{"id":7988,"date":"2016-04-30T07:37:24","date_gmt":"2016-04-30T11:37:24","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=7988"},"modified":"2018-06-27T16:31:56","modified_gmt":"2018-06-27T20:31:56","slug":"ridiculously-long-post-ehrs-expose-unspoken-hierarchies-within-medicine-maybe-just-bad","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/ridiculously-long-post-ehrs-expose-unspoken-hierarchies-within-medicine-maybe-just-bad\/2016\/04\/30\/","title":{"rendered":"A Ridiculously Long Post: How EHRs Expose Unspoken Hierarchies Within Medicine — Or Maybe Are Just Bad"},"content":{"rendered":"

\"Thinker\"<\/a>I am\u00a0consulted by a surgeon about a patient with something that might be infectious, might not. A very appropriate referral.<\/p>\n

After seeing the patient and reviewing the history and scans, I\u00a0decide a CT-guided biopsy is\u00a0the next step.<\/p>\n

The nice radiology fellow tells me “Just place the order in [enter name of EHR here]”.\u00a0Since this is\u00a0the first time I’m ordering this\u00a0test using our\u00a0new system, the prospect of doing so doesn’t\u00a0exactly fill me with joy.<\/p>\n

Nonetheless, I give\u00a0it a go. I place the word “biopsy” in the dreaded order search box, hit enter, and cover my eyes, at least metaphorically.<\/p>\n

A lengthy list appears, and I select\u00a0the test closest to the one desired — for some reason it’s called “CT IR MASS\u00a0ASPIRATION\/BIOPSY (NO CATHETER) (Order #152640784)”. The order then requires filling out numerous fields (some of them woefully tiny for anyone past the age of, ahem, failing eye accommodation), clicking several check boxes, and deciphering inscrutable warning messages.<\/p>\n

Since the precise diagnosis on this case isn’t\u00a0yet known, and a precise description of the problem doesn’t\u00a0come up in the formatted search, I do\u00a0what everyone does when trying to navigate these complex screens and\u00a0their\u00a0finicky criteria.<\/p>\n

I fudge it (in other words, make something up). Nevermind that the fudge doesn’t\u00a0really fit the case — voila,<\/em> it goes\u00a0through!<\/p>\n

But most\u00a0importantly, the order for the biopsy includes a free-text\u00a0box, where I enter the critical micro tests desired, specifically:<\/p>\n

    \n
  1. routine and anaerobic culture with gram stain<\/li>\n
  2. fungal culture and smear<\/li>\n
  3. AFB culture and smear<\/li>\n
  4. Nocardia culture and modified acid-fast smear
    \nNote to micro lab: \u00a0Prioritize pathology and fungal culture\/smear if there isn’t enough specimen.<\/span><\/li>\n<\/ol>\n

    (If that seems overly detailed, trust me —\u00a0I’ve been doing this ID stuff a long time. You’ve got to give precise<\/em> directions. Sometimes you might even need to go from being the ID Attending to, as my brilliantly funny colleague Libby Hohmann<\/a> once put it, the “Transport Attending”. That happens when you both specify the cultures to be done and<\/em>\u00a0are the person making sure the specimens arrive at\u00a0the lab appropriately.)<\/p>\n

    After completing the order without setting the computer aflame, I feel a\u00a0little glow of satisfaction — kind of like when you get a tough clue in a crossword puzzle, correctly guess your opponent’s hand in poker, or predict in advance\u00a0when the runner on first tries to steal second on a 2-1 count.<\/p>\n

    Or maybe that\u00a0glow is\u00a0simply the\u00a0computer screen reflecting off my face? Because\u00a0the satisfaction is\u00a0short-lived — soon after placing the order, I receive this from the radiology fellow:<\/p>\n

    Dr. Sax, thanks for your biopsy request. In addition to the order, we require you to put in separate orders for each microbiology test before the biopsy. Could you please place these individual orders- i.e. fluid culture, AFB, fungal culture, nocardia, etc and any other micro testing you think would be relevant? These will need to be entered as \u00a0\u201cSigned and Held\u201d orders.<\/p><\/blockquote>\n

    Brilliant.<\/p>\n

    Thoughts, emotions, reflections on this unfortunate turn\u00a0of affairs.<\/p>\n