Health IT: This Is The Best We’ve Got?
My frustration continues to grow and grow with the more I work and work. I find it extraordinarily hard to believe that with all the great minds in computers and medicine, we don’t have a system that makes practicing medicine more quick and error proof. Even at the VA, a hospital system that has arguably the best computerized medical record, things ar incredibly inefficient.
An example of my day: get to the hospital, see my patients from the night before. Write down their labs from the computer onto a sheet of paper for my “progress note”–my assessment of what’s going on with them over the last day, if they have any new problems, and what I’m doing to diagnose and treat their problems. So I get their labs from the computer. Then I go to their chart, and write down their vital signs (temperature, blood pressure, pulse, breathing rate, O2 saturation) and Ins and Outs. Then I go to their nursing clipboard and write down their medications. Then I write out my assessment and plan for the patient (what I think each problem is caused by, and how I’m diagnosing/treating it).
Once this is all done, then I copy most of it to a little reference notecard, listing the patient’s recent labs, their ins and outs, and any changes or updates to their medications.
After all that, I present the patient to my attending, where I have to read aloud the vitals, the lab numbers, the changes in the lab numbers, any study results, and on, and on, and on.
An absolute, horrific disaster. A waste of time and paper.
I can imagine a system where we all have computers, or PDAs, and all our patients’ latest data just automatically appears. But it’s just a dream.
The system is already here, the challenge is to make use of it. At our hospital we use EpicCare which is software for EMR. It’s pretty good actually and most of the things you mentioned are done electronically. Admission notes and progress notes can be done electronically and the system automatically pulls out vitals, labs, meds, etc. and puts them in your note. In a sense, future is already here. At the previous hospital, where I did my residency, the nurses record their assessment (interval hx, vs, physical exam) in the computer system. When you round in the morning you can see everything that happened since you left the hospital the previous day. It is so comprehensive that we use to joke that you don’t actually have to see the patient – everything is recorded in the computer… :-) But of course, you HAVE to SEE the patient.
Both hospitals that I am using as examples have computer terminals in patients rooms (portable or stationary).
I also used to use a progress nore template that you just fill out and then put in the chart. Email me if you want a copy.
Also check out these sample admission notes:
http://note3.blogspot.com/2005/01/sample-admission-notes-for-most-common.html
They can be used as paper templates or saved in the computer system and completed electronically.
Interesting to see your entry and comment. We’re in the midst of a huge project with 26 affiliate medical centers and clinics going onto EpicCare. I’ve been impressed so far with the product, but since it’s not in use yet, maintain a “we’ll see” attitude. Glad to hear such a positive spin on it.
lol:) and u forgot to say, that at the end of the whole procedure, u`ll get back to the computer, and write everything in it:)
I totally agree with Sara!
I hope you do not feel frustrated for real, because that´s the first step to the burnout.