great.

Bert, I keep saying we need more resources for new users like you!

No I started with Version 5.

Some of the things you allude to are part of the whole "flow" that I have had to learn in the EHR process, and is part of the challenge I have had to face. Let's say I am in progress note. First, I make sure the diagnoses are in. I would type "aldoster" in the "search DX" box, and I get about 4 choices. Now, like Leslie, I am not going to make myself crazy trying to figure out which hundredth of a code number to use; if it is not obvious, I pick one that is close and go with that. We have that luxury with no managed care, etc. I may not put all of them in, but enough to reasonably justify what I know is coming.

Then I hit Orders-> Labs. As I mentioned in previous posts, we use numbers before the name of the lab test to group the tests into understandable groups. Our group 3 is endocrine. 3.1 is TSH, 3.2 is free T4, etc. Sometimes one isn't there, and I do the "quick add" that puts it alphabetically at the bottom, and I'll rename it later when I have time. Then, like you, I hit "print orders". The printer is near the nurse's station, so they usually pick it up and clip it to the door of the exam room I'm in. If they're busy, I'll get it off the printer when I come out of the room. No more filling out Quest forms.

Imaging is same way. The common ones are numbered, to bring them close to the top to find easily. They could be grouped if appropriate.

Under Nursing we have our vaccines under vaccinations and I send the order to the nurse. The weak link here is that there is no notification currently of a new message, so the nurses have to refresh the messages fairly frequently. Hopefully this is going to get fixed. Under "Nursing->General we have things like EKG, colonoscopy and other things. Likewise, the order is sent.

Referrals I do later; most of our consultants want to see the letter and note before they will schedule anyway, and it gives me time to do a coherent (if somewhat ugly) letter.

Anyway, as I said, this is actually the one part of the EHR that I feel saves me time.

David,

Thanks for the ideas. I just think we have different work flows. But, I want to hear others as it may help mine.

Let's start with labs:

Using your numbered system, how do you get, say, the eight or nine labs, I would use on a first-time routine screening for abdominal pain. (By that I mean how do you have one name for the eight and click on one thing?)

Exactly. The irony is we can't win. Travis and Leslie hate change and partly because of the orders.

I love change and don't really like the orders.

Bert, I don't have a solution for that, unless you can work out something for the lab to make a custom panel. We have been able to do that for some things; like ANA with reflex testing. I would ask your lab manager if that is possible.

That would be kind of tough. They would like at those like reflexes, plus every time I wanted to add another panel, they would have to make one.

It is so much easier to make templates. Ironically, I just had to order an MRI and EEG. I happened to have MRI of the brain, so I chose that, but figured I would write in the diagnosis. I unchecked everything, and lo and behold, if you don't actually have something checked, it automatically enters whatever is there.

So Bert - can you not get your diagnosis to show up ? If you just type the diagnosis in the comments before you check the actual test or check-type in comment and then uncheck/check it will always show up... at least that is my experience. I don't know why everybody hates the orders - except for the fact that you have to code diagnoses it really is not hard.

I have no problem with the diagnosis showing up, that is if I can find the ICD-9 code. The lab and I both liked the fact I could type in the diagnosis.

I know a lot of people don't like the orders. I can only speak for myself. For me, it is for what I wrote.

This is clearly one of those love them/hate them kind of thing. In those instances, preferences or options really help:

1. Option to completely get rid of a category
2. After entering diagnosis, allow http://icd9cm.chrisendres.com/ to pop up to find the correct ICD-9 code
3. Allow panels of labs that can be done as a list and not a sentence. Our lab doesn't like that.
4. Automatically check the box when you add a lab. Why would you add a lab and then not select it.
5. It should make no difference which is checked first (ICD-9 or the lab)
6. Give the option of using free text for diagnosis after you have looked for five to ten minutes or patient starts to look at their watch.

By the way, I am confused with the numbering system unless it has something to do with the 3.1, 3.2, etc. They all are listed in alphabetical order. Or do you want the most common at the top.

Jon told a few of us on the phone that he needed to work on the orders.

The orders are a pain. Strangely, they are not my least favorite part of v5 after fighting with it for 3 weeks.

I do like that we can enter in the orders and fax them to the lab/radiology with the demographic/insurance/ICD-9 stuff on the sheet.
I wish the ICD-9 would go from a templated Assessment and directly into the orders but they don't unless you pull up the "Search Dx (ICD-9)" tab every single freakin time and click/find the diagnosis. Drives me insane (not a long trip The diagnosis part needs work or we need a "quick list" of the most common 20 diagnosis just like a paper superbill.

I absolutely hate that we have to enter someone to send the orders to. Silly, especially in a small office like mine. That shouldn't be mandatory and should be automatically left blank if you don't need it.

If we're going to do it, provide the ability to EASILY reconcile the orders when they come back in and alert us if a CT or Lab is a week out and still not resulted or whatever.

I don't need a Nursing category (can I get rid of it? No). I don't need a Patient Ed category (can I get rid of it? No). That's easy and not that cumbersome though.

The numbering system is so that the common things are on top.

Why does v5 seem to want to organize everything in alphabetical order? It's driving me crazy when I click on multiple templated items and it puts them in alphabetical order. I would love it to enter them in the order I click them because that's usually the order of priority.

Orders are close. Just some tweaks. i think they are usable and we're battling through with them. Maybe the AC crew needs to look at the way eMDs or some other EMRs have made this a bit more seamless.

I think you would love Praxis. Just because it "remembers" what you do.

Bert,

Here is the post i did about numbering:
http://www.amazingcharts.com/ub/ubbthreads.php/topics/20897/Customizing_order_of_lab_tests#Post20897

Thanks David. I'll look into that.

Ahhhhhhhhh....Version 4 rocks.

Version 4 1/2 is the best, otherwise known as v4eP

Well, actually I am still 4.062.

Sorry Brian

The Brian reference went right over my head.

Leslie just crossed over Brian's 975

Congratulations, Leslie

Finally picked that up.

So, I was just about to upgrade from 4.073 to v5 but now I am getting cold feet. The reason I wanted to upgrade was for the eRx, the better record of drug histories and the ability to record things like B12 shots. I assumed I would be able to turn off all the superfluous stuff and add it into our system as time allows. Maybe I should stall a little longer.

Wow. I am glad I read this thread. I was ready to go in an upgrade from 4.073 to 5.0 but no way after this thread. I think I am going to stick with 4 for the foreseeable future. As I surgeon I only prescribe lortab and phenergan. I do not need ERx. Thanks everyone.

Gerardo

After I stalled, I downloaded V5 at home and despite the fact that I couldn't really play with the eRx portion, I really liked alot of the changes that were made. As a Family Doctor, I will be able to use some of the health maintenance features and see how they work into my office flow. I think I will ignore orders for now. I am installing on the office computers tomorrow night.
Gerardo, as a surgeon, you might like the new Rx writer better. It seems like a better system. It also has a much better way of recording Rxs that are written. It keeps an entire history so you will know not only when you wrote the last Rx for Lortab or Phenergan, but also for how many. You can also add medication allergies directly from the summary page instead of needing to be in a note. Lastly, you can addend a chart the same way you would in a paper chart, so if you are anything like me and you close the chart and then remember 4 things you forgot to say, you can just reopen it and add on the note with an appropriate time stamp on it indicating it is an addendum. These 3 features were enough to convince me.

I will let you know how it goes.

Yeah, all in all, I think it is worth upgrading. Not really sure what the downside is.