Home Forums Discussions General Discussion Inbox management if I'm on vacation

I'm the "techie" of a 4-partner nephrology group. We practice in one main office and at two Satellite locations (we see chronic kidney disease patients in space we rent from two remote dialysis centers, and we have separate billing location codes for those locations).

I've seen the stellar reviews for AC on AmericanEHR Partners, done a web demo, and I have questions:
1. Assuming labs come in to my inbox through an HL7 interface, who sees those labs if I'm on vacation?
2. Can AC be used from remote locations?

Thanks so much.

I don't use the AC/HL7 lab interface: hopefully someone else will post a reply.

Here are discussions on accessing AC from outside the office network:
-- using Hamachi , also here .
-- using LogMeIn

#1 Whoever is logged in under your account if they are going to your inbox.
#2 Yes, like anything on your computer, you can access it remotely with GoToMyPC, LogMeIn, RDP, VNC, VPN, RWW or any other way you choose to remote in with.

I highly recommend LogMeIn. This works well for all aspects of management while away from work.

Thanks to everyone who's answered.

The gist of this, I think, is that I have two options. Either I make myself responsible for everything 24/7/365 and log in from wherever I am, or I give my login credentials to each of my partners and one of them is assigned to graze my inbox when I'm away.

Neither of those solutions seems entirely acceptible to a multi-provider practice. I'm a visual thinker, so I guess what I should do is create a half-dozen or so test patients and get messages into each provider's inbox about several of them and see what happens.

I use the gigantic "Epic" in its Kaiser incarnation every day; the featureset itself is so enormous as to overwhelm people who don't use it all the time, but it's so easy to see who's reviewed things, and when. I can see liability problems from the "solution" of doc 1 logging in as doc 3 when doc 3 is sick, on vacation, or (and this is the REAL worry) has become mentally unstable. The lawyers get involved, and in court the poor stable doc has to admit that we can't document from our software who has done what because we all need to "impersonate" one another to get our jobs done.

Am I missing something? Please forgive me if I sound dismissive or sarcastic. I really like the "look and feel" of Amazing Charts, and that makes this even harder, because there's something very difficult about accepting that a tool that "almost" works really doesn't, when the tools that DO work are so much harder to use.

If there are multi-doc practice users reading this thread, I'd be so grateful for their input about my concerns.

AC in its present form won't perform as you wish, with a detailed (pardon the term) "paper trail". I'm okay with it, you may not be. We all know the environment we practice in.

While I understand your concern, I guess I don't see the difference between partners covering on-call responsibilities such as rounding on inpatients, returning patient calls, etc. Your partner logs in with your password, reviews labs, contacts the patient or staff, and puts an addendum in the patient's chart documenting his/her actions, clearly stating "Dr. Smith covering for Dr. Jones". Isn't this what happens in a paper chart? They either have your back, or they don't. You probably would agree that those of us who have been in multi-doc groups (I have partnered with up to 5 docs), come to know the reliability of different partners, and govern ourselves accordingly.

As far as satisfying lawyers, being careful is important. But catering to their paranoia will make us all nuts. You may want to ask your liability carrier whether you need more security in an EMR entry than with a paper chart. In response to why your partner knows "your" password, maybe all the covering physicians should have the same password?

I agree with John completely. You don't need passwords with paper charts. This is where shortkeys comes in handy. The doctor just handles the situation, hits an appropriate shortkey which says, "Handled by Dr. Smith for Dr. Jones or simply handled by Dr. Smith at 8:45 pm on 1/2011.

At some point you have to treat the patients and not the lawyers.

You could also get a long statement using shortkeys that would have to be written out by another doctor. Another covering doctor may do a crappy job, but I doubt they are going to lie and type in your usual statement.

srnephdoc has a legitimate concern. Proper documentation of who actually is signing a chart is not legal minutia. In papercharts you generally can distinguish entries by handwriting. I suspect the majority of small practices do not feel comfortable sharing passwords. Particularly newly formed groups.

