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Topic Title: For those using Epic
Topic Summary: For those using Epic
Created On: 11/19/2020 08:17 AM
Status: Post and Reply
Linear : Threading : Single : Branch
 For those using Epic   - MDH - 11/19/2020 08:17 AM  
 For those using Epic   - smeyer - 11/20/2020 02:28 PM  
 For those using Epic   - Charlie - 01/10/2021 10:41 PM  
 For those using Epic   - mwarddoc - 01/27/2021 03:50 AM  
 For those using Epic   - MDH - 01/27/2021 11:56 AM  
 For those using Epic   - mwarddoc - 02/02/2021 03:16 AM  
 For those using Epic   - MDH - 02/02/2021 08:09 AM  
 For those using Epic   - mwarddoc - 02/03/2021 02:49 AM  
 For those using Epic   - James534 - 02/03/2021 08:54 AM  
 For those using Epic   - MDH - 02/03/2021 11:17 AM  
 For those using Epic   - mwarddoc - 02/05/2021 03:47 AM  
 For those using Epic   - James534 - 02/05/2021 12:03 PM  
 For those using Epic   - ax - 02/07/2021 03:14 PM  
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 11/19/2020 08:17 AM
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MDH
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Interesting article that my son's girlfriend sent me about Epic. Makes for fascinating reading.

 

https://www.nytimes.com/2018/12/20/business/epic-systems-campus-verona-wisconsin.html

 

MDH



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 11/20/2020 02:28 PM
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smeyer
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I met Judy Faulkner in 1998 when we were shopping for an EMR. She was a nice person and all about technology, not about money. As Epic grew too rapidly at one point, she suspended all new sales until she could bolster her technical support staff, forfeiting several lucrative opportunities. However it proved Epic to the the #1 quality EMR, which it remains today.
 01/10/2021 10:41 PM
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Charlie
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Epic, in my experience is a horrible EMR for outpatient use.

 

 01/27/2021 03:50 AM
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mwarddoc
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I use Epic for outpatient use, have used it for 6 years, prior to that I used two different EMR's. Hands down it is the best system I have used, IF USED PROPERLY, and that is the problem.

The other thing is that clinicians don't take the time to learn it, and just touch the surface of what you can do. When I started using it, I asked a bunch of clinicians in the office I was in about things and most of them had no clue. Then, one provider that had worked with Kaiser told me some things and I learned more from that one person than all the trainers and other clinicians in the office combined.

It has a steep learning curve. You can spend a long time learning all the little features, one of the benefits, one of the drawbacks. The first thing to do is customize your view, which I did immediately, then continue tweaking it. The second thing is to use the "search" window, that is a huge time saver.

It could probably be improved with a better GUI (the current one is really "busy"), and yet I'm sure that there are highly opinionated designers who came up with this GUI. It is also customizable, but not quite to the degree that I would like in some areas. On the other hand, I use it all day long and have gotten used to it.

However, in their defense, you can pretty much get anywhere and to anything you need to get to in Epic from any page quickly. But, if you are trying to find something, just use the search window, don't start looking through the chart.

I don't like how some of the "features" work, but the other systems I have worked with were simply not as capable, stable, and reliable overall.

There are two huge areas that need improved for patient safety and fraud protection.

The first thing they need to do is put a hard stop to the ability to copy prior notes bringing them forward as the current note. That part is just a shitshow. I don't use that feature but I know plenty of healthcare providers who do, and in some cases as much as 95% of the entire note is just copied forward...yeah, sure you did that entire head to toe physical every single visit for the last 4 years.

The other thing that needs to be done is to "force" association of all medications with a diagnosis, instead of letting it be optional. Many of my colleagues do not associate their prescriptions with a diagnosis. It is just plain stupid to write a prescription and not have an associated diagnosis, every single time. I've spent way to many hours trying to figure out why metoprolol was prescribed by someone in 2010. With forced associations, you know immediately, without searching the chart. You can't order a lab test without associating a diagnosis, so you should be able to order digoxin or losartan without doing the same.

