Extended Interview: Dr. Charles Shepard
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SUSAN DENTZER: What’s the value to you as a physician having all this information at your fingertips?
DR. CHARLES SHEPARD: The value is just enormous. Prior to the electronic record, in our community we had separate medical records in three different clinics and the hospital. And information in each one was inaccessible to the other. And so now this is an integrated system. We capture all the information from all three clinics, plus the hospital, and it’s in one source. So I can look back and see what’s happened at the clinic, I can look back and see what medicines have been taken in the past, what his regular doctor was thinking. If he’s been seen at the Mayo Clinic or referral places, those letters and results are all scanned in. So there without leaving my chair, I’m able to access information that was so fragmented that was nearly impossible to get before.
SUSAN DENTZER:And you just showed us this entire battery of information in several minutes, a very different time table than in the past.
DR. SHEPARD: Tracking down the chart was primarily with a student nurse in some far room. Once you located the chart, things were pretty cluttered and hard to retrieve, but laboratory information would not have been displayed in a serial way. We could not grab it, we could not follow trends. Now the information is more accessible, it’s cleaner, easier to analyze. And the imaging, previously they had to go down to X-ray department if we wanted to actually look at a film. So now we can pull up films ourselves.
We still have the option of going to X-ray to talk to the radiologist if we wish. But it, for our purposes it’s fine most of the time to just pull up the image. I can look up what the radiologist thinks and if we have different views we can go down and talk it over.
SUSAN DENTZER:Are you a better physician because of these tools?
DR. SHEPARD: I think so. We’ve tried to make information available to point of care, and so carrying all the patient information compiled in one place, easily accessible, is a huge advantage. The imaging is an advantage. You also have an electronic medical encyclopedia on line. It’s searchable. You can have a couple of books here, one on preferred antibiotics for various situations, and one for adjusting medication in the case of kidney failure.
So we’ve never had so much information at our fingertips as we do right now. And I think in the end it leads to better decisions in patient care and more efficiency. As I can see what his previous doctor did in the last clinic so I maybe don’t need to repeat that test or that x-ray. So it’s a great opportunity and a huge sea change for medicine.
As part of the computerized provider order entry system in the emergency room, they created a catalog which you can order from and there were 2,500 medicines, 800 imaging tests and 600 laboratory tests. For inpatients, the medicine catalog will probably be 10 times that size, between 20 and 25,000 ordering choices.
The other thing we have to create is order stats. To enter an individual order takes about 45 seconds which is way too long and so we want to create in a preestablished order stats for individual conditions based on best practices so doctors can select or deselect certain things that makes it go faster. It’s also an opportunity for standardized care on the best practices.
It’s really an unparalleled improvement opportunity to develop these order stats and have conversations about what’s the best treatment for a condition. So we’re expecting to have about 200 of those when we go live and so teams are, are working on that right now.
Implementing the electronic records
SUSAN DENTZER:What were the bumps along the road in implementing the electronic health record?
DR. SHEPARD: Probably the first thing that we ran into was the prescription writing program wasn't very good. Previously we'd been able to make a few scratches on a piece of paper and hand it to the patient, now we have to enter prescriptions electronically and then attempt to fax them to pharmacies which really weren't all ready to receive faxed prescriptions. And so that system slowed people's workflow and work fitfully.
Patients would show up in the pharmacy expecting a prescription to be there and the fax machine would have failed and so there, there are a lot of issues which subsequently have been we initially we had part of our program that checked drug, drug interactions.
And it was so sensitive that it, you could never refill a prescription or write a prescription without being warned about 10 different things that might happen. So there was alert fatigue, and we eventually turned that off. One kind of pain medicine, Darvocet, interacts with 250 different medicines, most of them are inconsequential. But the doctors just got tired of looking at those alerts so we turned it off. We still use the allergy checking, but the drug-to-drug interaction and the drug-food interaction were just such a nuisance that we turned them off.
SUSAN DENTZER:And you said initially this really did interrupt the work flow and delay the work flow. What actually happened?
DR. SHEPARD: Well just speaking personally as an internist, my patients take quite a few medicines, six to ten would not be unusual, and so previously when I needed to refill a medicine, I would just give a note to the nurse saying refill these medicines for six months and I was done with it. Well, when we changed the process, it became my job to do that. And it took me five minutes per patient to labor through that.
