Somehow, at the beginning of this week, something went wrong with our computerized order entry system, and we were suddenly unable to order appropriate lab monitoring for our patients’ medical conditions.
In the old days, before EHRs, doctors would check off on a paper form what labs they wanted done on their patient, and send them off to the lab. Billing for these labs happened through long, contorted, disconnected sets of systems that ultimately bundled the charges for the labs into the charge that was dropped as the reason for the visit, the medical care we were providing. As we entered the age of the electronic health record (EHR), and things got more sophisticated, hard linkages were created between the order entry and a particular diagnosis.
When this first started out, the rules were pretty loose, and any old diagnosis was accepted for any old test you wanted. I remember seeing all sorts of really bad examples of this, such as when cholesterol profile was associated with iron deficiency anemia or fatigue as a diagnosis, or a chest CT was ordered with a diagnosis code of diabetes mellitus.
It makes sense that we order tests for a real reason, that there be some clinical symptom or medical condition that makes it reasonable for us to order this lab at this particular time for this particular patient. I can understand why I shouldn’t get hemoglobin A1c on a patient unless they have diabetes. But if a patient comes in for a preoperative evaluation and they need an EKG and coagulation blood tests, why have we allowed a computer system to tell me the patient can’t get these tests with “pre-operative evaluation, ICD-10 code Z01.818” as the diagnosis, since that is the only reason I’m doing these tests?
Ultimately, the filters became more sophisticated, and rules were instituted by the insurance companies that allowed certain lab testing under certain conditions, for certain symptoms, and at a certain frequency.
While this feels like a little bit of a burden for the providers trying to do their work, ultimately it makes sense, and probably does lead to some more cost-conscious spending of healthcare dollars by providers. When you get these warnings in other situations, it’s nice to be reminded that you really want to tell the people who are paying for these tests why you’re doing them, so that it’s justified. However, somehow this week all the systems got crazy, and everything went into lockdown.
We tried ordering thyroid stimulating hormone levels on our patients with hypothyroidism, or hemoglobin A1c on our patients with diabetes, or lipid profiles on our patients with high cholesterol. Denied. Colleagues told me they were sitting in their exam rooms, typing in orders for patients, selecting what they thought were appropriate diagnoses, and getting nothing but a response saying this lab was unable to be ordered with this diagnosis.
Since we were used to some of this, people started searching around for possible fixes, including creative ways of recording the diagnosis (“disorder of lipid metabolism,” instead of “pure hypercholesterolemia”), or grasping at obscure ICD-10 codes in the hope that something would stick, before ultimately resorting to smashing our fists down on the keyboard and telling patients they could not get their labs done today.
When nothing can be ordered for things that we know they should be orderable on, it makes us feel that once again someone flipped a switch somewhere that added some new module, some new monitoring system, or some new set of rules, and they didn’t think about the downstream ramifications, and didn’t test it out enough under non-simulator conditions to ensure that this would not make our lives miserable when we came into work on Monday morning.
It reminds us once again that our friends over in IT really should ask us our opinions about this stuff — let us take it out for a spin around the neighborhood and make sure we get all the kinks out before they roll this out for real-world real-time usage. We understand that there are a massive number of moving parts in all of the systems that are working together to let us chart for our patients in the EHR, but when this sort of thing happens it does nothing but alienate us, the end users, from a system that is supposed to be there to help us take care of our patients.
I can only hope that this situation, and the flurry of complaints to the help desk it generated, will make the coders and developers a little more willing to reach out to us and let us know what’s coming before it’s a foregone conclusion. Believe it or not, when technology works for us, we love it, and we are willing to put up with a lot to get the functionality of a really good EHR, but do us the courtesy of checking with us first.
With the next iteration of our EHR, we’ve learned there are a lot of really cool bells and whistles that will address a lot of the pain points that many of us have with the system, and we are appreciative of the work that went into making these things happen.
But remember, the customer always comes first.
Last Updated January 10, 2020
Source: MedicalNewsToday.com