How do other EHRs handle this? Until AC has the "covering doc" feature allowing a doctor to designate another provider to recieive all messages for a defined period... hmmm

Can I temporarily change my password for a week or two and provide the covering doc with it? 2 weeks of exposure vs 52.

Not to interrupt things as I am curious about this answer as well and would appreciate understanding how the large groups are handling this. I am however a bit confused. When labs come in do they automatically go to the box of the ordering physician? Is there a way to sort them elsewhere?

I'll chime in with a couple thoughts from a systems perspective.

One, in those cases where you are 'sharing a password', I recommend that you actually change the password before sharing it, and then either change it back when you return, or better still, rotate your password!

Knowing when the password was changed, and changed again, you know when the other Doc was making the entries, I'd suggest that you ask him to forward the charts to you(yourself), so that you can review them on your return, and annotate as you see fit.

For labs, I would wonder if it makes sense to send the labs to both Docs - what say you folks?

It sounds like this is another place that should go on Bert's list of things to add/enhance.

Neil,

Depends on how you choose to input/integrate labs.

Some folks scan faxes into imported items, some folks use UpDox, some folks use local fax servers. During the step of importing the lab results, office staff could do a variety of things, but one of those steps is forwarding the lab to the Doc for sign-off.

I agree with many of the ideas advanced here help to address the issues raised by the "senior nephrologist" (please, give us a name ).
As stated by Bert and John, a comparison to the paper system is often instructive. Currently, if a patient calls with chest pain or a lab reports a K of 7 while a doc is away, you do NOT want that message put on the doctor's desk or inbox, only to be reviewed when they return. By the same token, your staff must be careful not to send such a message through AC to a vacationing doctor's inbox. Liability is essentially the same in each instance, and appropriate precautions are also the same: messages go to a covering doc when someone is on vacation.

So the differentiating issue is messages that are put into a box in automated fashion. Neil, as Indy says, how often this occurs is determined by your set-up. Labs coming in by fax or paper or imported by a staff member (with or without Updox) and they chose whose box to put them in for sign-off. In that case, again, instruct staff: "Dr. Kidney is on vacation this week so be sure to put his labs in Dr. Nephron's box". If you have a lab interface, then some labs will be coming into a doc's chart in automated fashion without anyone routing them. If you really don't want to let other docs get in and sign them off, then let someone (e.g. the office manager) have the doc's password. (Someone will already need to have this anyway.) Their job is to go in daily and forward all imported lab messages to one of the other docs for review. You have a record that the messages were forwarded and a record of who signed them off. Not ideal, but pretty minimal liability.

I would respectfully suggest that if your "real worry is a mentally unstable doc", then the potential damage done by inappropriately signed-off messages is the least of your concerns as that scenario plays itself out.

Indy, having labs sent to two docs is not a bad idea. I assume the interfaces have the capability of sending your system the results twice. On the downside, it would require that each time the about-to-vacation doc ordered a lab, he would have to remember to "cc: Dr. X" and would also mean that ultimately two copies of each report was in the chart (I think).

I am a solo doc but I still have the same concerns. When I am on vacation, I have a competent staff member in the office to take calls, schedule appointments, direct patients where to go for care, etc. I have been reluctant to convert from Paperport (which receives all the faxes which can then be viewed by all the employees) to automated importing interfaces for the very reasons above.

My staff can review labs when I am gone and contact me directly by phone if there is an urgency. If they cannot get me, they can call any of several colleagues with whom I have made arrangements. They can weed out the normals. They can even do simple refills.

I generally check in via Logmein daily and handle the other time-sensitive stuff. That is unless I am hiking in the Tetons. I think as long as you make a legitimate attempt to have some system in place your behind is covered.

Leslie,
I share your concern about viewing automated interfaces when I am away. My approach has been to check daily via Logmein, but that does "tether" you to the office, and is tough during the mountain hikes.
Updox, of course lets you or your staff see all incoming faxes. I predict that one of these days the Queen of Paperport will make the switch!

