Using the Electronic Medical Record Advantages and pitfalls for Radiologists

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1 Using the Electronic Medical Record Advantages and pitfalls for Radiologists Brian R. Herts, MD Professor of Radiology Imaging Institute & The Glickman Urological and Kidney Institute Cleveland Clinic

2 Objectives Understand the role that the Electronic Medical Record (EMR) can play in Radiology Learn ways to use the EMR to help you in your practice Learn the pitfalls of information in the EMR in order to avoid them

3 Survey of physicians and EHR (Mass) Arch Intern Med. 2007;167:

4 Advantages for radiology Organization read office visits, operative reports History and HPIs problem lists, check allergies Lab results do your own clinical correlation Pathology results the gold standard Documentation notes from radiology visits Order sets groups of orders or common orders Alerts soft or hard stops based on certain parameters contrast allergies, low egfr, utilization (ACR guidelines), MR incompatible devices

5 Disadvantages for radiology Disorganization too many places to look for info History copy forward, copy and paste (same error) Lab results are pending!? Pathology from outside hospital Documentation - lack of application training Order sets - are not kept current / order same test Alert fatique run through yellow lights

6 Examples of easy things to do Nursing documentation of the visit IV starts for CT and MR Contrast given Pregnancy - asked / test results egfr, creatinine, Point of care testing (POCT) results IV hydration

7 More easy things to do: order sets Order sets for commonly Rx d medications, fluids IV hydration orders Steroid / benedryl prep Glucagon for MR Enterography Secretin for functional pancreatic studies Pain medication Auto-generate screening forms MRI safety

8 Easy things to do, continued order sets Order sets following procedures Admission orders CXR following thoracentesis VS checks Flush & Record I s & O s from drainage catheters Lab specimens Gram stain, culture & sensitivity; AFB Creatinine for suspected urine leak Amylase for pancreatic duct leak, bilirubin from biloma

9 Set alerts for contrast allergy and CIN risk factors Set an alert for contrast allergy Provide recommendations for severe allergies consider MR or US (or call the department!) Link to an order set for recommended premedication Rx Pitfall search iodine, contrast, dye & x-ray dye (GIGO) MRI safety screening form CIN risk factors Diabetics, h/o CRI (search by text or ICD codes) No creatinine or egfr on file provide a link to an order Low egfr consider IV hydration or NC CT scan

10 Sample alerts

11 Check lab results Things to consider: CBD dilation post Chole with normal alk phos and bili Elevated amylase and lipase in suspected pancreatitis Abnormal LFTs Alk Phos/bili or ALT/AST? D-dimer for PE chest CT protocols Tumor markers - CA-125, CEA, AFP, PSA, CA19-9 Tumor sizes and margins FGr1 2 cm RCC v. 12 cm RCC for chance of metastasis Recurrence - was the entire tumor resected???

12 Order set example hydration, premed, meds

13 Order set example post procedure

14 MR safety screening form

15 MRI Screening report

16 Curbside Consultation To document or not to document? For cases that matter, clinicians are going to document what they think you told them (or their resident, medical student or secretary), so why not document what you actually said and copy them?

17 Signed by: Brian R. Herts, MD August 15, :15 pm Radiology Opinion Note

18 Certified Physician Order Entry (CPOE) Top of the list phenomenon Abscess 1 st degree burn fingr with thumb Certified physician Unit clerk order entry Multiple orders not sure what to order? Order everything and let radiology figure it out Chest CT with and Chest CT without contrast Physicians may batch sign orders entered for co-signing Study indications may not have been given

19 The dark side of documentation Permanence Difficult to delete erroneous information Typos! Dictation systems Missed transcription errors Poor transfer to EMRs (symbols don t always transfer) Copy Forward Errors or mistakes permeate through the medical record because they are either copy and pasted from the previous clinical note or auto-populated via templates

20 Meaningful Use not focused on radiology just yet, but will be soon Core objectives without exclusion criteria Implement drug-drug and drug-allergy interactions checks Maintain up-to-date problem list of current / active Dx Maintain an active medication list Maintain an active medication allergy list Record patient demographics (gender, race, ethnicity) Report ambulatory clinical quality measures to CMS Implement one clinical decision support rules relevent to specialty along with the ability to track Protect PHI

21 Meaningful Use For the average radiology practice, there are two things you need to know, Number one, this is on the horizon, and Number two, it s not something they can blow off. --Jonathan Berlin, a radiologist at Northshore University Health Center and associate clinical professor of radiology at University of Chicago Pritzker School of Medicine:

22 Needs: People, process and support EMR representative dedicated to radiology Someone in the compliance world Someone in the billing world A radiology team to filter requests and set priorities Contact in legal department at your hospital for documentation

23 Conclusions The benefits of using the EMR clearly outweigh the problems - - and it will be required (MU) Use standardization to help you organize Make use of order sets and templated notes ASK for training most Radiologists are an afterthought in the EMR cause we don t see patients? HAVE THE EMR OPEN! If it s not open, you won t use it! ( cheat by checking labs, Op notes, )

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