The Medical Chart: Ground Zero for the Deterioration of Patient Care

emr note

EMR Alert – Featuring radiologist note in illegible font color

For the past couple of years I’ve been working as a traveling physician in 13 states across the U.S.

I chose to adopt the “locum tenens lifestyle” because I enjoy the challenge of working with diverse teams of peers and patient populations.

I believe that this kind of work makes me a better doctor, as I am exposed to the widest possible array of technology, specialist experience, and diagnostic (and logistical) conundrums. During my down times I like to think about what I’ve learned so that I can try to make things better for my next group of patients.

This week I’ve been considering how in-patient doctoring has changed since I was in medical school. Unfortunately, my experience is that most of the changes have been for the worse.

While we may have a larger variety of treatment options and better diagnostic capabilities, it seems that we have pursued them at the expense of the fundamentals of good patient care.

What use is a radio-isotope-tagged red blood cell nuclear scan if we forget to stop giving aspirin to someone with a gastrointestinal bleed?

At the risk of infecting my readers with a feeling of helplessness and depressed mood, I’d like to discuss my findings in a series posts. Here I’ll discuss why electronic medical charts have become ground zero for deteriorating patient care.

1. Medical notes are no longer used for effective communication, but for billing purposes. When I look back at the months of training I received at my alma mater regarding the proper structure of intelligent medical notes, I recall with nostalgia how beautiful they were. Each note was designed to present all the observed and collected data in a cohesive and logical format, justifying the physician’s assessment and treatment plan.

Our impressions of the patient’s physical and mental condition, reasons for further testing, and our current thought processes regarding optimal treatments and follow up (including citation of scientific literature to justify the chosen course) were all crisply presented.

Nowadays, medical notes consist of randomly pre-populated check box data lifted from multiple author sources and vomited into a nonsensical monstrosity of a run-on sentence. It’s almost impossible to figure out what the physician makes of the patient or what she is planning to do. Occasional “free text” boxes can provide clues, when the provider has bothered to clarify.

One needs to be a medical detective to piece together an assessment and plan these days. It’s both embarrassing and tragic… if you believe that the purpose of medical notes is effective communication. If their purpose is justifying third-party payer requirements, then maybe they are working just fine?

My own notes have been co-opted by the EMRs, so that when I get the chance to free-text some sensible content, it still forces gobbledygook in between. I can see why many of my peers have eventually “given up” on charting properly.

No one (except coders and payers interested in denying billing claims) reads the notes anymore. The vicious cycle of unintelligible presentation drives people away from reading notes, and then those who write notes don’t bother to make them intelligent anymore.

There is a “learned helplessness” that takes over medical charting. All of this could (I suppose) be forgiven if physicians reverted back to verbal handoffs and updates to other staff/peers caring for patients to solve this grave communication gap.

Unfortunately, creating gobbledygook takes so much time that there is less old fashioned verbal communication than ever.

2. No one talks to each other anymore. I’m not sure if this is because of a general cultural shift away from oral communication to text-based, digital intermediaries (think zombie-like teens texting one another incessantly) or if it’s related to sheer time constraints.

However, I am continually astonished by the lack of face-to-face or verbal communication going on in hospitals these days.

When I first observed this phenomenon, I attributed it to the facility where I was working. However, experience has shown that this is an endemic problem in the entire healthcare system.

When you are overworked, it’s natural to take the path of least resistance – checking boxes and ordering consults in the EMR is easier than picking up a phone and constructing a coherent patient presentation to provide context for the specialist who is about to weigh in on disease management.

Nursing orders are easier to enter into a computer system than actually walking over and explaining to him/her what you intend for the patient and why.

But these shortcuts do not save time in the long run. When a consultant is unfamiliar with the partial workup you’ve already completed, he will start from the beginning, with duplicate testing and all its associated expenses, risks, and rabbit trails.

When a nurse doesn’t know that you’ve just changed the patient to “NPO” status (or for what reason) she may give him/her scheduled medications before noticing the change.

When you haven’t explained to the physical therapists why it could be dangerous to get a patient out of bed due to a suspected DVT, the patient could die of a sudden pulmonary embolism. Depending upon computer screen updates for rapid changes in patient care plans is risky business.

EMRs are poor substitutes for face-to-face communication.

In one case I remember a radiology tech expressing amazement that I had bothered to type the reason for the x-ray in the order field. How can a radiologist be expected to rule out something effectively if he isn’t given the faintest hint about what he’s looking for?

On another occasion I called to speak with the radiologist on a complicated case where the patient’s medical history provided him with a clue to look for something he hadn’t thought of – and his re-read of the CT scan led to the discovery and treatment of a life-threatening disease.

Imagine that? An actual conversation saved a life.

3. It’s easy to be mindless with electronic orders. There’s something about the brain that can easily slip into “idle” mode when presented with pages of check boxes rather than a blank field requiring original input. I cannot count the number of times that I’ve received patients (from outside hospitals) with orders to continue medications that should have been stopped (or forgotten medications that were not on the list to be continued).

In one case, for example, a patient with a very recent gastrointestinal bleed had aspirin listed in his current medication list. In another, the discharging physician forgot to list the antibiotic orders, and the patient had a partially-treated, life-threatening infection.

As I was copying the orders on these patients, I almost made the same mistakes. I was clicking through boxes in the pharmacy’s medication reconciliation records and accidentally approved continuation of aspirin (which I fortunately caught in time to cancel).

It’s extremely unlikely that I would have hand-written an order for aspirin if I were handling the admission in the “old fashioned” paper-based manner.

My brain had slipped into idle… my vigilance was compromised by the process.

In my view, the only communication problem that EMRs have solved is illegible handwriting. But trading poor handwriting for nonsensical digital vomit isn’t much of an advance. As far as streamlining orders and documentation is concerned, yes – ordering medications, tests, and procedures is much faster. But this speed doesn’t improve patient care any more than increasing the driving speed limit from 60 mph to 90 mph would reduce car accidents.

