Daily Docblock: EHR Style.

Its been a long road to readjusting to my EHR, and for the most part its been worth it. (see previous EHR articles). I’ve fine tuned my typing skills, I’ve become a black belt of check boxes, a jedi of templates, I whip through e-prescriptions and referral letters like Liam Neeson through eastern European bad guys. Yes, I am Neo, the promised one, of the EHR world. But a recent EHR update had me making yet another change to they way I see patients that I’m sad to say, has tripped me up. This relatively minor problem is that, with this recent update, my EHR takes too long to open after I log in.

Huge amounts have been written all over the web about the EHR and  how difficult it is to adapt to. To those EHR haters my response has always been this; The EHR is our new reality, if you just get used to the idea that you need to adapt to the computer and not the other way around, and just get on with the process of adapting your typical routine to this new reality, your life will be much better.
But this newest update has me questioning that philosophy. Yes I have adapted my workflow to the EHR, and made all of the changes I mentioned above. Now I have to make another change after a recent update that made only modest changes to the EHR’s functionality. The update has caused a 15 to 20 sec gap from when I log in to the time that I begin to enter information. I’ve tried to fill this time to prevent an inevitable awkward silence, but 20 seconds is a long time to make small talk. Plus I can only ask “how’s the weather outside” so many times per day.
On the other hand if I delve right into history taking, I’m then 20 seconds behind when I do start typing.
So thus far, my interim solution thus far has been to log in first and then go make physical contact with the patient before entering anything in the EHR. This usually involves  a handshake and maybe a few preliminary questions. In some cases, if I’m already familiar with the patient, I may begin my physical exam right away, before I even start entering data. In any case, if you’re one of my patients and you are reading this, I apologize that I am listening to your lungs before I finish getting your complete history, now you know the reason why. I’ll probably keep going with this interim solution until I find a better one, I’m more than open to ideas if anyone out there has any. Meanwhile I’m hoping all future programming updates don’t force me to change my workflow.
Incidentally, a similar problem has occurred at the hospital’s computer system. When logging onto the hospital’s system for the first time of the day, there is about a 30 to 45 sec wait before the program will open.  I now log in, hang up my coat, maybe get some coffee from the machine or check my mailbox, and then come back to the computer.
Either way, suffice it to say, this is getting kind of ridiculous. I am dearly hoping that all future updates will not similarly dictate a change in how I go about seeing patients. . . are you listening Allscripts?

I’m Tired Of. . .

It’s been a long few months. What with the recent death of a family member, the usual barrage at work, and trying to raise a family, I think I may be in the early stages of physician burnout. So I’m going to give myself liberty to do something I rarely do. . . I’m gonna complain. Oh yeah, I’m gonna gripe and whine, and cry like a little baby. Just this once. But don’t worry about me.  Because as you read this I’m sitting in a meditative cleansing trance, taking in beautiful scenery, and trust me,  it feels oh so good. So I’ll be back soon, batteries recharged, taking all the things I’m griping about here with a swing in my step and a smile on my face. Continue reading “I’m Tired Of. . .”