Jon, believe me, I have looked at it but I find the cost per fax way too high

Leslie,
Have you read my post about having a program convert your faxes to emails (done silently, in the background)? Updox charges nothing for emails, so your price is essentially fixed. Just guessing, but I bet my fax volume is comparable to yours and I have never paid more than the base $35 a month to Updox. (And they are fine with this...in fact, they suggested the idea to me).

No, Jon, I did not see that post? Can you link me to it?

This is sad.

You are sick and grumpy

Doubted that rumor that you guys were married. Now I am starting to wonder.

Bert, what prompted the "sad" comment?

Leslie,
Updox charges a base fee for 3 users, plus a charge for faxes over 500 a month. They charge nothing for emails. It is simple to configure a conversion program (we use Fax Talk; others use Snappy Fax) to automatically convert all of the incoming faxes to emails. You never even know this is happening...until you get your monthly bill from Updox which shows roughly zero faxes for the month.
Again, the Updox people are fine with this.

Bert, Honey, are you still mad at me? Would you please stop and pick up some milk on your way home?

Jon,

Thanks for that info. I will look into it again. Or I may wait until after the ACUC as I intend to hit you guys up for a demo. Gotta go now. Bert's laundry just buzzed!

Please forgive me. I'm not sure what you're referring to.

It is indeed sad that we just can't use whatever documentation tools we use to care for our patients without worry about proving who did what. However, we live in a litigious world, and most of us have read mailings from our malpractice carriers chronicling disastrous consequences of not acting on information we've received (abnormal mammograms, dangerously low hematocrits, elevated calciums, potassiums, BUNs, etc.)

As soon as an individual becomes part of a group, there will be differences in style - documentation, work habits, personal mental filing cabinets, whatever. Unless there's a way to track who has seen what and who has acted on what there's enormous potential not just for misattributed negligence liability but also for information not to be found easily.

Most of the EHRs I've looked at that are designed to be used by groups bring data from labs, imaging centers, etc. into a PRACTICE inbox that's monitored by a staffer. That person works from defined lists of "panic values" for labs before placing ANYTHING in the designated doc's inbox. There's a precise analogy to the paper-based office, where all incoming correspondence, reports, etc. are viewed by a staffer and distributed manually.

It seems to me that it wouldn't take a huge amount of coding to modify Amazing Charts so that there could be such a shared inbox for the practice as a whole. A real person would see everything that comes in; the software would record how he/she handled it. If there's a lab report for doc A, but he's away, the screener would route it to the covering doc, and the software would record who has processed it.

Of course, the doc who ordered the study will want to know the result, so he should see, when he returns from vacation, that the covering doc has seen the report, and ideally, there'd be an interface in the software for the covering doc to annotate the report if he did anything with it other than look at it).

In our paper based office of four docs we have little trouble tracking these things, because we sign reports when we review them, route them to the vacationing doc's "review when you return" inbasket if we're covering for a partner, and attach notes that become part of the chart if we do anything with the report other than attest that we've looked at it.

I most respectfully submit that an electronic workflow that's decidedly inferior to that ("just log in as the vacationing doc") is unacceptable. The notion "the vacationing doc couldn't have seen this and ignored it, because he was thousands of miles away, so just look at the practice schedule to see who was covering" is wrong on two fronts: first, people have suggested in this thread that the vacationing doc COULD just use LogMeIn to do exactly that; second, the burden of retrieving an accessible record of "who covered when" months or perhaps even years later (outside the EHR/practice management software) defeats one of the main purposes of using a robust database to record what we do.

I want to love this product, because it "nails it" in so many ways as regards how docs work, and so many EHRs are NOT designed by people who actually do what we do.

Thanks so much.

I always hate it when I forget to add a topic to my watch list. I have always thought it should be an opt out vs an opt in.

I guess a few either too offense to this comment or didn't understand it. Wow! My apologies.

It was simply meant to reflect the sad commentary on today's medical system and how we must practice defensive medicine. I think it is a valid concern to know who is documenting what on whose patient, but I am just not concerned about the medicolegal aspect. I just don't have time for that.