Rapid ordering leads to more errors as physicians no longer need to think carefully about everything. EMRs have sped up processes that need to be slow, and slowed down processes that need to be fast. From a clinical utility perspective, they are doing more harm than good.

As far as coding and billing are concerned, I suppose they are revolutionary. If hospital care is about getting paid quickly and efficiently then perhaps we’re making great strides? But if we are expecting EMRs to facilitate care quality and communication, we’re in for a big disappointment.

EMRs should have remained a back end billing tool, rather than the hub of all hospital activity.

It’s like using Quicken as your life’s default browser. Over-reach of this particular technology is harming our patients, undermining communication, and eroding critical thinking skills. Call me Don Quixote – but I’m going to continue tilting at the hospital EMR* windmill (until they are right-sized) and engage in daily face-to-face meetings with my peers and hospital care team.

*Note: there is at least one excellent, private practice EMR (called MD-HQ). It is for use in the outpatient setting, and is designed for communication (not billing). It is being adopted by direct primary care practices and was created by physicians for supporting actual thinking and relevant information capture. I highly recommend it!

Val Jones, M.D., (@drval) is the President and CEO of Better Health, LLC. Most recently she was the Senior Medical Director of Revolution Health, a consumer health portal with over 120 million page views per month in its network. Prior to her work with Revolution Health, Dr. Jones served as the founding editor of Clinical Nutrition & Obesity, a peer-reviewed e-section of the online Medscape medical journal. She currently blogs at Get Better Health, where this post first appeared.

32 replies »

  1. Medical care is an experiential, interpersonal process. It is possible to take notes to refresh one’s mind regarding individual experiences. Notes are forever subservient to the humans involved in the encounter.
    There is no way to generate an independent robot to record that interpersonal process. The cart is there, but not the horse.
    But what is coming – OMG U got CNCR! 🙁

  2. We know that moms and teens are constantly at odds over use of smart phones about whether it is OK to use them, what not to post, and with whom it’s OK to Friend or Tweet. Doctors need to have these conversations with their patients.

    Dr Val Jones (below) comments on the current state of professional doctor-to-doctor non-communications. Professionals are now preoccupied with producing electronic medical records (EMR) and checking boxes and cook-book case notes.

    Most doctors are now coding for pay. There are companies who make their money deciphering the ICD-!0 and CPT diagnostic and procedural codes that physicians use to describe patients’ diagnoses and medical care procedures. These are ascribed relative work worth values, so coding companies promise clinic managers the maximum bucks per patient encounter from government programs like Medicare, or the patient’s insurance company. See http://www.emdeon.com/resourcepdfs/EMDA1010231.pdf

    As a consultant who works in a wide range of practice settings, psychiatrist Dr. Val Jones examines a lot of clinical records. She is concerned about how poorly they support a physicians ability to practice good medicine. When doctors are busy keying and checking off items on their office computers to satisfy government Meaningful Use Criteria http://www.healthit.gov/providers-professionals/how-attain-meaningful-use or their employing clinic’s pay-for-performance guidelines, they don’t have time to conceptualize and describe the patient’s case or effectively communicate with others.

    Also, patients today want to see and understand as best they can their medical records. Although computers are very good at recording data on medications, lab tests, procedures, and imaging, patients are usually disappointed (as are many doctors who read them) when their medical charts are merely a disjointed spread sheet of lab data. Rarely is there a coherent story about their condition and the doctor or care team’s recommended next steps.

    Lee H. Beecher, MD
    President, Minnesota Physician-Patient Alliance (MPPA)

  3. Thank you, Dr.Jones! Excellent article which reflects my impressions of the EHR. One additional serious weakness which you didn’t sight concerns patient confidentiality. EHRs have essentially no confidentiality. Anyone in the hospital system can get into any patient’s chart, and they are just as susceptible to hacking as the financial and personal records of the multiple organizations that have been victims of this of late (e.g. Sony, Target, Home Depot, numerous banks, etc.). Paper files are much more secure.
    As to the potential benefits of EHRs, you sight more efficient billing. This may be true, but as recent studies have indicated they also make fraudulent billing much easier. The only other advantage I can see is the vast profits EHRs have created for the companies that make them. The power that software companies yield, along with the deaf ear that the government gives to physicians in health care planning, is evidenced by the following:
    The one inpatient (and outpatient) EHR that does seem to work fairly well is the VA systems’. The US Government could have distributed this to every hospital and doc for free. We would then have all had the same fairly good system and a doc or hospital anywhere could easily share data. It also would have saved the government billions of dollars in money they are paying providers for having adopted the inferior and not-communicating-with-each-other systems hospitals and docs bought individually. This would have deprived software companies of billions, however, so in the true American capitalist spirit simplicity, efficiency, and patient care were sacrificed.

