Computerized Progress Notes and CPOE.

Yesterday I gave a talk about computerized progress notes to some of our staff physicians. As we are now doing 100% CPOE orders, our next phase is to be paperless at some time in the near future.

I am very proud to say that our group of hospitalist are now 100% paperless. This includes computerized physician order entries, admission and discharge medication reconciliation and now progress notes.

I started doing electronic progress notes almost a year back. It was a challenge for the first few days but now I don’t think I can go to paper again. So these are some of the advantages I see in doing electronic notes.

• All the data you need can be pulled into your progress notes including labs, microbiology, radiology, vital signs, pathology and is updated automatically everyday.
• You don’t have to look for charts which are never there when you need them
• This makes it a one stop process, rather than first writing your note, place orders somewhere else and review data under 10 different tabs.
• You can see all your patients and than sit at one place and complete your charts.
• When you sign off, your partners can copy your notes and edit them and create a new note without inventing the wheel all over again.
• You can improve your coding as your note has more components.
• It is a much faster process.
• You can create your personalized templates and use them as needed.

Next stop history and physicals, if they become user friendly.

CPOE vs. CAPTCHA vs. Diabetes.

You must be wondering what is CAPTCHA? This is an acronym which stands for “Completely Automated Public Turing test to tell Computers and Humans Apart". This is a combination of different letterers and numbers you see at websites for security and prevents spam.

Regardless of how fail-safe our security is; you will always need a human interface. Or maybe it is my intrinsic desire to be superior to computers.

I have been a strong supporter of CPOE (Computerized Physician Order Entry) as you may have read it in my previous post “I Stole A Cow”. Recently I came across a Leapfrog study. Leapfrog group partakes in reducing medical mistakes and try to improve quality of care. There has been several studies in the past regarding safety and reduction of medication errors. However, a recent study conducted at 214 hospitals using a simulation tool missed one half of non fatal appropriate warnings and missed one third of fatal  order errors. Now this is something to think about.

I was attending a physician staff meeting last night. The speaker pointed out how there is a degradation of clinical protocols with time as new data emerges every year. One prime example is Leuvin Belgium study regarding Intensive Insulin therapy for hyperglycemia. We all jumped and started to mimic these results. However, later we realized that intensive glucose control can lead to increase mortality as shown by NICE-SUGAR and VISEP protocols. Since then we have changed our target numbers for normoglycemia.

My point is, that though we see a significant benefit from utilizing all new protocols, devices and systems. But we should not loose our skepticism. In my heart I am a skeptic, not so much to ask God for an ID card but enough. I believe in this analogy that if one person calls you an ass, don’t worry about it, if two call you an ass, step back and think about it. If three does, get rid of the tail!

I Stole A Cow-Episode I

OK maybe I didn’t steal it, I borrowed it. Let me enlighten you how it started… just few years ago.

There was this doctor(Me) who was minding his own business, printing his own list, carrying stacks of labs, writing encrypted doctor notes and filing them in the wrong places. He was approached by a suspicious looking character with thick glasses, smoking a cigar (Stop, OK maybe he was not smoking a cigar!). The only think he was missing was a long overcoat and a brim hat. He whispered “I am an IT tech and I think you should get a cow”. Hmmmm… my mind started to wonder, what will I do with a cow? My house is not big enough to keep a cow. I don’t drink milk. Is he saying that because I am from Pakistan. I am sure that my wife will not approve of it. I can make her steaks! How about if I ask this guy to give me some sheep and lambs to go with it then maybe I can convince my family to open a petting zoo of some sort. I started out by saying “how about”… he cut me in the middle and said “you know a COW, Computer on Wheels”. “Ohh…. oh I know what you mean” I said sheepishly but never blinked.

Apparently with time I got acquainted with a spanking new COW of mine….. my precious.  I found COW and all it’s cousins as an invaluable tool. Whether you carry a laptop, a tablet PC or a notebook, all of these devices improve your efficiency and may in turn improve patient care and satisfaction. Data is essential to patient care. For example if you are in the room and you have a data device on you, you can show patient’s what their chest X-ray looks like and what their labs are as compared to the day before. Rather than doodling on a napkin, you can show them an illustration from various web resources.

This process transformed in few years and made way to CPOE (Computerized Physician Order Entry). CPOE is tough love, it is like breaking a wild horse. It takes time and relentless effort in the beginning but once you break it, it becomes your best companion.

Unfortunately people steal my COW all the time, not literally. They “borrow” it and than I have to send a search and scout party to find it. Sometimes I am forced to steal someone else’s COW.  

Hence I am a COW thief. You may wonder why is there an Episode I? In the next episode I will discuss “COWS go through Identity crisis”. So bear with me.

About the picture: I am on a prowl, stalking a potential unsecured COW.