The other problem that I see is that you cannot easily export your smartphrases, and once you have a large number it is hard to work on reconfiguring them in Epic itself, it would be nice to be able to export to a spreadsheet and work on portions of them then reimport, but that comes with a whole host of other issues.


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mwarddoc
 01/27/2021 11:56 AM
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MDH
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I have been using Epic for just over 1 year. Prior to that we initially had LSS (starting in 2006, as it was the only EMR that fully integrated with Meditech), followed by Greenway PrimePractice (starting in 2010). Providers wanted to switch from LSS to a different EMR primarily because it was "too clicky". I believe that at the time of the vote, there were 36 people who voted to change to Greenway, and 2 or 3 people who voted to stay with LSS, but advance to next generation version. I was in the LSS camp primarily for 2 reasons. I thought the loss of full integration was going to be a very big negative. Turns out that the Greenway interface with Meditech was fraught with endless problems. The other reason that I voted to stay with LSS was that I had figured out how to "make LSS purr" with custom speech commands which markedly reduced the required clicks. That said, no one else used custom commands, and did not wish to use them even if I was willing to hand the command set to them on a silver platter. They "didn't have time" and were "too busy" to be bothered to do some up-front work to become more efficient and save time, clicks, and aggravation. Well, turns out much to everyone's surprise, that Greenway was more "clicky" than LSS. People were even less happy campers. Even though there was more functionality, the ongoing integration and server issues were terrible, and people were really unhappy about the clicking. Once again, I developed custom commands to beat Greenway into submission. As an example, to reply to my medical assistant in Greenway was an 11 click process. Guess how many times per day a physician communicates with their MA. Do the arithmetic. Just for that one task, you were talking something like 500 clicks per day, not to mention all of the other clicks needed to use an EMR. But instead, I had one voice command (Reply to Hannah) that accomplished the 11 clicks. Once again, people had no time to do the same; no time to save time and clicks. Given the level of physician grumbling and reduced productivity (which never rebounded over 4 years) using Greenway versus LSS, and the ongoing integration/server issues, the hospital decided to bite the bullet, spending tens of millions of dollars to get Epic to integrate the hospital and 20+ outpatient clinics (and dumped Meditech). We started Epic October 2019. Training was poor. And much to everyone's surprise, Epic was even MORE CLICKY than Greenway! That said, Epic had way more capability/functionality than Greenway. And the interfacing/server problems were gone. Once again, I developed custom commands to beat Epic into submission. I notice most provider notes are worse in Epic than in Greenway. Lots of crap included/copied that has nothing to do with a visit (e.g. who does a neurologic exam/takes family history/discusses social history/past surgical history etc., etc. on someone coming in for bronchitis???). And yes, the clicking continues for all. Many of my associates stay until 8:00-9:00 pm finishing their work every night. No surprise that physician burn-out is rampant. The increased functionality of Epic is a 2-edged sword--nice to be able to do stuff, but what actually needs to be done given time and efficiency constraints. My extensive use of custom commands allows for much more complete and readable notes, devoid of the "filler garbage" in most provider notes, and allows me to do it much quicker. Similarly, I can barrel through my tasks quicker, thus responding to patients quicker, and allowing my MA and myself to get out quicker. Dictation is only a part of what is needed to use an EMR. When ordering labs or imaging studies, instead of voice entering (or typing as most do), then scrolling through a list to choose the correct test, or alternatively clicking to and through the Favorites list of commonly used orders, to find and choose the desired order, I simply call a command such as "Choose Left Wrist X-Ray"  or "Choose CAT Scan of Abdomen With" (with contrast) and the order is automatically placed. I have just over 500 lab, imaging, and referral order commands that I created that are institution-independent (not affected by individual institutional set-up), are Epic version independent, and don't use mouse-positions. (Additionally, I have 250  medication commands to allow similar ordering, however, because of the way that Epic is set-up, these need to be user and institutional dependent.) Basically, I skip all of the "up-front data input" and go directly to the otherwise hidden "back-end" input to quickly accomplish the order. Was creating this very time-consuming--you bet! But I only had to do it only once. The payback is that I do not add an extra 1-1.5 hours to each day to get my work done; my work is more complete, timely, and readable and personal, and I don't need to cut corners. I save probably in the range of 3,000 clicks per day! But the main benefit is that I am a happy camper. I enjoy my work, look forward to it, and can afford to spend more time with my patients. I am not one of the 60% of physicians who admit to being burnt-out.