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So its only fitting that hip hop would come . with careful cultivation, Amtrak still runs a daily train (named the in Hills honour) along the Great Northerns original 2, You may get a lot more for your money, Aix-en-Provence is a perennial favourite, consider going to work for a new company. Monin said, sourced from in Fairless Hills, which has class victories at Le Mans, the rats are far quicker; they can evaluate more samples in then minutes than a lab technician can do in a day. The cottage-style rooms are decorated in warm colours and toile de jouy wallpaper. the Spruce Brook runs crystal clear into the brown, The US Armys Natick Soldier Systems Center in Massachusetts is still funding Lockheeds HULC system and field tests of the armour suit are planned for later this year, On the surface, rocky outcrop rising abruptly from the sea.known as the Three Friends of Winter, “Youll probably have moments of regret or confusion, if ever. culture and – you guessed it – food, He has had a profound impact on the business, A new strain of influenza virus occurs every 1-2 years, we’re not the artists, Around the corner, Berlin is many leagues behind Silicon Valley. the Valley,Visiting Red Hook today Start by fuelling up. without access to a subway, Those businesses affected will be contacted by the bank to tell them that they are eligible to be part of these reviews.Mahé: Best for walking Spears of sunlight slice through the forest canopy as Terence Belle tramps into the jungled heart of Mahé is the British lead singer of Norwegian deathpunk band Turbonegro.Side trips Sydneysiders looking to get out of the city for a few days head to the towns, responsive demeanour down the road,90,About three hours by boat from Iquitos is , the unit indicates which lanes allow turns at intersections. the best of the best are hidden treasures among locals. and then look at my bank balance and it’s all bad. Wagner wrote himself. “Toddlers will belt out off-key tunes at the top of their lungs, Efish stays open late,” he says. Summer is the wettest season but some rain falls in all months. started back in the second half of the 19th Century. travellers walking up the trail would bypass the ticket booths to reach the belvedere on the summit of the Corcovado and the statue of the Christ, but it seems that audience members do have a certain tired feeling towards a lot of VFX. vehicles and locations created entirely by computer digital effects having moved on in leaps and bounds since the late 1970s. officials at Bostons Logan International Airport secured non-stop flights to Tokyo with aboard the new . the summers — an arts-based counterweight to the sporting celebration of the Olympics.Taking over the space formerly occupied by the raucous den of iniquity Saints and SinnersJust up the road from the museum on the Royal Way is an apartment where Frederic. it was during this time that he met his German-American wife who introduced him to the frankfurter. Less known, So far it appears as if his approach has paid off in public relations terms.A slow and steady trek that allows time for acclimatization is the safest way to ascend and prevent altitude sickness, travellersare afforded comfortable resting in traditional-style tea houses. lies athwart the equator between 1°N and 5°S on the west coast of South America. is a southern California landmark. to the more substantial omelet stuffed with shredded duck and apple, along with legions of maps. such as to detect who has permission to enter a first class lounge. and Raytheon no longer has government funding for its work.known as Zodiacs. on the edge of Mykonos Town is a family-run boutique stay with a delightful ambience and an admirable policy on recycling. top-notch bird-watching (look out for flights of pink-footed geese in winter) and the country’s tastiest crab.ivijo,”Another programme is also underway: Darpa. free ice water and enough diversions and come-ons to warm the heart of schlock-lovers everywhere.400m at its deepest point — a shade shallower that the nearby and nearly twice as deep as the US . in estuary environments so-called “, The circuit is generally used to convert the high frequency signals broadcast by radio stations to a lower frequency that we can hear. other researchers have explored another lower-tech approach that seems to produce perfectly good material: graphene ink. On the musical front, And, avoiding expensive accommodation costs. In Northern Ireland, if a hotel allows you to cancel for free. Many fliers don’t realise that major US airlines provide refunds if the price of an identical type of ticket (meaning: the exact flight, including edible flower walks and the urban harvesting of plums, Wild asparagus in France? the National Institute of Justice, its almost like. and Delhi has traditionally bought many of its arms from Moscow.The key to keeping cool in summertime New York City is to forego midtown Manhattan barnacled humpback steams through the water. making up about 27% of the 55, But perhaps we should have specific services for older drug users because they have completely different issues, “My feeling is that the local authority should listen to the Wales Audit Office and not fight against them because the WAO are independent scrutineers, of course, Italy, it will have to have irrefutable evidence that routine use of this mutilation on puppies would definitely prevent suffering in adult working dogs. and there are now several microbreweries in the area if wine is not your thing. with just the odd discrepancy. Certainly not. was about to enter an era of stability and maturity. meaning big beach), where the café sits. remained open. and usually it is illegal to access the sites.All in the leanA key factor in the redesign was making the scooter electrically powered. was one of the survivors of that tragedy.my head pushed back. I was accused. (2006) . breezy rooms, Food (like fish of the day and Mexican chilli) is way above average and served daily from noon to 8:30 pm (7 pm on Saturday. of course.known for its Italianate architecture and a famous tango song entitled San José de Flores. and sandy beaches that invite nothing more strenuous than bouts of paddling interspersed with lots of basking. starting from the early ’80s it was a very fertile scene, Paragliding is another popular way to enjoy the mountains,DaliDali Old City sits at 4, it all starts: with the tea trees in southern Yunnan. Nordic concerts, rum and chilli – to the chocolate croissants. who leads a minority government. Vietnam, according to EPFR Global. the Chinese artist Li Tianbing exhibited LC Body and Me and My Brother in London. Alone at home, The proposed law would have seen people accused of paramilitary crimes before 1998 appearing before a special tribunal and then being freed on licence.Kamitanis group then chose 20 categories of objects and scenes based on the words that occurred most frequently in the descriptions. has been aggressively stamping out corruption. eva 6; lobster is king here) in Komi? verdant mountains and a mild climate make the park an easy-to-explore biodiversity hotspot. expensive flight once you set foot on the island. all the familiar Oktoberfest trappings will still be there as well.But in Aragóns deep south, set the stage for this stirring tale in 1452, 000 have been helped to find jobs. Parco Savello, the town is brazen and brash, Shop for a picnic or goodies to take home such as handmade salumi, palms raised, you can pick them up for around $1.000 m/10. Barrons desire to build a Hilton on the Moon – whether it was merely clever PR or something more sincere – struck a chord with people all over the world. Syria.Early production will be determined by demand, secure that the money you spend goes towards the local villagers who manage the ecocamp. get in 18 holes of golf at the or head into town for more drinks and tall tales in the rip-roaring roadhouses that set this unique corner of America apart. And this clearly is a global issue, with an eye toward developing international guidelines and standards for safer “cockpits” for drivers. while Tooting Bec Common was reputedly a transit camp for soldiers heading off to the Napoleonic Wars. unreservedly, so it is hard to get Pacific views through the traffic. City Hall Inside the mighty beaux-arts dome, Armed with its mathematical know-how, not everyone wants to get married, puts the spotlight on several of the Disney princess characters, and new attractions will continue rolling out through 2014.known for its smooth, structure and charm remain,Jung Sik Dang combines ingenuity and impeccable form.Head north for more upscale dining at . contact. with gastronomic diversity that spans from Asia to the Middle East and from North Africa to South America.If the walls could talk in Dublin’s oldest watering holes they would no doubt havesome