So, yes, it is sad.

Srneph, thanks for sticking with your thread and elaborating your concerns. Bert, thanks for explaining what you meant; I think we can all agree that it is sad to have to worry so much about the medico-legal aspects of chart signing. It is also clear that there are some legitimate quality of care issues as well.

Srnephdoc, in my post above, I explained why I think the automated messages are the real concern here. Again, a message left in the wrong place for a vacationing doc is a recipe for disaster; that is true with a paper or electronic message. Did that make sense to you and fit with your experience? If so, then perhaps your interface(s) can be configured to be brought into one common message box. All the labs, etc. would come to one box which is opened by a staff person who sends them to the appropriate doctor, and if someone is away, they would know to route it to the covering doctor. That doc reviews it, files it, AND sends it to the box of the vacationing doc who sees it upon his return.

I didn't see one of the previous posts. I really have to go back and look up the definition of sad. It's like I said, "This thread is stupid and anyone including me that is reading it is stupid."

Anyway, I am not sure what your work flow is, but this is part of the downfall of HL7 interfaces and labs coming directly into AC. Or scanning directly into AC. Many people on here have all of the faxes come into one inbox (not in AC) where they are screened and sent to the appropriate doctor.

Not to belittle this issue as it is very important to patient care, but a lot of people say it would be just a few lines of code. While it may not be designed properly and while it should be changed, it is likely quite a bit of code. And, everyone who suggested the 81 recommendations (not to say that most are equal to this one) think it is very simple to incorporate their ideas into AC.

Jon's idea of changing the way the labs and x-rays come in to one box (maybe a fictitious doctor) sounds like a great idea. I may have had a better idea, but we don't use Imported Items mainly because the folders don't stay closed. That last statement is a joke.

And, no Leslie, I am not ignoring you. First, I wasn't following the thread since my awful comment. But, second, ironically, while everyone was stupified by my unjust and extremely curious comment, I WOULD have been just as stupified by yours, given I didn't know mine was so awful. Does that make sense?

Bert,
As stupifying as your comment was, I can see how stupified you might be by my stupifying comment which was a response to Jon's amazingly stupid (but really funny)comment that we were married

I am not able to complete all the charts on the same day or even in several day. Charts forwarded to different users in the office remain in their box and I have no access to them right away.

IS THERE A WAY TO ALLOW THE CHARTS WITH INCOMPLETE VISIT/S TO REMAIN IN COMMON POOL SO THAT ANYONE CAN ACCESS IT ANYTIME TO EDIT OR ADD DATA BEFORE FINALLY SIGNED BY THE PROVIDER?

You can pull out the charts you have sent to other users by going to the "Outbox" tab of your Messages window and retrieving the chart.

Don't type in ALL CAPS. It's hard to read.

To answer your question, yes, just create a User called "Chart" or something, as a common area to "park" charts. Everyone will have to log out their usual account and log into the "Chart" user account to make edits, however.

Just realize that this will allow several users to non-sequentially make edits to the same Encounter Note. Not good, in my opinion. You may find several copies of a single Encounter floating around in different message boxes. Probably best to keep the uncompleted notes in your box until you sign off.

I agree with John. In fact this is one of the areas users want to work on in AC.

I know you probably know this, but the faster you can get to the point of finishing charts in the room, the better.

That's exactly the situation about which I expressed concern, and also the kind of solution most offices use with paper. It results in as many as three people instead of one having to handle incoming "stuff," but dramatically decreases the likelihood something will get stuffed into a paper or electronic chart without the proper eyes seeing it. In our nephrology practice, the most common potential problems are things that result from additional decline in GFR in patients with advanced CKD (hyperkalemia, dramatic decrease in hematocrit, big rise in BUN, worse metabolic acidosis, etc.