 

MDH



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 02/02/2021 03:16 AM
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mwarddoc
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MDH is right on target, exactly what you have to do with each and every single EMR change. But, what happens, is that you get much better at it and you can recustomize commands in DMPE to do this and revise them. I have almost 3,000 voice commands in DMPE and around 14,000 smartphrases that are driven by the voice commands.

I don't remember any of them, and don't even try, they are part of my workflow.

But, does it REALLY save mouse clicks?

To put it bluntly, I've saved enough mouse clicks that I was able to invest them in Gamestop and drive the price through the roof. Those hedge fund traders never saw that coming.

I've got hundreds of barrels of mouse clicks buried around the country in bunkers that are blast resistant, and when the end times come I'm going to be able to sell them to the government so they can get their computers to work.

Does it prevent physician burnout?

Yes, if you save enough of them, you can actually blend them up into a smoothie, it is very refreshing, and the energy will last you all day.

In fact, MDH and I are battling to control the market on mouse clicks, so that we can sell them to other providers in a cap and trade system.

"Lots of crap included/copied that has nothing to do with a visit (e.g. who does a neurologic exam/takes family history/discusses social history/past surgical history etc., etc. on someone coming in for bronchitis???)."


MDH, you must work with some of my colleagues, I'm always impressed when some of my colleagues manage to do those exams and review all that information with some of my patients who take forever to just answer a simple question, and have their notes all signed off within a short period of time of the patient leaving the office.

You don't suppose anyone would use Epic to just past in a standard exam that was not really done, do you? No, doctors would never do that.



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mwarddoc
 02/02/2021 08:09 AM
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MDH
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mwarddoc,

 

You are definitely in the running for a Nobel Prize in Literature for your prose, with stiff competition from Amanda Gorman! 

 

You put a smile on my face while waking-up this morning. Thank you.

 

MDH

 

 



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 02/03/2021 02:49 AM
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mwarddoc
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You are welcome, we could all use a little bit of humor during the pandemic.

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mwarddoc
 02/03/2021 08:54 AM
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James534
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MDH

It seems like you have put a lot of time into macros and dragon. I have a different EMR and have set up many. Do you have a specific oragnizational system for setting up the macros to remember them.

Thanks

James
 02/03/2021 11:17 AM
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MDH
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As mwarddoc said:

 

"voice commands in DMPE and ... smartphrases that are driven by the voice commands.


I don't remember any of them, and don't even try, they are part of my workflow."

 

I totally agree. You can't possibly remember hundreds or thousands of commands. I name mine based on what I see or what they do. I start most commands with the same word, in my case I use "Choose".  If it is a point in the EMR, such as "Vitals", I say "Choose Vitals". By the way, the vitals in our EMR are best displayed (for my preference) in the Synopsis tab. But instead of remembering that, since I am after "Vitals", I named the command "Choose Vitals" rather than "Choose Synopsis". Just one less thing to remember and as mwarddoc implies, it becomes a much more logical part of natural workflow. Or if I want a left wrist x-ray, I say: "Choose Left Wrist X-Ray". Occasionally Dragon will balk at a name chosen. In that case, one needs to choose a different name with similar logic, or renamed a different way. So, for example, the command "Choose Hemoglogin A One Sea" did not work, nor "Choose Hemoglobin Ay 1 See", etc., etc., but "Choose HbA1c" works reliably. Of course, also no point in doing extra work. If I am looking over a specific Task, and the patient wants imaging results, there is no direct path/view to get there in one step. So I name the command "Choose Imaging" since that is what I want. It will click "Chart" as the first step, then the page changes (allowing for just adequate Wait step for that to happen), then clicks "Imaging". Or, if I want to order a test for a rather uncommon diagnosis such as Myasthenia Gravis, or Scleroderma, or Pheochromocytoma, rather than trying to remember the test or tests that I should be ordering, I will one time figure out which tests those are then say: "Choose Myasthenia", "Choose Scleroderma", or "Choose Pheochromocytoma" instead. Similarly, "Choose Hyper Coag Profile" orders about 6 different uncommon tests. This brings up the point that I may have the same command with an alternate name, such as "Choose Hypercoagulation Profile" in case that name comes to mind on a given day rather than "Choose Hyper Coag Profile". Generally, the simpler the name, the better (so "Choose Hyper Coag Profile" is easier to say). Also, I may not know if it is indicated the order a CAT Scan with, or without, or with and without contrast for a given possible disorder. So I make that determination once, then say (for example)  "Choose CAT Scan of Head Headaches" and the proper test (here without contrast) is ordered. If I readily know what to order, instead I may say "Choose CAT Scan of Head Without" instead. (Note, no need to add the word "Contrast" which is unnecessary and makes the command name more of a chore to say). So I am a strong believer in the "KISS" principle--Keep It Simple Stupid". 