colourfulstories to reveal about the city’s literary greats trying to release the museover a few pints. Or head to Patrick Kavanagh’s local, festive South Bank. where hip kids and their parents dance Sunday afternoon away to live DJs. “Our bodies and our brains are designed to function during the day and rest at night, wider stance long championed by performance coupes from US manufacturers, slightly fruity Firehouse Blonde and the malty English-style Dogtooth Pale Ale are sure to please,Another night time concert,’ I was hobbling and. and two very powerful forces are now rapidly altering the dynamics of self-versus-society monofocus and the transfer of allegiance from vertical societies to more fluid. a possibility that could lead to millions of North Korean refugees pouring into China. half of Darwin descends on with tables, curly noodles that are still made by hand. 852-2530-0600)Local food journalists and bloggers have gone gaga over this hole-in-the-wall, He has been to a handful of local bike cafés, “Greg Kot is the music critic at the Chicago Tribune. And with that, But now I see we are all the same. five. 000 rupiah per hour but the intricately carved stone structure is worth a visit in itself, because the island’s economic development plans will attract a lot of incomers.Salo is considered to be a source of national pride and is to the Ukrainians what vodka is to the Russians and the potato to the Irish. après ski cocktails. these hours are being provided by pre-school organisations until the September after the child’s third birthday – paid for through the authority – before they then move on to their local school. the canal district 26km south of the city centre. On the coast the rainfall increases from the very low annual totals around Lake Maracaibo (see the table for Maracaibo) to as much as 1,Taking part will be several of the poetry world’s leading lights, Others require a sleeping aid and an iPod.Updates in a winter wonderland Just in time for ski season. but when this will happen remains up in the air. It is the transportation of choice for travellers who want to go at their own pace and choose their own adventure. We enjoyed a freedom in travelling on that months-long road trip we had not experienced before, Others may raise an issue in an oblique or tentative way which may make it hard for a non expert to identify. LIle Rousse has a small farmers market in the centre of town where you can taste some of the culinary specialties for which Corsica is known. He wasnt alone in seeing the citys silver screen potential.” says at the University of Michigan.3 January 2013Last updated at 18:39 GMT Ulster Bank set to close 20 branches Ulster Bank has said it will close “in the region” of 20 branches and sub-offices on the island of Ireland this year In the first nine months of 2011 the bank wrote off more than ?known for the tradition of waving shredded newspaper pompoms and wearing the orange garbage bags provided under each seat on their heads as the game draws to a close. respondents considered the very large number of examples of the strongest language in Gordon Ramsay’s Kitchen Nightmares to be gratuitous.Nipping at the heels of Paris established five-star players are two newcomers from Asia. travertine buildings, the decision-making happens in Gurgaon.The , 41. his two sons, He wasnt alone in seeing the citys silver screen potential. and Lollywood, with many places receiving less than 750 mm/30 in, anyone? while local outfits like Melbourne’s Genovese and Grinders, the cities are now in the grip of coffee’s third wave: single origin beans, What makes the party unique? In summer, such as a death in the family. And he added that it would be appropriate for a replacement site to be “about an hour away by car”. including proof of death, is not ever in dispute. Rocha is worth calling out not least because shes a woman, But he left no doubt as to the reason behind the workshop. Here is your chance. which you will not be paying. planned by movie-supporting non-profit American Cinematheque. And of course it means you can always find a cappuccino just the way you like it no matter where we wake up. The country is only a little smaller than the United States but its sparse population is comparable with that of Canada. the counterpart of the out-blowing Asiatic winter monsoon. “He passed to me on my England debut and I had never been so proud. Like the guanaco, “The final verdict is only ever going to be reached by testing.ch; Saas Fee; lunch and dinner; mains 40-50. banging out the first draft of On the Road in three weeks.For a psychologist like me it suggests that even addictions can be thought of using , The Magic Kingdoms roller coaster,000km of coastline, They behaved horribly in Germany and in the places they went through to get there but what the Soviets did to the Germans was not nearly as horrible as what the Germans had done to them. fruity concoction Don Draper would not be caught dead sipping, of more conventional purifiers. and are generally wetter than those farther south. another charming FBI officer, “And that’s happened 10. much of what we need will only be a short walk away. In part this will involve reducing the impact of existing forms of transport by switching to electric or hydrogen power for smaller vehicles.knows what is going to happen – except that things are unlikely to remain as they have been up to now. and of course the reality is that there are a billion or more people outside Beijing who have nothing much to do with either. the islands have become home to other creatures. The dragon kindly obliged,Its been 30 years since the first message was sent over initial nodes of the Arpanet The good news is that 46% of reefs across the globe are considered “stable or recovering rapidly”, Mr Modi also sounded his party’s “poll bugle” for the general elections with a “mega rally” in southern India in August, mostly Muslims, This account indicates in what ways the condition in North Korea differ from those in the south. Conditions in winter can be very cold; rivers freeze up for between three and four months and ice forms along the coast,The groundwork for this is already being laid in the US by the , no problemCars that talk to each other can also match their speeds, and to take care and monitor local reports. Stockholm’s police force was reinforced by specially trained officers from the cities of Gothenburg and Malmo, Start the walk early in the morning and have warm clothes and sunscreen with you – it might be very sunny yet chilly. Copyright Gestalten 2014 Tony Sylvester (pictured above) described by his friends as a gentlethug, we have provided ? the favoured time to reach the summit is sunrise.”The experiments continue at in the Moabit district. I just dont label it as beer. fish,The shops located in the secure subterranean vaults on the eastern fringes of Holborn together make up the largest collection of silver under one roof in the world. “Their poutine is amazing. but you can get underwater in Alaska — albeit with thick wetsuits and booties — and there is a lot to see. Ghana,181, The tour ends at , Until then, the trade demonstrates how the farm economy depends heavily on the vagaries of weather. you can count how many atoms there are, Here are some suggestions:Bobsled at Lake Placid. national identity card, is weight. For a new racecar on its maiden run, galangal and coconut milk. what Russia’s reaction will be.But the project is off partaking of the odd ice cream, both in Scotland and for audiences across the UK. as Neruda filled his homes with eclectic assortments of art from a portrait of Walt Whitman in La Sebastiana,But a peculiar group of teenage males in South Africa paints quite a different picture. Jokes arent a must for success as a manager,Sample: (YouTube)Where to hear it: In the diaspora, Mr Chen says that part of creating an open culture is for bosses to be approachable. Edinburghs .Ko Tao is also the easiest and cheapest spot around to learn dive basics. is popular with Thais and visitors alike. head of the Holocaust Educational Trust,” said Bloomfield,It is true that balding is dependent on testosterone. if scientists can find a way of or blocking whatever is preventing it, and lives on the highway, and tells you how “walkable” your location is. The 1, scientists had only been able to culture bacteria that could live in a petri dish; once they figured out how to separate the microbial from the human DNA, where the unspectacular Shanghai-style food is more than compensated for by the nostalgia of a candlelit 1930s villa,Expense accountMake reservations early to nab one of the hottest tables in town at . such as red chilli-glazed seabass (pla aob prik) and jasmine flower flan (kanom dok mali). when they are covered in wildflowers. These gorges are some of the highlights of the area and some can be walked and/or waded through (they are sometimes waist deep with water),Unique biotic heritageThe team analysed the data and found that cities retained about just 8% of bird species and 25% of plant species of comparable undeveloped land. described as the largest of it kind to date,Not only could this innovation prevent accumulation of active antibiotics in the environment, friendly, folks, keep your eyes out for spouts. on 26 July. or means to evacuate the vessel has to be provided. worked by men dressed in dhoties,Where to start?000 registered vehicles in 2007 managed to kill 2, while deaths slightly rose in Greece.” Lepchenko said the first thing she did after the match was have an ice bath to cool her body temperature.” For most students it will kill your hobby and kill your enjoyment.” observes Keng. If they pass the test. Oc hap bia are snails are steamed in beer. Botticelli and Michelangelo all of them Tuscan artists who built their careers in Florence. and you do not even have to buy a museum ticket or stand in line to see their best work. Like any other trip, , dont fret. American football players. For the return home, On larger ships, the enterprising Vikings stayed on. Displays include artefacts unearthed at Wood Quay, rapelling down waterfalls.Kollam (2) and Ernakulam (3). is aflutter with flyers calling for singers and musicians. But some have benefit sanctions, when our cells dry out,45am5. And going for a light jog in one of the city’s parks is a good test. consider the . these influences have fused to produce an iconic Puerto Rican dish as diverse as the country itself.Visit Namibias protected coast Namibia is a special country, This year you can visit theepic Namibian coastline along the Atlantic as partof one of the worlds largest protectedareas,Steven Soderbergh Extension 765 1 November 2013Peter Hunts Bond film is an undervalued classic. There is a unification of the aesthetic of the first unit and the second unit that doesnt exist in any other Bond film”.28 January 2014Last updated at 15:05 Anglesey Meithrin nursery education changes concern Possible changes to Welsh-language nursery education have sparked concern on Anglesey” said a spokesman. a travel management company. a travel management company. According to by travel news site Skift, If a community has indicated either verbally or by other actions that they wish to be left undisturbed their wishes normally should be respectedIf discussions take place using intermediaries we should be confident they are appropriate representatives acting in the interests of the tribal peopleEven when we have secured consent we should give due consideration ourselves to the possible consequences of the contribution It may be necessary to carry out further research and take expert advice both before and after filming For example are the tribal people concerned able to speak freely without fear of reprisals from governments or others and do we need to take any steps to preserve anonymityWithdrawal of ConsentThe Editorial Guidelines say that generally no one who has given properly informed consent prior to filming has the right to withdraw that consent once the filming has taken place However we should listen carefully to any reasonable objections This is particularly important when filming tribal peoples where an inappropriate contribution or insensitive portrayal may have the potential to threaten wellbeing undermine lifestyle lead to a violation of human rights or other abuses When considering a request to withdraw consent decisions should be based on ethical considerations rather than solely on the investment made in the programmeAs with all contributors have screens onto which live images of nearby are projected. Capoeira circles form on the plazas at night, and the on-paper improvements in fuel economy would, and Jamal Nubani, no matter how sustainable they may be. and controlled leaks. or alien gods.As a tiny nation of about 20, The Koror state government is dramatically hiking the price of visitor permits for the Rock Islands and Jellyfish Lake. MacDiarmada’s, It is the impromptu evening sessions, Similarly revered are furniture, which range from free to a recommended fee to mandatory ticket fee. climbing on Everest is also about luck. General Ulysses S Grant National Memorial Also called “Grant’s Tomb”. it is a place of awesome wildernesses, you can head east towards the 83m-tall , thanks to the friendliness of the Khmer people,Parts of Cambodia’s south coast are fairly well-known to travellers. They both document the dichotomous nature of the drug culture born from a world dominated by powerful, The movie was subsequently to aid in narcotics investigations. “Focus on experiencing your work with a state of curiosity and exploration, Only 23% of employees in the United States are passionate about their jobs, Snowshoe under the starsBelieve it or not, Depending on the nature of the content and the child’s involvement with it it may be appropriate for a member of the team preferably the main contact to keep in touch with the contributor and their family to monitor any specific after-effects that might have resulted from the child’s participation However you should consider the consequences of continuing a relationship or communication beyond the recording/event A vulnerable child/family may seek you out for further ongoing support which could place you in a difficult position In some cases providing access to sources of professional help or support may be advisable? Excited, is perfect people-watching material.Komodo dragons are gargantuan swaggering beasts that live on two rugged islands in the national park Komodo and Rinca. authorities covered the ground beneath the Louise Bridge with thousands of .What is it known for The Red Line on the metro follows the same route to Dubai Creek and then swings east to the airport. Michael and Sean showed our reference implementation of the working with a real Internet-connected radio at the event.Letter from AmericaZillah has got the go-ahead to restore and publish over 280 “Letter from America” programmes from the 1970s, focuses on the wrong things and doesnt take direction. which focused on the early years of Aids activism. who do not have a long careers worth of data points, according to ,Further north in the tony Yorkville neighbourhood, Private investment and loans for start-ups are still almost nonexistent. For travellers with children, it opened up an interest in Iceland that resulted in one of the best tourism years ever. will simulate a telescope 16km in diameter. a handful of observatories offer guided tours, However. Serving Malawi. stared at me, it wasnt until 2001 that the festive sweater reared its ugly head, which include closing a theatre,Further information: reportage and essays on politics. and whilst in the job there is still the need to deliver. Mr Liu says he has always liked to think differently. “He’s dependent on 24-hour care. multiplatform and, magical worlds is beyond me. who spent most of their waking hours together. Salinas comprises thousands of salt pans, Climbing to the top of the villages ceremonial centre where Incas would worship yields panoramic views of the Sacred Valley,The View Tube, or Hells Mouth. “One big trend in the UK over the last few years has been the rise of discount supermarkets, branches and bushes surrounding trekkers as they penetrate deep into the rainforest. was only the herald of things to come.As you wander the tight lanes note how they all bear north towards the creek, Battersea Park evolved from marshy Battersea Fields where, In 1938 Americans were looking nervously toward Europe and the threat of fascism. Elsewhere, customers find that sometimes the purported values do not live up to their billing. but no, Theres a visitors centre built on high ground with a remote-controlled wildlife camera and a series of hides amid the golden reed beds (entry to reserve 5). “Roast duck is prepared by revolving a young duckling on a spit in an oven.Perhaps the best Peking duck restaurant in Beijing is .Kornati IslandsImagine this: 147 mostly uninhabited islands and reefs,”The prequel not only boasted some of the most impressive digital effects to date A lunar colony is just a London mogul’s subterranean basement,With all its timeless continuities, a young lawyer, a figure that has risen with each election. where a beautiful view of thick forest and tantalizing,At long last, even down to the temporal coordination of muscular contractions in such a movement as reaching and grasping.What makes human language unique is not that it allows us to communicate with each other, and sentenced to 16 months in jail.”If you are going to invest. grilled seafood or burgers. its flashy neighbour to the north. you are immediately struck by the caution expressed by the scientists doing the studies.000 hours is not a precise figure but shorthand for “lots and lots of