Home Forums Discussions General Discussion ED reports form my local hospital

So, our local community is constantly changing the EMRs everyone uses in WICs, EDs and hospitals. Not only that, the local groups get along like oil and water, and do not share information.

All of the WIC, Family Practice, Consultants and EMMC hospitalists and consultants use Centricity. The ED used to dictate, which was awesome. All of these are uploaded to Powerchart so I can review them along with labs, x-rays, progress notes, etc. EXCEPT the Walk-in Care notes, which are not uploaded to Powerchart. Their labs are.

Over the weekend, the entire EMHS (Eastern Maine Healthcare System) which owns Eastern Maine Medical Center and everything else including Amazon has changed to a different system. Of course, PCHC, the states larges FQHS (I won't go into them) has their own and St. Joe's has their own. PCHC rarely sends their WIC visits except when they feel like it, or we call. Calling will generally get the note in about a week as a Centricity document. St. Joe's is hit or miss. As the mafia would say as far as x-rays and labs, trying to get them from the FQHC and St. Joe's is a "Forgetta bout it," situation.

I have uploaded a pdf of a recent ED visit. First, go to

https://mmodal.com/products-services/

to see the product they are using now across the board. I suppose it would be OK, if it produced a somewhat soap-like note. But, it doesn't. I received 26 of these, some duplicates this morning, as they back transcribed these, although I believe they were done by the actual physician. The three noticeable things are the fact that there are no spaces from the top to the bottom. Second, they give the diagnosis first, and it is very hard to find the HPI or the assessment and plan. Their clinical thinking, at the very top under the diagnosis seems to act as their plan.

https://app.box.com/s/6sljnytczho4kvwcpnq9virh77e2wgmj

This is one of the 26 documents. Notice the fact that is painful to read through, but if there are any labs prior to the ones recorded they use a historical feature so that the sodium is listed for say 8/17/18 then then again below it for 8/3/18. The entire eight sheets or more of labs could have simply been entered in the format that our labs uses with a CBC and CMP, and it would be readable. I as well as you I am sure can glance through a CBC with diff and CMP in seconds. These are two painful to read. There are times when I am following a bilirubin or a ESR/CRP trend where more than one lab value is helpful. But, our Powerchart portal does this for us anyway. There are times when the past values are helpful, but there are many more times when the past labs mean nothing.

The info from the company providing this states it is great for HIPAA, Meaningful use and code documentation.

Would be interesting to get Jon's input or other consultants. I am a pretty big fan (could go either way) of the Assessment and Plan being at the top with the subjective being at the bottom as most PCPs and hospitalists are only looking for what the consult thinks and recommends. Consultants tend to have very good EMRs and notes, and many here use what I just wrote and put the PMH, PSH, FH, etc in the margins.

Once again, a company who solves a problem that did not need solving. I suppose you could have similar software, which takes you through different fields and formats a note that follows the Soap note format and is easy to read and even has paragraphs and lines between sections.

I believe we can all say we share your pain, Bert.

With the sole exception of AC, so far as I can tell, the various EHR's are written for the benefit of the shareholders of the companies that own them, the administrators of the hospitals that use them, and possibly for insurance companies and pharmaceutical companies to mine data.

Not one --- except possibly AC, and even there, I am not truly convinced -- solves any problem that doctors or patients had, or in any way advances the state of health care, or makes my day or my patients' days more fulfilling.

There is no reason why a hospital discharge summary needs to tell me who the tech was who drew the labs, or why every single test needs to be on a separate page. There is no reason why cut-and-paste notes need to look like they originated on the day of the visit -- usually it is impossible to distinguish historical data from the present day.
Among the worst is the tedious "artificial intelligence" listing of all possible ideas about what might be wrong with a patient -- that passes for a well thought out differential diagnosis by a human clinician.

Of course there is lots more wrong --but my point is, that in the last 15 years things have only gotten worse.

I wish AMA, AAFP, AAFP, and all the other once upon a time physician oriented groups would get their heads out of their asses and stand up for doctors rather than their corporate overlords.

I have been a loyal member of those groups in the past, but am now pretty much resigned to living in my little mouse-hole in NW Oregon, waiting for the day I can no longer practice because I refuse to join a corporate organization and become a slave to the shareholders and bureaucrats.

Well said Tom,

Fortunately, if you take five minutes out of your day to go on the hospital portal, you can read the progress notes and consult notes, which seem to be formatted much better. I also find the consultants whether they just write the H & P or say, "I know that you kow about the patient, but let me summarize it for my documentation."

One thing you bring up, and I am not sure it is AI or not, but the doctor I lease from and I have had talks on this. But, there are times a patient will come in with throat pain and a fever, and an RSA is negative. Of course, they still making one wonder why they got the lab in the first place, but they are forced by the higher ups to write this medical thinking which becomes a differential diagnosis. In the pharyngitis and fever case, it becomes I thought of, retropharyngeal abscess, peritonsillar abscess, meningitis, etc. I guess if it doesn't turn out to be meningitis, you are fine, but it seems obvious to surmise if you thought of meningitis, what did you do to rule it out.

The lack of spaces and the ridiculous six pages of labs, which adds the "historical" lab values, which I see no added help. The clinician could choose certain labs such as the ESR was 72, last week being only 24, etc. Normally, I would glance at labs both separate and printed inside the document, but I just have to trust them as I am not going to try to read these.

While I never convinced anyone and generally caught flack for it, I felt rather firmly when H & Ps were given my medical students and residents in daily rounds. While I understand it is probably more efficient to put all the labs in the objective section after the exam with the reader and listener likely understanding that the platelet count was done in the ED. But, I was taught that labs done prior to admission should be in the HPI as it is a good part of why the patient was admitted. Anyway, I digress.