Doctors Are Being “Gagged” by Gas Drillers

First of all, let’s all agree on two things. First, that energy independence is good for our country. Second that clean drinking water is also good for the country. The development of America’s huge stores of natural gas, have given us a remarkable opportunity to accomplish the former. In particular, the process of “fracking” has made it possible to increasingly tap those huge natural gas stores.  Natural gas sits in rock formations, but releasing it is much more complicated than simply drilling a well and pumping it out. In order to tap the gas, it first has to be liberated from its rocky confines, after which it takes the path of least resistance, in this case is up a gas well. The technique of releasing natural gas from rock  formations is known of hydraulic fracturing or “fracking”. The process involves drilling down thousands of feet to create a well. Huge quantities of water, often a million gallons or more, are forced into the well. This opens fractures in the rock and allows the natural gas to escape. The water that was pumped into the well is a proprietary mixture that contains various agents which are potentially hazardous to humans. Only a fraction of the fluid is recovered, much of it stays in the well and is dispersed into the depths, (hopefully) never to be seen again.
The process of fracking has huge potential and not only for the drillers. As anyone who has paid close attention to their gas bill has seen, the glut of natural gas has lead a drop in gas prices, and this comes at a time when we could all use a break on fuel prices. The fact that it’s homegrown means that there are no foreign entanglements, it creates domestic jobs and reduces trading deficits. Natural gas even burns cleaner with less CO2 than gasoline. It’s a veritable win-win for the entire country. The tremendous upside of this cheap, cleaner,  home-grown energy source has lead to a boom in the industry, with thousands of wells sprouting up across the country, most use the the process of fracking.
But the rush to cure America’s energy woes has been well, rushed. One has only to look at the results of our attempts to harvest corn ethanol as an energy source to see the law of unintended consequences in effect. In a climate where a modicum of caution would be wise, both the government and the industry has proceeded with what can only be thought of as reckless abandon, summarily sweeping aside questions of safety and health concerns. This was typified in  2005 when the federal government passed what is known as the “halliburton loophole” wherein frackers are exempt from significant EPA regulation.

And that’s where we physicians come in. In the rush to create a business friendly environment for drillers, state governments have generally laid out the red carpet. This includes passing laws to protect  proprietary information about the content of fluids being pumped into gas wells during the fracking process. In many states, if a physician suspects water contamination, they may request to know the materials, but must sign a confidentiality agreement thus effectively barring them from disclosing this information to others.
Imagine being the physician in Dallas who saw patients who were exposed to fracking fluid, one of whom developed renal failure. Or the dermatologist in Pennsylvania seeing a cluster of people living near a well who presented with non-healing skin lesions after their water was contaminated. In such a situation it would be paramount for a physician to share this information with other physicians, to discuss the case with other consultants, to inform the public about potential threats. The medical community would need to disperse this information both through word of mouth as well as through published literature. Forcing physicians to sign confidentiality agreements would likely limit the transmission of such information. Even if such communication were technically legal, the confusion and fear created by such laws would make many uncertain about whether they could disclose such information.
I do believe that state governments are trying to do the right thing, in facilitating the procurement of what appears to be a cheap, abundant, domestic energy source and increasing their tax base at a time when it is sorely needed. However, it should be pointed out that government is first responsible to the people they serve. The process of fracking is being looked at with increasing scrutiny by the public as cases of contamination by fracking fluid and natural gas come to light in greater numbers. The current approach only fosters an environment of fear and suspicion and heightens the perception that drillers do not take the public welfare into account.
If the scientific community  was allowed greater access to information, the causative agents could be identified, and potentially replaced. Such an approach could be beneficial for drillers. There are indeed historical precedents for this type of relationship. The study of lead, and freon and their subsequent removal from gasoline and refrigeration has benefitted society, yet both of those industries continue to flourish today. In addition, drilling companies with poor track records could be weeded out and replaced by companies with better techniques. This process is the American way. It is taking place as we speak in a number of different fields including the medical community, and the drilling community should be no different.


Daily Doc-Unblock: Thanks Insurance Company, and I Mean It!

I’m used to getting the endless stream of useless notifications. Whether they be a fed-ex parcel with the latest black-box warning of sneezing from a new brand name skin emulsion, that I never prescribe. Or a an urgent fax, with an important announcement that the medication that was previously labeled as a 0.0083% solution  is now going to be labeled as 137 mcg solution.

So it was with a mixture of surprise, delight, and disbelief that I scanned over the following fax message from an insurance company in regards to a patient that I see:


Apparently this insurance company is informing me that one of my patients has been naughty and is not refilling their inhaler prescription on time. I can already see the follow up appointment. . .

Patient: Well doc, my breathing doesn’t seem to be all it could be.