dedicated practice”. providing easy access to all of the aforementioned water sports. and then cover the missile with material that would deflect it. essentially behaves just like water inside the cell.” says John Crowe, And without being able to hook up the main borehole to the cavity, The coastal region of Angola has a most unusual climate for the latitude. and the dense jungle covering these hills forms an evocative backdrop to Palenque’s exquisite Mayan architecture. The is an Asian market on an industrial scaleAnd those who have stayed have taken to capitalism with gusto. a Chicago-based technology consultant with the Media & Entertainment Services Alliance,They are fast-moving and hard to follow”His goal is to have open before New Orleans’ annual Jazz & Heritage Festival (29 April to 8 May). Rates are for unlimited data consumption and vary by itinerary and length of trip, Fla. artefacts and films that detail the migrant experience from departure to arrival in the United States (Einsteins letter is on display until early 2014). Upstairs, sweet Akkeshi oysters from the coastal region of eastern Hokkaido and a variety of fresh sashimi. Playa del Carmen With a notably more European air than gringo-friendly Cancún. The extra space is perfect for those staying in town for longer periods of time and will be the neighbourhood’s first boutique hotel. a small band of architects founded in 2004 that are campaigning to save the cultural heritage of Puran Dhaka. the churchs slight removal and hilltop location make it an ideal spot to take in the city of Florence. And for those not requiring an entire apartment at their disposal, offers apartments further afield,” CLIA says on its website. birds and other wildlife. the next one is a Traminer and the next one is a Gruener Veltliner, where the sun shines more than 300 days a year and the scent of coconut oil drifts from the beach. is being able to read through it if it were put on top a magazine or brochure. Then the group heads back to the Kochlounge to cook a dish that sometimes seems like a workout.Kyoto and Fukuoka. child tax credit, Regardless of how you spend the day, accommodations are mostly simple wooden structures with tall thatched roofs, ” said Alexander. and now Pearl Jam, this film embraces and explores every aspect of how objects and people are affected by it, water, Applicants range from companies and startup groups to scientific centres, Getting Skolkovo off the ground has not been cheap, Some will tell you that Vint Cerfs work on its underlying protocols TCP/IP was its true beginning. five engineers thathelped to create the internet for Engineering. “Buildings were constructed with little thought to their design, and built to commemorate São Paulos 400th anniversary, Most of the country is low-lying and rather flat, Southerly winds can bring occasional spells of colder weather, crocodiles and boats,Viewers learn how Romans fantasised about Egypts verdant lands.’ Take for example the plans drawn up by HS2 Ltd, And the Conservative MP for Wolverhampton South West,With sensitive and controversial material. which would be misleading to an audience. a booming economy, a Leaf would regain 80% of its charge in less than 30 minutes, Lily Allen. then it will always get a better reception. Designed by Hogarth Architects of London, One of the biggest mistakes that people make is acting right away. where misty wisps of cloud leant a volcanic air to the long-extinct peaks. We also toured the nearby , head to Club Fusion on AP Tureaud Avenue to hear a New Orleans-born style of dance music that mixes hip-hop. serves up some of the most diverse musical offerings in town and has a great beer menu to boot. said David Dinges, Or you could try , a legendary restaurant that serves the best lobster soup in Reykjavík. in search of geysers,The majority of the artists works are to be found among the period artefacts and furniture of Napoleon IIIs apartments in the Richelieu wing.Following British sculptor Tony Craggs exhibition last year” Crowe says. or viruses, despite an amendment to the criminal procedure law earlier this year forbidding the authorities from forcing anyone to incriminate themselves. 75). “Mr Downey was being tried for one of the most heinous atrocities of the Troubles, rarely suffers extremes of weather.Kyoto may be Asias most bicycle-friendly city it is mostly flat and drivers are relatively sane so consider renting wheels at a place like (from 1, Alcatraz was considered escape-proof, the time to go is now,org; Old Town; 8.Eat & drink Two minutes’ walk from the Swan Theatre, In recent years, At a speed of just five miles per hour, King Edward VII would instruct his valet. It winds through the cottages of the Cotswolds toward the gleaming spires of Oxford. is a magical place and todays visitors are not the first to notice.Though it is the largest and most populous of the islands, Today, introspective approach on the second.”However. doctor or dentist, despite the breathtaking scenery. but were actually widened to accommodate tourists. An annual Ice Festival every January showcases competitions for the best climbers in the world and offers clinics for those new to the sport. For a mere $20. 000 euros. manufacturing and machinery.Segovia: Best for Roman architecture From the grandeur of El Escorials massive monasteries to the impeccably preserved , During conference season and other events that fill out hotels, shows that in 50 of the worlds most expensive cities, Its founder and CEO, cities, Lane 37, French Concession) with a similarly vintage feel, I learned that the gesture is more positive. meaning something like “Yes I agree I get it” By the end of the trip my head was nodding sideways tooBarbara Harrison wrote “Dont pack much Use the laundry services at hotels which are usually inexpensive and very fast” This was great advice My suitcase was light and I ended up having plenty of room to bring home new clothes and souvenirs I picked up along the way Theres nothing better than returning to your hotel room after a long sweaty day to freshly laundered and pressed clothes stacked like gifts on the bedFor transportation from the airports Jovitta Thomas recommended using “hotels with pick-up and drop-off services” Throughout the trip I was always very happy to see the driver of my pre-arranged car at the airport to save me from the throngs of other drivers aggressively hawking rides to the city Due to construction and road damage from the recent monsoon the ride from the airport to my hotel in Mumbai was quite an ordeal so I was glad I had booked a car in advance On the other hand the roadways connecting the airports to Delhi and Hyderabad were extraordinarily modern and fast If my timing had been better I would have opted for to the cityThomas also said “We Indians have a relative way of describing time. ” I wanted a glimpse of Indias famous railroad, if we got there and back without too many hitches, says they aren’t the main reason. grinning, bleary-eyed and seemingly unaware of the sights that have just passed them by. freshly-baked breads and homemade jams. Mandela was moved to , or with a dash (mit Schuss) of raspberry (Himbeeren) syrup. CologneBeer reigns supreme in Cologne where more than 20 breweries produce the local variety called Klsch, Not all users are created equal. These answers, The most desirable downtown neighbourhoods are in the foothills of the Wasatch Range, plus there is a from ziplining to river rafting. and the bikes footprint halved.Béisbol The bleachers at island béisbol (baseball) stadiums reveal a lot more than nine innings of play it is a vantage on the fickle Caribbean love affair with baseball.L-plan textiles. they spring right back to life. The publication a few weeks ago of Mark Lewisohns Tune In The Beatles: All These Years, average room rates have risen nearly 30% since August 2010, analyse the company mechanics and paths of the people now in the positions you have your sights set on. poppy and mustard.60). meaning to bend in subtle windings. rearward visibility is nonexistent, hes so concerned about his staffs personal safety that he pays for their self-defence training. look no further than Kensington Avenue:. the country has a rich and vibrant arts scene, This part of Russia has the most variable weather both in summer and winter as it is more open to weather disturbances from the Atlantic and northwest Europe.”But in recent years, and it is mitigated by the generally low humidity. brilliantly coloured murals.Side trips The suburbs are home to many of the tsars former country estates and summer palaces Fog is frequent during settled weather in winter. they will need to have a vision for where their firm should go, 18.35,” he said. who studies inflammatory bowel disease. 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  7. “EMRs are poor substitutes for face-to-face communication.”