And so eventually we worked the process so that now I have to verify that the medicines are exactly right in the medical record and now I give that job back to my nurse. But there, it changes work flow. And the provider order entry is going to change work flow. It's estimated people's jobs change by about 30% when you go to provider order entry, so it's a big cultural change.
SUSAN DENTZER:How so? Give me a sense of how that will play out.
DR. SHEPARD: Well, nurses are used to associating orders with the presence of a doctor. And now order can just appear in the provider order entry environment. And nurses were used to charting in paper, that's gone away and now it's electronic. And coming in the near future we hope is bar-coding so that when the patient is given the medicine by the nurse, the nurse will run the medication and the patient and be sure that they match before the medicine's given and then they will no longer need to chart because it will be entered electronically.
There are huge opportunities for safety in the provider order entry. You can eliminate uh most of the medication errors, the ones that come from poor handwriting, the ones come, that come from misreading the handwriting, the ones that come from administering the drug for the wrong patient. Those should pretty much go away with provider order entry.
SUSAN DENTZER: So what advice would you have for physicians in some other community contemplating going down this road?
DR. SHEPARD: I think it's the absolute right thing to do, but you have to understand that it's going to be slow going, that this is a multi-year project, and that you're never going to be completely done because there are going to be more opportunities that are going to, that's going to need to be maintain the order sets and update them indefinitely. So we've been at this for six years so far. And I really think it's going to take us another three years to complete what we have in mind. And then it'll be time to start over with parts of it. So it will go on for indefinite future.
That's the other bit of advice. People who are implementing this program need persistence that borders on stubbornness. You have to understand there are lots of barriers and you need to just keep working through them. But I think the prize is worth it.
Getting national electronic records
SUSAN DENTZER:What's the biggest of those barriers?
DR. SHEPARD: They're all over the map. Problems with the vendor, problems with staffing, people problems, and then just the mass of the project. When we finish with our ordering catalog, we'll probably have 25,000 medicine choices and so getting that together and maintaining it is a big task. And trying to coordinate so many people over a long period of time, it's like a large construction project.
We've started to use Microsoft project to manage this, keep track of all the tasks in the, during the provider order entry in the emergency room, we were up around 1,600 tasks. And this year's project is going to be more tasks probably by 50 percent. And so medical people are not used to working on projects of that complexity. So this is a new terrain for us.
SUSAN DENTZER:When you hear that a President Bush called for nationwide electronic health records by 2014, or presidential candidates call for huge additional investment on the federal side to spur this along, what do you think? Does it sound plausible to you?
DR. SHEPARD: I think it's about time really because this is the way things should be in the future. And it would be a great help to have some standardization in the industry. I mean for example we try to send electronic images of our x-rays, CT scans and MRIs. The Gunderson Clinic has a compatible system, but the Mayo Clinic does not. And so we struggle sending information back and forth.
So standardization would be a really good thing and I think a lot of the things that each hospital is currently doing on their own could be done centrally. Each hospital develops their own medication ordering sequence. They're very similar. I'll bet they don't vary by more than 10 percent. Somebody should just do that and be done with it instead of having each hospital do their own.
So I think that done well a nationwide standardized EMR it would be a big advantage and the federal government has resources that we don't have. They can do quality studies and test things out and rather than having community hospitals and work along using their best judgment.
SUSAN DENTZER:So if anything it sounds like you're on the side of wanting even more forceful federal intervention .
DR. SHEPARD: Yeah, that's true. It would be a big help to I think patient care. We have a lot of patients that move around in the winter and Minnesota people go to Texas and Arizona and Florida for the providers down there to be able to access records from here I think would be a big help and vice versa.
In April and May I get snowbirds coming back and then trying to figure out just what the heck happened to them while they were down in Arizona. You maybe get records, and maybe you don't. It would be a big help to able to access all that.
There's a lot of repeating of tests that occurs because of the fragmentation. So I think there'd be some cost savings and some quality. We should be able to improve the quality with lots of people working on it instead of a few.
SUSAN DENTZER:Would you or any of the physicians here ever want to go back to the status quo pre-2002?
DR. SHEPARD: Oh, that would be a nostalgic wish. We're trying to manage data streams that go back 10 years and try to remember when the last colonoscopy or the tetanus vaccination was and we, we just can't do that in the paper environment.
To improve the chronic disease management and the preventative care that we're expected to provide, I think this is really the only viable way. So I just don't think that anybody want to practice 21st century medicine and go back to a paper record.