Gaining fluency in the new EMR


This EMR I’ve started to learn

I’m done when it’s time to adjourn

But it’s too many clicks

To get meds to the sick

When others are waiting their turn.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, I am back on the job in western Iowa. Any identifiable patient information has been included with permission.

After a week on the job here I find myself waltzing through the Electronic Medical Record (EMR) system with fluency I didn’t expect last Wednesday.

This EMR has the advantage that signing back in normally takes 4 digits, the equivalent of a day key on a safe. While pretty robust, today it locked up twice and towards the end of the day the all-important diagnostic search function stopped working.  Thus I had to restart my computer 3 times.

I have to pass through 9 data fields to send a prescription. Finding the right ICD-10 diagnostic code requires passage through the ICD-9 codes, obsolete for two years.

Still, I can free text the heart of my note. I have to click through dozens of fields for the physical exam, but it gives me good choices.  For example, I can click that the patient smells of cigarette smoke.

Allergies and allergy-like problems dominated the clinical landscape. The constellation of itchy, watery eyes with itchy, watery nose and sneezes coming in multiple strings helps distinguish problems originating with pollen or harvest dust from those related to viruses.  When cetirizine went over the counter at the end of the last century, I bid my summer allergy business goodbye and good riddance.  Somehow, the patient population here hasn’t gotten the message that drug and Flonase can be purchased without a prescription.

But we’re also seeing a good amount of urticaria, sometimes called hives: welts like mosquito bites all over accompanied by intolerable itch. I first turn to antihistamines, but for those few who don’t respond I prescribe a short course of prednisone.

Other patients with respiratory issues for the most part suffer from a combination of viral infection and tobacco smoke. I spend a lot of time explaining that in most cases antibiotics cause more problems than they solve.

About a quarter of the patients have a serious problem that requires experience, knowledge and research to diagnose. Sometimes a result will come back abnormal, and when I call the patient I say, “Just because you can see a bear out there with your livestock doesn’t mean you don’t have to worry about wolves.  So I’ll treat what I’ve diagnosed but if I don’t cure you we have to re-evaluate.”

I attend patients of all ages, from infants to nonagenarians. I took care of two Hispanic monolinguals last week and greatly enjoyed using my Spanish.  When an English speaker struggles with a medical term, I’ll  pronounce it, then immediately say, “I speak a little Chinese, too.”

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