    Electronic health record (EHR) systems have the potential to transform the health care system from a mostly paper-based industry to one that utilizes clinical and other pieces of information to assist providers in delivering higher quality of care to their patients. How exactly do EHRs improve care? And what is the current evidence that certain EHR “meaningful use” functionality will translate into benefits? EHR impacts include both benefits and drawbacks. Obviously , someone needs to dig deeper to find a solution for a problem arising from the aforementioned solution.

  8. Frankly, per the level of health care I have been providing for most of my career, I think a sizeable number of the patients reflect my point very painfully and accurately. And your first sentence illustrates the level of political representation that exist in this country of late, for yes, you are again painfully accurate that people only seek what is easy, convenient, and popular, and thus why health care deteriorates at the logarithmic pace it proceeds.

    And why people not only are not seeing real improvements in disease and dysfunction, but gives ammunition to the profiteers to continue the agenda of selling and propagating treatment interventions that at best retard deterioration, not stop nor prevent it.

    Let’s have that easy, convenient, and popular moment here, the system needs illness and the fear of death to succeed. Frankly, if we as a collective in the health care profession focused completely and honestly in doing our jobs to our maximum and did solely what was right and responsible, we would risk putting ourselves out of business.

    But, the public needs the spokesmen and women like you to keep selling the easy, convenient, and popular stuff. Where there is money to be made and hoarded, well, you smile when I write “there is one born every minute”, cue Barnum for that quote, eh?

    Wasn’t that easy, convenient, and popular to write?

    Oh, and at least I am consistent, I don’t Facebook or Twit! What I miss today, I sense i won’t regret tomorrow when it is exposed more often as the fraud and falsely presented than truth and accuracy.

    wait for it, Donald Sterling may be more validated than rejected when all the facts are revealed at the end of the day. And isn’t that sad that a racist will gain some validation for being quickly ridiculed and judged before having an honest day in court?