 

MDH

 



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 02/05/2021 03:47 AM
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mwarddoc
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James

A lot has to do with how your EMR is driven. Look at what you currently do and all the repetitive tasks that you do, every single one of them, see if you can come up with a system of commands, like MDH has suggested, or different based on what you see on your EMR's GUI.

MDH and I shared some command information around 3 years ago, unfortunately, due to workstyle differences and the way people think and operate differently, it is hard to adopt someone else's methodology directly as it is.

HOWEVER, you can retrain someone's methodology. I had a bit of a headstart in Epic, comparatively, but I was hampered by the fact that I was trying to work with our integrated Dragon Medical 360, at first, (which sucketh almightily) until I finally got DMPE 4.x and really got cracking.

So, if you are part of a 5 person clinic group, and you all have a series of commands that each of you could use, all you would have to do is to retrain the command, not recreate the step by step functions of the command.

You might want to order a CBC, and it may take several steps/clicks to order that lab test.

Each step can be built out to a voice command. Using the same voice command you can build order commands for literally all of your lab and xray orders, by just tailoring the steps to achieve a different result, using "new copy" in command browser. You can build a lot of commands fairly quickly. It is a lot of work, but it saves you time down the road.

On the other hand, that particular type of command may not save you time in your EMR. That is where you have to decide what is fastest. It all depends upon the features built into your EMR.

I use Epic and when in front of patients I don't use voice recognition. When I place orders, I have just over 1000 shortcuts to orders, and panels, which is a feature of Epic.

So if I want to order the labs for a dementia workup, I have a shortcut "dementia labs". I click into the order field and then I type "demen.." and before I finish typing the words "dementia labs" that shortcut will appear and I will click to select it and it will place all my orders (2 clicks and 5 letters typed instead of 9 clicks and a lot more typing). I created shortcuts for all of my labs, x-rays, workup panels, etc, etc.

Regardless of your specialty, you will get repetitive questions, that have the same answer, and that is a good place to start. Build for those (for instance, I got a message today from a patient asking about OTC constipation medications, I built a shortcut to answer that question, for the next 10 years, until I retire, that shortcut will be used over and over and over.

However, I do use some voice commands for orders.

If I want to voice actuate that , I can actually have the voice command "dementia labs" and I will click into the order field, say "dementia labs", it will type a few letters, select the panel, enter it, and it is done. This reduces 2 clicks and 5 letters down to 1 click and a single voice command ("look ma, no typing").

Also, don't try to remember your commands. Use natural speech forms that you use. The computer can remember them for you.

Example: Sore Throat and you want to send instructions. One time you might say "Instructions for sore throat." The next time you might say "Sore throat instructions." the next time you might say "Directions for sore throat." the next time you might say "Sore throat directions."

So you build the initial voice command, then, you use the "new copy" in command browser to create new copies with all of those different commands doing the exact same thing. Pretty soon, no matter how tired you are you can say what you want and the computer will do what you used to type.

You have to test them and be aware that you might get some unusual output, for instance, if I burp while dictating, DMPE thinks I say "USPSTF Guidelines", but that is really rare in my experience.