All our incoming paper lab reports are screened by a staffer who works from parameters we've given her. Nothing goes directly into a chart or onto a vacationing doc's inbasket without being seen by a covering doc, but those with "alert" level values are put on the covering doc's desk flagged to be seen today, and of course anything with a "panic" level value is called to the doc immediately. Results with no "alert" or "panic" values are still screened by the covering doc before being put on the vacationing doc's desk. Of course, if the patient is in hospital and the covering doc is managing the patient daily, sometimes things that happen to an individual doc's patient can go to the chart from the covering doc without passing underneath the vacationing doc's eyes, but they've been "handled" by the covering doc who's temporarily doing the patient management anyway.

The EHR should have a similar capability, and because of the swarms of lawyers just ready to pounce, it should be able to track who did what and when.

It's not perfect, but it can track:

Date | Time to the second | User | Operation (Insert, Sign, etc.)

Description (Created patient message, Created SOAP note, etc.)

Row ID | Originating computer
__________________________________________

What is weird about the log is that it gives the RowID (SQL database) and the audit number (SQL database).

But, at least for now, you would be able to track who did what to whom from where at what time. (If passwords were good).

You would be able to see the entire note, message, etc.

Srneph, I am not certain, but you may be able to get exactly what you want very easily. All automated labs are set to come in through interfaces. Set up a user named "Incoming Labs". Tell AC you want ALL imports via interface to come to that users message box.
A staffer reviews the messages and distributes them as we discussed above.

Would that not solve your problem?

I know it would be best if AC did it better. They should.

But, this is one of those times when doing it somewhat outside the program at least first may be helpful.

By the way, I think I have your name from your email. Do you mind if we use it. Just easier to type than your nick. Of course, some don't want their first name on the boards, so let us know.

I suspect it would. I wonder what would happen as the program evolves, though. My understanding is that the lab interfaces are one-way at this time; i.e., docs don't order labs via the interface. If it becomes bidirectional, then the problem might recur(?).

Does a similar issue exist for ePrescribing and eRefills? For example, do eRefill requests go directly into the original prescribing doc's electronic inbox? If so and he/she is unavailable, they wouldn't get processed unless someone else logs in to the inbox, and my guess is that an "incoming Rx request" inbox wouldn't work, because my understanding is that Rx traffic is tied to a specific doc by UPIN or NUID or License or DEA (or all of them?).

Thanks for your suggestions and for helping me to understand the program better.

Does that solve my issue? Let's say that I'm on vacation, and I decide to log in as me to review labs. I'm at a sidewalk cafe on the Champs Elysees, having a really good time, and I'm not as attentive as I should be. A serum potassium of 7 slips by me (we see those all the time in my business, and hopefully we never miss their import).

My poor partner who's agreed to log in as me daily to review labs while I'm away never sees that K (because I processed it remotely), and the patient arrests before dialysis. If I'm unwilling to 'fess up that I reviewed labs from across the pond and blew my assignment, my poor partner's defense will be that he's certain he's certain he never saw that report. However, he'd have to agree that it was his responsibility to do the lab reviews, and that he did so using my password. Can the database review indicate that this particular lab check was accomplished via a remote login? He might be saved if all the rest of his reviews were done sitting at his own desk (and the database records the computer used to process the report).

Please don't think I'm trying to belabor the obvious. However, I think it is often the case that group practices have people with very different styles and degrees of attentiveness, and the best of us in terms of our obsessive-compulsive behavior may not be seen that way by our patients (the person in our practice who is most detail oriented has been labeled "Dr. Hi/Bye" by one of his particularly difficult dialysis patients because she doesn't think he gives her ALL the attention she deserves on dialysis rounds).

Jim Robertson

Jim,
With regard to the "Paris scenario", I don't think AC would be able to differentiate between a sign-off via log-in and one done locally by your partner. On the other hand, logmein does create a log which would record when you were signed in (and from what IP address). So...in the above scenario, with a little research, your partner's legal beagles could match the date/time of the sign-off with a time that you were signed into your computer with logmein, and voila, he is off the hook.

Certainly that is not the ideal mode of documentation, and it is for that reason that I might not favor the "shared password" approach, but still it is a reasonable fall back position.