Me: Well, let me see, I’m going to concentrate really hard, and look into your past. Hmmm, wait a minute, I think I see your problem . . . you haven’t filled your  inhaler prescription in over a month!

Patient: Well doctor, I actually have been taking it. I’ve been getting my prescriptions filled overseas for a third of the price of what my co-pay was.

Me: Crap. Just when I thought this job was getting easier.

I Need a Reminder. . .

. . .To Remember All These Reminders!

Walking around the hospital the other day, I came across a notice reminding physicians about documentation requirements. I had seen the note when it was first posted a few months earlier, but it had since faded into the background  wallpaper, and I don’t remember noticing it since. It made me wonder about all the notices that go un-noticed around the workplace. So I decided to start looking out for them, and was surprised to find just how many reminders there were. Here a but a few for your perusal.

Continue reading “I Need a Reminder. . .”

Daily Docblock: International Espionage Edition

Around the world right now, there are evil nerds plotting attacks on our nation’s computer systems, while ours are plotting counter-attacks against theirs. But in my daily grind of looking at images sent from radiology centers, I have discovered something which could be wielded as a sort of super weapon in this war; the CT scan on C.D.  My plan is simple,  just send one  CT scan on C.D. to a high-placed member working on a sensitive computer network of one of our adversaries. It would labelled appropriately to entice the user to place it in the CD drive (“grandkid pictures”, “porn”, “Lady Gaga’s Latest Shoes”, etc. . .) Once the user places the CD in their computer, and clicks on any screen, then if these things work they same way they work on my computer, they are simply moments away from complete system shut down.

Their computers will freeze, becoming completely obstinate in their refusal to continue. If an attempt is made to close the program, or remove the disk, the program will ask for the disk to be placed back in the computer. If the disk is placed back in the computer, the program will state that the disk is not recognized. If an attempt is made to shut down the computer, the program will ask the user “are you sure?”. If the user clicks “no” the program will ask “why not?”. If the user clicks “yes” the program will reply with any number of vague responses such as “in progress…”, or “why?”.

 The process will be frustrating, maddening, even tech support gurus will be beffudled and have no choice but to  wonder about the wisdom of messing with a country that could produce something so diabolically powerful!  

Daily Docblock: Denied Edition


It seems the doc-blockage never stops. A particular thorn in my side has been Care Core. They manage imaging services for an insurance that we accept and often deny coverage for CT scans. Once the requested test is denied, the physician may appeal by calling a 1-800 number, and much of the time, they end up approving the requested study. So my question is, why make the physician jump through hoops just to get the study done, when ultimately you are going to approve the test if a physician calls? Then again, maybe that’s the point, not every physician will have time in their day to call and appeal, and many of tests will not get done.

The Daily Docblock: Self-Block Edition

Sometimes docblocks come from the most unexpected of places. . . ourselves! Recently I’ve had a slew of patients see me in follow-up after me or my partners saw them while in the hospital. . . sometimes months later. Problem is, there is not always a dictation summary available, meaning I’ve gotta spend lots of extra time digging through test results (over a painfully slow remote access system) until I can finally suss out the reason for the follow up.  Eventually we get it all figured out, but those extra minutes are surely frustating.

The Daily Docblock: Jurisprudence Edition.

We usually have a nurse practitioner who helps round on hospital inpatients. Unfortunately she got called away on jury duty, which means I will be seeing more patients on my own. Luckily it’s not too busy in the hospital today and I’ve also got a fellow doing a critical care rotation, which should make things easier.

The Daily Docblock: Vacation Edition

Sometimes a doc just wants to get away from it all, ya know go back to their hometown and let the grandparents get some grandkiddy time. Unfortunately the docblockage followed me to the airport, where Delta airlines cancelled our flight, then got us to an adjacent city sans luggage and car seats. . . at 1 am. Luckily we now are now in possession of our prized possessions 2 days later. . .though I was  starting to  get used to wearing my dad’s 1970’s leisure wear.