TOPHER SHARP
FROM THE CLINICAL TRENCHES TO THE SERVICE DESK...
Topher Sharp, chair of the HIM Committee
Christopher “Topher” Sharp, chair of the Medical Staff’s HIM (Health Information Management) Committee and associate chief medical information officer, helps bridge the gap from “in the trenches” practice to IT implementation, which is led from a physician perspective at SHC by Kevin Tabb, vice president for medical affairs, and Pravene Nath, chief medical information officer. Sharp’s own practice, Stanford Medical Group, was one of the first two clinics to go-live 15 months ago, and he was extensively involved in pre-launch planning.
Sharp, once a chief resident in medicine at SHC, offers some thoughts — and tips — for physician colleagues about where SHC and clinicians stand in the transition from paper to EHR:
Q: How do things look after a year?
Sharp: Overall, I think our implementation went well. We have launched Epic in every intended area, and our adoption has succeeded without undue disruption to the delivery of care. During the stabilization of my own clinic a year ago I felt the same impatience as others when trying to integrate this complex system into my routine delivery of care. However, those who have been through such implementations before reflect that we have had a very smooth transition.
Q: Was the transition harder or easier than expected?
A: Happily, a few things may have been easier — the inpatient physicians and informatics teams say they were generally pleased by the solid implementation and the robust functionality of the EHR in the demanding inpatient care environment. On the other hand, the Cancer Center, probably our next most complex environment, has required caution and a staged implementation rather than the aggressive launch we had hoped for. In particular, this applies to Beacon, the chemotherapy management tool, which has gone live in a limited pilot and is expected to be fully in place in October.
Q: Have physician attitudes changed toward the EHR?
A: We’ve reached a tipping point where we have more people actively using the system than not. Even those not using the system in their clinics yet know Epic is a fait accompli and are saying, “When do we go live? Whenever it comes, we’ll be ready.” The initial hesitance or skepticism seems to have dissipated. We’re at the point where physicians are beginning to see Epic’s fully integrated functionality and the benefits to the institution’s practice and patients — even if it isn’t always a timesaver for the individual.
Q: Was getting up to speed intimidating?
A: A key strategy in each clinic was to reduce clinical workload by 50 percent the first week, and then gradually ramp up to 100 percent over the first few weeks. This policy provided a measure of comfort and safety for physicians as they got used to the new system. It is impressive that nearly all physicians moved back to their prior patient load in the scheduled time. However, in the first months, physicians may be staying later to catch up with their work as they learn to become fluent in the system. The payback is that the information that is put into the system will provide added value later.
Q: So Epic is not necessarily a time saver?
A: True, especially during the first six months to a year. Some tasks may take a little more time, other tasks may go more quickly. In the end, though, efficiency improves. There is no doubt: typing takes longer than scribbling a note, but personally, I would rather spend a bit more time typing in patient information that all of us can find and read later.
Q: Has Epic changed practice?
A: Of course. Physicians are almost universally turning to Epic as the tool to read up on their patients. As more and more information is added to the system, it will increasingly become the robust, comprehensive stand-alone chart for even long-term patient histories. The rhythm of practice has clearly changed. Another simple example: When my nurse takes a message, it doesn’t come to me any other way than Epic.
Q: Is that sort of dependence on messaging vs. personal or voice contact desirable?
A: If used exclusively, certainly not. As we grow with the EHR, we need to make sure we are using the form of communication that is most appropriate for every situation. And that varies. Certainly the EHR or an email can never replace a detailed or nuanced phone call or face-to-face conversation. For example, as a primary care provider, the system notifies me immediately that my patient has come to the emergency room or has been admitted. That’s wonderful information, but on the other hand, I’d love a phone call to fully understand the decisions made. One of the challenges of the EHR is that communication, while factual, doesn’t always capture the flavor of the interaction or the intent. And let’s face it, most of us can talk faster than we type.
Q: Any tips on when it’s important to talk vs. sending a message?
