[ThaDood]

I mean, are there any good EHR systems? Lol

I would love to see more wide spread adoption of FOSS EHR systems, once with actual feedback and development input from doctors. I don't think it will happen. Meaningful use and interoperability have basically made it so Epic and Cerner and the other big players have an advantage due to resources for development.

I had a glimmer of hope, Ohio (where I'm from) was considering allowing a companies to bid on a contract to to host a low-cost/subsidized OpenEMR instance and letting healthcare systems use it. Sadly nothing ever came to fruition.

[devilbunny]

It's big, it's complicated, and nobody wants to write all the necessary but mind-numbingly boring interfaces to a thousand older devices and systems to make the glue unless they're being paid well to do it.

For all that CPRS - the old VA EMR, paid for by the federal government and thus openly available - got a lot of flak from all angles, not least of which was IT (the whole thing is written in MUMPS and the CLI underneath the GUI could be charitably described as "arcane"), it was a fairly easy EMR to "get", and once you learned how to filter things, you could at least see everything going on.

With Epic, Cerner, and the others, you don't. You have a silo'ed role. Early on in our Epic migration, I discovered that I had been misclassified by the system. I was a doctor, yes, but I had a range of options open to me that were appropriate for an ICU doctor, not an anesthesiologist - I simply couldn't do a lot of things that were my bread and butter. Finding information outside your normal specialty is difficult and requires a very precise set of clicks (which are not in any way intuitive) to get to the information you want. I stunned one of the cardiac surgeons by showing him how to get access to the OR status board (which he had, just not as simply as we do) and how to customize it to show him everything going on in every cardiovascular surgery room and in the cardiac catheterization lab. Now, when a cardiologist calls him to say "I'd like to consult you about the patient I just did a cath on, think he needs bypass surgery instead of stents", he can skip getting a medical record number and just open the chart directly from the list.

I can't read nursing notes. I've tried, and I know the information is there somewhere, but unless I've been given access to a flowsheet that shows it (and that is another obscure thing), I can't see it. Labor and delivery nurses don't have access to anesthesia records, so they can't see what medications their patient got during a C-section, and end up having to call one of us to tell them precisely what was given and when. Most surgeons don't know how to look at the anesthesia records (it's not easy) for their own cases, let alone their partners' (when covering call), so again - they have to call us to ask. I had to open up one for the head of the peer review committee to show her what had happened in the operating room after a patient death.

There are always going to be privacy concerns, but these systems all have aliasing ability, and in any case retail-level, one-by-one accessing of sensitive people's info is going to raise a lot more flags than data breaches involving millions. Not letting me see what went on before, during, and after for a patient I have to care for is far worse.

[goda90]

These systems are highly configurable because every hospital wants to do things their own way. There's a good chance many of your complaints are a result of configuration that can be changed. Go to your IT staff with a list.

[devilbunny]

I'm sure that it can be configured that way. But they won't give me the keys to set up custom filters. I've got contacts that realize that I'm not a moron, and I would never touch defaults in production, but I can't even get a playground where I can do EVERYTHING to figure out where the problems might be.

And if a guy who has their own IT staff telling them it can't/won't happen, despite actual onsite EPIC staff saying it's entirely possible, you see why. When you tell users to go away, and tell interested users that they can't share their improvements, not even privately, you are doing a disservice and you owe me at the least an explanation of why doing it is bad. Maybe there's a good reason that I should be allowed to mess my own system up but not let anyone else enjoy it that way, but I struggle to understand why. The whole thing can be re-imaged if I screw up too badly, after all.

[haldujai]

You're blocked from the Epic-PLY and developer sandbox environments?

Are you talking about custom chart review filters? Also not sure why that's blocked, I use those a lot and we can copy them from other user profiles without going through IT. But yes to have this be a default for new users we still need IT approval which no one has bothered with.

This sounds like draconian institutional policies are the limiting factor.

[devilbunny]

There's a playground, but I have no more power there than I do in my own production environment except that I can write an order like "all-unicorn diet" and nobody would see it. I don't know precisely what you mean by Epic-PLY and "developer sandbox"; I'm an end-user, not a developer. Other than knowing some of the IT team and being the local point of contact, I'm no different from any other anesthesiologist in terms of control. What I would like is a sandbox where I can do anything, figure out what's possible, and then report to the team the things I've found and ask if it would be possible to put them in production. Maybe yes, maybe no, but we live and die by the status board (if you ever get involved with EMR and anesthesia, a good status board is the most critical piece of infrastructure). And I can't even share mine with others.

Draconian institutional policies are indeed an issue. WiFi calling is blocked, despite the fact that a significant part of our first floor has zero cell signal.

If you get bored, PM me and we'll set up a time where I can show you some samples. I'll need a few days to sanitize them of identifiable info.

[haldujai]

Got it, Epic-PLY is the playground version that comes with every Epic install. Sounds like they've restricted playground user roles as well, you'd need your hospital IT to change that in the playground environment.

There's a developer sandbox as well that's more feature rich but from what you're describing I doubt they would have enabled access for you although most hospitals do. I would ask someone in IT you know to either give you a superuser role in the playground or access to vendorservices.epic.com

You can't PM on here but my e-mail is in my profile. If you're hitting a dead-end shoot me an e-mail and I can add you to my developer playground to mess around with.

[haldujai]

This.

Every hospital I’ve worked at has used Epic and every one has a different “custom” version with different UI and user role configuration.

Even within the same hospital the UI and default displays widely varies based on context and role selection when logging in.

Nursing notes are definitely accessible in every version I’ve used and I also read them fairly frequently (often more useful than MD progress notes) so your hospital may be hiding non-provider notes from you. It would be strange though, are you sure you don’t have “show provider notes only” checked off (or that box hidden)?

[devilbunny]

I've looked under the Notes tab, and under Chart Review -> Notes, and turned off all filters. Nope. I get nursing "plan of care" notes, but not their regular floor notes.

[haldujai]

Strange, I'm a radiologist and this happened to us at the very beginning of the Epic transition as well (they also dropped ER MD notes from our profile) but we gave that feedback and they changed it within a few weeks as we used the magic words of "impacting patient care".

This limitation isn't an Epic default feature and must have been set by your institution or whoever created the anesthesia role for some inexplicable reason, there wasn't actually a justification or privacy concern for why this was set this way for radiologists at my institution and seemingly was set by someone in IT thinking it was extraneous to us.

[devilbunny]

That's the vibe I get. "You don't need to change it"... yes, we do.

Dunno, at this point I'd settle for being able to establish custom filters for my status board. But I've learned that a lot of weirdnesses have to do with interfacing with other software.

[sxg]

This is true, but these custom configurations have become so ossified into each hospital's workflow that there's minimal hope of reversing the mistake.

[goda90]

Epic takes actual feedback and development input from clinicians. They aren't just ignoring them. But it's not straightforward to make a system that handles all kinds of healthcare, integrates them together, avoids any bugs that could put a real human being at risk, and also appeases the clinicians, the regulators, the insurers, the lawyers, the administrators, and the capitalists.

With all those requirements, even the smallest feedback might require many hours to implement so things don't break or piss someone else off.