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As I write this, it has been over a month since we implemented our MEDITECH EHR. We have had a number of successes, and the adoption has been very good. Although there are a few holdouts, the majority of our physicians and midlevels are actively and successfully using the EHR. There are also a number of ongoing challenges, some of which I will cover below.

Carry Forward

MEDITECH has a function that the Regional Physician Advisory Committee (PAC) voted to implement called Carry Forward. Carry Forward pulls the information from the previous day's Progress Note forward and populates the next day's note. Carry Forward pulls your note forward. It is important to know that this function also pulls in the information that was entered by your midlevel the previous day if the midlevel documented the previous day's note under our name.

It is critical that we review and edit our notes before we sign them if we are using the Carry Forward function. We are seeing instances of physicians coming in and placing a note in Pdoc and signing it, with information contained in the note that is pulled from the previous day's midlevel note. Unfortunately, these notes have not been reviewed and edited for accuracy before signature. There have been patients who are still on ventilators a day or two after extubation. Please remember to review and edit any notes that contain material that is populated from the previous day before you sign a note.

Consult Pharmacy

There are Pharmacy Consult orders in MEDITECH that can be accessed in the Order Entry module. In the Order Entry module select the "Meds" and "Name" buttons. Type "Pharmacy" into the search box. A list of Pharmacy consultations and services will appear. These include Renal Dosing, Vancomycin, Warfarin, TPN, etc. Please do not enter a request to Pharmacy into the "Comment" box, as this does not trigger a Pharmacy consult.

Admission vs. Place in Observation or SDC (Outpatient)

Most of you are aware of the new Medicare requirement that we enter specific Admission order, as well as certify that a patient's inpatient admission is medically necessary. When you select the inpatient admission order, you must edit this order on the second (CDS) screen. Completing the required fields in the CDS screen fulfills much of the Medicare documentation requirement. You must also however document the reason that the patient requires inpatient treatment, your plan of care and the medical necessity of the patient's admission. Note that Medicare uses "Admit to…." for inpatient admissions and "Place in…" for Observation and SDC (Outpatient) stays. Although it may seem like a trivial detail, this is the language that Medicare expects to see for these levels of care.

The screenshot below is what the 'Admit to…" CDS looks like in MEDITECH.

The asterisks represent required fields that must be filled out: Expected Length of Stay, Rationale for Inpatient Admission and Admitting Physician. The Priority and Date fields are required, but are pre-populated by the EHR, and can be edited as needed.

Messaging and Favorites

In Texas Region the ability to save a "pick list" of favorite medications and procedures is active. This allows us to build a list of frequently used orders to help speed our work in the EHR. There are times when medications have new black box warnings added or are withdrawn from the market. As you have noticed, the logon screen in MEDITECH allows us to add a message to this screen, as shown below:

As you can see, this screen contains the support numbers for MEDITECH. We are planning on using this messaging function to communicate messages regarding Black Box warnings and market withdrawals when they may impact our Favorites (Pick List.)

Order Set Change Process

The Adult Order Sets in Texas are Regional. That means that the content is developed here and then reviewed and approved by the Electronic Order Set Committee (EOSC). The EOSC is a multidisciplinary group that includes physicians, nurses, pharmacists and others. Once the EOSC has approved an order set change or a new order set it is submitted to the SJH Enterprise CIS (eCIS) team for review of formatting and style. They order set(s) are then "built" and placed into the MEDITECH "test" system before being moved into the "Live" (active) system. Requests for order set enhancements or new order sets may be submitted via our Regional Physician Liaisons or to the EOSC for consideration. Order sets must be consensus sets developed by the Specialty Sections, or when there is no Specialty Section by the groups who comprise the specialty who practice at Covenant Health. The full policy is available here.

Lastly, change is always difficult, and at times learning to use a new software application, such as MEDITECH is frustrating. I ask that you please not take your frustration out on the Physician Liaisons. They are working extremely hard to support us as we learn to use the EHR, and are very good at what they do. It is not appropriate to direct out anger at the changes we are going through on them. They are here to help. Please don't make their job any harder than it already is.

As always, if you have any questions please feel free to contact me at 806.725.0265.

Lawrence Martinelli, MD, FACP, FIDSA
Chief Medical Informatics Officer
Medical Director, Case Management/Utilization Review
Covenant Health
3615 19th Street
Lubbock, Texas 79410