An easy way to start is to sit down in front of your EMR, and look at the keyboard shortcuts that operate the GUI, and I am assuming you have those, and build a voice command for every single keyboard shortcut. When I am working, wearing a headset, I can type and command the EMR. If I want to see the next appointment, I say "next appointment", it will bring up the appointment desk for that patient and show me their next appointment, then I say "back to chart" and I'm back to my typing and dictating. I built voice commands for every "button" in Epic that I use. I get a message from a patient, I click on it, it opens up, I then dictate my response, after doing so I say "send that" and off it goes.

Sometimes you will find that you built something but see a better and faster way to build them (this happened to me recently"). Rebuild them ASAP and it will pay off. I recently rebuilt 15 very commonly used commands that were lengthy step by step commands, that are all particular to the way I document notes, they are easily twice as fast now, but I wanted to vomit when I thought about all the typing I had to do to do it. That was 6 weeks ago, two hours of nonstop typing and rebuilding has saved me around 5 minutes a day every single workday since mid December. That doesn't sound like much, but by the end of the year it will have saved me around 15-20 hours, and that will continue till I retire in 10 years. That is a big return for 2 hours of work.


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mwarddoc
 02/05/2021 12:03 PM
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James534
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Thanks I really appreciate the comments.

I think the following was biggest issue I was struggling with:

Example: Sore Throat and you want to send instructions. One time you might say "Instructions for sore throat." The next time you might say "Sore throat instructions." the next time you might say "Directions for sore throat." the next time you might say "Sore throat directions."

I try to pick a common and systematic way to remember the commands, but having mulitple copies of similar commands might work.

I currently use nextgen and the interface to control ordering by a bunch of keyboard steps is somewhat time consuming , and some times I get unpredictable and frustrating results which I suspect is more due to timing since I am working on an RDP type connection

James
 02/07/2021 03:14 PM
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ax
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Thanks mwarddoc and MDH for sharing your tips and years of experience!

Know-how, time, and discipline (more precisely: lack thereof in all 3, and scarcer in that order) are what stand in the way of some of us (myself included) being able to automate repetitive tasks to a degree of our satisfaction.

There are other "physical" barriers as you mention, James.  For any type of VDI solution, be it RDP, or Citrix, or VMWare Horizon View, your ability to automate is basically hamstrung - unless you can run automation software on the SERVER side.  By automation software I refer to any number of voice or keyboard based macro/scripting tools.

Case in point: once I moved my office EMR to a Citrix-based "Cloud-Solution", which fine computer folks refer to as an "Application Service Provider (ASP)", as opposed to running off my own server onsite, I actually saved some money as maintaining my own server was a separate monthly cost on top of the EMR subscription fee. 

 

Nevertheless I lost the ability to run my preferred automation tool, which happens to be AutoHotKey, on the server-side.  Let alone Dragon.

The ASP Server abides by a locked-down "white-list" policy: "That which is not explicitly permitted is forbidden" - any executable not on their white-list cannot run.  It's basically Inquisition.  But hey ...

Now you may still be able to fall back to last ditch CLIENT-side methods such as mouse-grid commands, pixel-detection commands, or even Image Search when confronted with various dumb-as-a-log VDI interfaces with no access to the server-side.  But these methods are inflexible and just PITA to use and to deploy.

In this regard, the noveltiesh Meditech Expanse brings at least a fresh approach to the table IMO with the browser as interface.  This opens up a host of automation possibilities through Javascript / CSS selectors.



P.S.,

As to the rampant "copy-and-paste", or so-called note "cloning" or carry-over mentioned by the 2 old-timers, this is so-so-NOT-new.  From the get-go it was a "feature".


"Meaningful Use", no?  To many this is simply a reflection of the larger, dysfunctional medical culture in NA.  I am pessimistic as to the possibility of good solution in sight.

 

https://www.healthcareitnews.com/news/ehrs-are-overflowing-copy-and-paste-records-jama-study-shows


"Only" 18% of GDP ... Surely there is room to grow in healthcare.  Room to accelerate, some might say.  And wouldn't all that note "cloning" also grow the legal industry on the flip side of the coin?

Some folks call "win-win" - your friend Nuance may not even disagree.



KnowBrainer Speech Recognition » DMPE, DMO and EMRs » For those using Epic

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