Continuing Saga of an Install Gone Wrong

The blog which I've been making has skipped a bit. The system is now in 3 weeks. Current problems include not being able to see a past diagnosis without getting the exact date of care, not being able to see past diagnoses when making a bill (superbill), and persistent log-outs (all the way out) when locking the screens for HIPPA purposes.

The first and second, not being able to see or call up past diagnoses would normally be only a partial nuisance; however, the system expects a diagnosis and treatment for each visit and that information may be available in the paper chart. Ah yes, the paper charts. We are doing a parallel system awaiting the install of the EMR side of the system. As before charts are hard to locate and more difficult to find than ever. Although the notes are still written , the diagnoses are not carried forward so unless the clinician wrote the (coded) diagnoses and treatments, its anyones guess.

The system is rich in features, but again, because of a patchwork installation, which appears from this clinician's view, to be graded toward bringing the administrative portions up to specification first, the clinical wallows in a purgatory of half electronic and half paper. I ask again: "whom do we trust?".  I find this the most important of questions since diagnoses and treatments now exist in two places.  If audited and there is a discrepancy between the electronic billed forms and the paper chart, which is real; or are both.  My general experience has been that the physicians are responsible for what is billed using the chart record as a backup. Billing errors have not been kindly accepted by government payers like Medicare, who hold the billing record as an 'attested document'.  I do hope that the new system will bring online the ability to see the submissions and rejections so that we, the clinicians, can adjust our billing methods more efficiently.  Our former electronic billing program was unable to supply that information. 

The last, the persistent log-outs so that each patient requires 60-120 seconds of administrative boot-up/login time is more than a nuisance, its frustrating.  As a clinician I use more than one room while a patient is being treated or awaiting some test or documentation; I cannot leave the computer open with a patient in the room. When I lock the screen (the traditional windows 'flag key' + 'L', I have to log onto the system, log into the program, select my patient category, refresh the screen and then find where I was in the programming. If, heaven forbid, I was in a working screen when I locked the screen, the system locks access to that part of the program, apparently permanently, locking the screen. There is no 'unlock' facility and I have created a 'read-only' record in that portion of the program. The IT folks are unable to execute a fix for this. The real problem is that many users do NOT lock their screens and as I walked around the clinic today there were more than eight screens open in unattended rooms.

The other day (remember its now nearly four weeks since implementation) I wanted to print out a portion of record. I have two separate types of terminals, one a thin client (WinCE) and the other a standard WinXP computer to work from. The XP terminal long has access to most of the printers in the organization, but requires an administrative pass word to implement access. No problem. Wrong. This program requires its own internal workings to implement printing from the program. Our admissions and business people do have printing enabled; however, they don't have the access nor the energy to print out each piece of the record I might need for access. Making a preauthorization call or answering questions from insurer's on the phone has become a new write-down task, since terminals are not located adjacent to phones.  After many days of tweaking with the system, the XP system now can print from the program; of course the printer isn't selected so EACH time a print run is done, one has to go to 'select printer', select the printer, then go to a separate print program to print. There is no 'multiple print copy' slider, key or pull down, so each document copy needs to go through this iterative process. Occasionally, the program will print then dump to a login (yes that's a SYSTEM login) once again.

Thoughts and measures:

1. The IT folks have done no training specifically for the clinicians .
2. The installing company has released no additional training manual portions
3. The installing company trainers have not yet asked for the specific specialty and sub specialty documentation which will be needed for each clinician.
4. Although the system is marginally faster there are still times of the day when there are noticeable halts and delays in process.
5. Although the design is multiuser multitask, the implementation appears to have significant delays as more portions of the program are used.
6. From a 'consumer' standpoint, I find that long useless logins are interruptive to the clinical process , disruptive of the patient flow and more important are begging for violations of HIPPA regulations.
7. Hobbling a very in-depth system only frustrates the users and makes it less likely that team leaders will arise from those who can figure out the system

Some thoughts for improvements.

1. Even though there is always a heavy push from the administrative segments to enable all the administrative portions of programming, some nod to clinicians who are essential to the aggregation of accurate data, should be made on a continuing basis.
2. Although in clinic settings the administrative decision makers are often separate from the clinicians who need to use the software, it is crucial to bring the providers along step by step. In our organization, rumor and partial information are released through the usual impromptu chains rather than regular news or even updates from IT. A regular, perhaps even daily, available newsletter might quell a lot of fear and make even a seeming availability of an overworked IT division.
3. Trainers and the IT department should early on make contacts with the clinicians, both to assure them of their role in the installation and to involve them early in the process with contributions to the medical record (this is an EMR system).  There was no involvement of clinicians, clinical departments or department heads in the choice of this software.
4. We evaluated the reason for the halts. Each process in this system starts a remote desktop process, often running as many as 10-15 processes from a terminal. Involving the clinicians and staff so that they understand the importance of closing unused processes to speed the system might have helped to clear a lot of the log jam. Additionally this system is currently used with only 30-40% of its clinical processes. The delays seen with the billing only side might be avoided with better factoring of process sizes and needs.
5. Delays and interruptive processes, often not evident to designers and IT people (ours routinely joke about the numerous required logins), a back channel of system complaints and concerns from the users should be maintained so that at least there is an appearance of caring about end-users.
6. The design of an implementation that makes for HIPAA violations, either because of paucity of equipment or work areas or trips in the system that require extensive log-on should be evaluated. The IT team should be making regular rounds and inventory of open terminals, evaluating the reasons for their being left open and reporting in a non-punitive way, how corrective action may be taken. Again early and cooperative action with those at the point of the knife is essential to system security.
7. As a final drumbeat about involving the clinicians, close cooperation of clinicians is essential to the implementation and eventual smooth running of the system. In our particular implementation, IT has not directly addressed the clinicians after the initial install date, has not tracked problems from the clinicians in any forum, and has not made timely updates for clinicians. Most information for the clinicians has come bottom up from the administrative assistants or by proxy with e-mail warnings about system shutdowns or maintenance.

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