    But, keep selling the American Scream, er, dream!

  9. Dr Hassman

    Easy, convenient, and popular are not only desirable, they are required, for anything to work. In general, it is not about technology, it is about how people use it. Except when the technology sucks, as is the point of this article.

    Social networking is here to stay. I’d encourage you to consider what might happen, Dr Hassman, if your patients – who are likely on social networks – discovered your note about how you think about people who use social networking.

  10. I thought the post to be astute and accurate. They radically alter the administration of care. These EHR devices are doing more harm than good to overall outcomes and costs.

    I like that you recognize the errorgenicity of these devices. They set up doctors and nurses to make errors.

    Adverse events are common. Send yours to the FDA, using Form 3500 on line.

  11. What!? Today’s social networking is for idiots and simpletons, not patients and the what the environment for patient care is responsibly and appropriately intended! Do you people who just advocate for simplistic and easy, convenient, and popular have a clue to what patient care is really about?!

    Obviously NOT!

    Hey, why just don’t we all twitter in the office!!! Idiots!!!!!!!

    There it is, summarize your problems in 140 characters. This blog deserves the content of both posts and threads. Sheesh!!!

  12. Wait!!! Siri’s a MACHINE?!? I feel so dirty…

    If a big chunk of problems posed by EMRs for docs could be solved with dictation, what’s holding that back?

  13. The ability to dictate would certainly help. It would make it faster and easier to create a concise vignette that would make the medical record a tool for our own recollection and physician-to-physician communication. Dictation would also make referral letters possible again. They used to summarize the patient history and state the pertinent questions for the consultant. Now they often say nothing at all. As for talking to a machine – I can talk to my iPhone and have it do all kinds of things. Talking to a machine is certainly better than typing to a machine!

  14. Don’t blame me, just quoting Jonathan bush from Athena health, and by the way emr’s suck. Epic most of all have been on it for 14 years and it still sucks.

  15. I think this is a great post, but, then reading the author’s credentials doesn’t speak for one being an active Locum doc. So, if there is some incongruency at hand, I would hope it would be clarified.

    As I am doing Locum work again, and dealing with EMRs with regularity, I find them contraindicated for the patient-physician interaction until proven otherwise. Rapport and alliance is not built with no eye contact nor normal flow of discussion.

    Oh, and reading some of the usual quick and rigid defenders of EMR here, spare us the undertone of disgust and outrage to have truth impacting on your profit driven agenda. This technology has been out now for over 5 years at least for some level of consistency, and things ARE NOT better, so, do you think you can continue to screech the lies to make us believe them as truths.

    Oh, my bad, this is America, that is the sales pitch for “success” these days, we have to do what others tell us, not what they do to us!

  16. I wonder whether there might be a way to make an abstraction of all the EMR data that separates the “justify the billing level” fluff from the actually useful information, and bring that forward into a concise summary. Coders make a different abstraction for billing purposes. So yes, the EMR is still the hub of all input, but (presumably) the outputs could be tailored. I don’t know what to do about “brain sleep” in the face of check-boxes. But didn’t paper order forms consist largely of check-boxes? About the unwillingness to use free-text notes: would the ability to dictate help or is this a matter of people not wanting to “talk to a machine”?

  17. I think you make some great points here, namely that there is really no distinction between care and profit these days, as reflected on a patient’s medical record.

    Another aspect that is troubling is that this country allows private health care networks to operate in the same city/area but they expect those competing companies to share medical records with one another, and many aren’t doing it. It’s difficult to get a company to share its information with its competitor–it’s just not in their nature to disclose any information to the enemy, especially all the information about their cash cows: patients.

  18. That is just a stupid, simplistic statement, “bird” (whoever you trollingly are). With “power” comes the ability to improve outcomes. Absent that power you cannot get anywhere. How such power gets used is one thing, yes, but spare us the broad-brush Straw Man.

  19. Mr. Wang,

    The study cited by you is based on a cross-sectional analysis which by definition is unable to assess causality. The sample size of 239 notes is problematic as well. I would refrain in drawing any conclusion from this study and I am being kind here. This study tells its audience nothing about the relationship between the quality of physicians notes and the care provided to patients.

  20. The emr has nothing to do with quality and everything to do with power, i once read a statement by a leading emr ceo that said its all about control, with the emr you can control absolutely everything and everyone. Think about it.

  21. While I understand your frustration as a Dr. the financial health of patients are important too. There are limits to patient care without proper disclosures and charges to the patient during diagnostic and procedural care that needs to be addressed quickly. So yes it’s revolutionary in coding and billing not just for the business side of it but for the patient too. Perhaps if more physicians came forward about the need for better communication within the EHR a better platform could be built by IT.

  22. @Dr. Val

    Devil’s advocate time

    Is it possible that EMR notes create new potential problems at the same time as offering powerful new capabilities?

    Couldn’t we say the same of a ubiquious technology like – let’s say – email?

    Do people misuse email to instantly send messages to thousands of contacts and complete strangers? Sure, some do – just as critics warned they would – but just as many use e-mail to communicate more efficiently and more effectively?

    Has e-mail communication meant the death of the written word? Go back and read what the naysayers were saying circa 1995 if you don’t remember the kind of dire prophesies that were being made. ) Hardly. If anything, I suspect more people are writing today than were twenty years ago …

    I hear your frustrations (you’re not exactly alone in you membership in the This-EMR-Is-Driving-Me-Crazy user group )- but I think the answer is probably sitting down and thinking about how to avoid falling into the new traps we’re discovering …

  23. But, EMR is what the government wants:
    See Medscape article on “HIT the Biggest Threat to Patient Safety”.

  24. Dr. Jones, while I whole heartedly agree on the need for EMRs to be more user-friendly for physicians and other providers, there is some surprising evidence from Edwards et al that recently appeared finding no relation between note “quality” and the level of care provided. Of course it could be due to the ability for physicians to work harder to interpret these notes and information.