A: There are no hard and fast rules, but I’ve found when you find yourself in an email dual with someone, it’s probably time to pick up the phone. And we should never lose sight that sometimes the conversation needs to happen outside the factual record to ensure the richness of communication. Another simple rule is that urgent communications almost always requires a face-to-face interaction or a phone call. You can flag a message to me as urgent in Epic, but if I’m not in front of the computer, it’s not urgent to me. Sometimes the most effective alert is the urgent look on the face of your nurse or assistant.
Q: Speaking of help, can you think of some ways that Epic has tangibly improved service?
A: Absolutely. For physicians, prescribing using Epic is a notable improvement. On paper, I had the embarrassment of calling a pharmacy to ask what my last prescription for a patient contained because the prescription was missing from the paper chart. Now I can prescribe the medication on line, and I have the same information the pharmacy has. The patient’s medication history is right in front of me, and I can be alerted to potential interactions. On the patient side, we’re rolling out MyHealth, an Internet tool that allows patients to get test results, communicate with their clinic, view past and upcoming appointments and more. Patients tell us that this is a significant improvement in service to them.
Q: Are there new challenges introduced by the electronic system?
A: A year after starting, I think we are comfortable enough with the functions to ask questions about how to use Epic more effectively. For physician practice a good example is how we record notes. In Epic it is easy to cut and paste. When I had to make handwritten notes, I was parsimonious with my comments and careful to limit what I wrote to what was necessary. In Epic, there is a tendency to paste huge chunks of yesterday’s note into today’s note — sometimes even when information is stale, or worse, no longer correct. We need to focus our practices and our supervision of housestaff so that we fill the record with useful information — not just more information.
Q: What about help to bring physicians up to speed?
A: Some attendings spend only a small portion of their time in inpatient or outpatient clinic settings. The team is focusing attention to make residents, nurse practitioners and others in the clinic prepared and ready to help busy attendings. We also are cognizant of the special need to respond rapidly to community physicians, who typically don’t have residents to support them and are often working outside the Stanford firewall. At the end of day, the best help is often from a colleague, but we also need to provide immediate and accessible informatics help.
Q: Epic leadership is piloting a one-on-one help function.
A: Yes, 4-Epic. In essence, when physicians dial “4-Epic”, they are connected to onsite clinical support with Stanford-specific Epic expertise — not someone who just takes a message. Most of the 4-Epic support team members are nurse informatics specialists who know that when you say you are calling “from E-2” you are in an ICU with specific needs. Inside the Stanford system, the nurses can log onto a mirror of callers’ computers and see exactly what the caregiver sees on the screen. The support team won’t have instant answers to every question, but they have the online resources and second level backup to answer questions rapidly. So far this is working well, and we are gathering feedback about whether to extend 4-Epic hours.
Q: Is Epic impacting hospital practice?
A: I believe so. The surgical boarding pass, a checklist that the operating rooms use to make sure that surgeries are good to go, is recorded and displayed in Epic. We are also using Epic to track data and to compare outcomes by controlling for specific measures, such as whether DVT prophylaxis was administered.
Q: Any advice for physicians who may feel a bit frustrated when they have to type in information they didn’t have to before.
A: One of the goals of the electronic health record is to know that all of the data that you’re putting in you’ll later be able to pull out in a useful way. The ultimate goal of the EHR is not speed or convenience to any one person. The ultimate goal is higher quality, safe, and efficient overall care of our patients. And to do that, everyone has to contribute his or her part.
Q: How do you plan to use your role as chair of the Medical Staff’s HIM Committee?
A: The Health Information Management (HIM) Committee has existed for decades in its oversight of the legal medical record. The electronic medical record has changed HIM processes significantly. We will have important questions about processes which ensure the integrity of our records in an electronic system. For instance, what expectations will we set for physician chart completion? What will be the best method to assure that our medical students’ and residents’ notes have appropriate oversight? I hope my colleagues will contact me if they have suggestions or questions about how we continue to assure our medical record is intact, durable, and usable. I’m at csharp@stanfordmed.org.
