Meanwhile, as my tenure as chief of staff winds down and I prepare to return to more rigorous activities in neurosurgery and graduate medical education, I’d like to talk about a transition in the lives of all of us — the move to the CIS-Epic Electronic Health Record — coming to our changing lives April 25.

The CIS-Epic design team, collaborating with physicians, has done a great job to make the CIS-Epic launch feel as natural and intuitive as possible. But natural and intuitive does not mean business as usual for practicing physicians. In fact, we will face huge changes in our day-to-day hospital workflow. Specifically, we will be using a different program to enter our orders, so we need to go with the flow to alter how we do things so that our practice meshes with this new electronic system of medical organization. Overall, I am optimistic that this change from Carecast to CIS-Epic will be positive, and we will be well served to think of the changes as opportunities to ultimately improve patient care. But please be patient through the learning curve.

One change affects physicians accustomed for years or decades to giving verbal telephone orders. No longer can we just give a succinct order and then hang up the phone. To phone an order into CIS-Epic, you will have to remain on the line with the person taking the order until it is fully entered into the computer. The reason for this change is that the nurse receiving your order will have to clear pop-up screen alerts and prompts before the order is complete. Nurses have been instructed by their leadership that making assumptions about handling these alerts and clarifications is beyond their scope of practice. Instead, they must check with you in real time while on the phone. So if you do give a phone order, do not blame the nurses when they keep you on the line to do their jobs as instructed.

Many of you will find this process inefficient, and happily, there is an alternative. You are encouraged to enter the order yourself from any computer with Internet access. If I remember correctly, one of the hopes for physician order entry initially had been to get rid of verbal orders altogether.

The next year or so will be a time of staggered implementation for CIS-Epic after the “big bang” on April 25, when Care Cast and Care Vue (in the ICU’s) are switched off and Epic is switched on. But we will not be fully implementing CIS-Epic on that day, since for the first month people who wish will still be able to write notes on paper instead of entering progress notes in the computer. I urge anyone who would feel more comfortable with a few hours of focused support on entering online progress notes to take advantage of workshops scheduled throughout May by the CIS-Epic implementation team. [See related article].

I believe this transition will be a difficult time, because until we completely get rid of paper charts — up to 30 days after April 25 — we may have to check both paper and online records for needed information. We will still be functioning with both paper and the computer in the clinics until they are all converted to full use of CIS-Epic on a scheduled basis over the next two years. Remember that CIS-Epic will not be fully efficient until the whole system is running and we get rid of all our paper charts, including shadow charts in our clinics.

Yes, it is going to be interesting times! But I truly believe once we are through the period of adjustment we will ultimately wonder how we ever did things without a fully computerized medical information system. That’s what colleagues at comparable institutions are telling us.

[click to download: Advanced Beneficiary Notifications Form.pdf]

Another issue which could affect our workflow involves Medicare ABNs (Advance Beneficiary Notifications of Non-Payment). ABNs are not a new Centers for Medicare and Medicaid Services (CMS) requirement, but they have become an area of increased focus. ABNs, which apply primarily in the outpatient setting, are a form of written notification — a “heads up” — that healthcare providers, i.e. SHC, must give patients who face potential financial responsibility for a test or study because Medicare may not pay for it. This issue often comes up when a test ordered for a patient isn’t deemed medically necessary by Medicare for the ICD 9 (diagnostic) code you’ve entered for that patient. For us, this means making sure that we’ve entered an appropriate ICD 9 code that includes approval of the needed test.

Government regulations require us to screen all ancillary outpatient services ordered for Medicare patients and ask the patient to sign an ABN form, when appropriate, before the service is provided. Anything less is considered out of compliance.

Here’s how the scenario is likely to play out:

1. Clinic desk staff will enter the ICD 9 code provided with the ordered test or service on a computer program that utilizes Medicare coverage rules.

2. If the program shows no match to the test or service, clinic personnel may ask the ordering physician if additional diagnoses may apply.

3. If the new diagnostic code leads to approval of the test by Medicare, no action is required. But if there is no approval, the patient will be given an ABN, informing the patient that he or she may be financially responsible for the test or service. The form provides an estimated cost and also notes options and recourse for the patient.

You can imagine that for some of the studies and tests we order, patient responsibility could involve a hefty sum of money. But even smaller dollar amounts could be a real hardship for many of our patients. So we will need to understand the ICD 9 codes and ensure we are thorough and complete in our coding to increase the likelihood the studies and tests we order are covered. I realize that this creates a workflow issue, because until we are fully educated on the matter, we will sometimes have to stop and come up with another diagnosis for patients when our perfectly reasonable initial one is incomplete and doesn’t pass muster. Materials will be available in clinic workrooms to assist us, but some trial and error will likely be required and your patience and understanding are requested.

Yes, the only constant is change itself. Those of us who wish to put our head in the sand and resist it risk extinction. I for one am not going to let that happen.

For questions or information about the CIS-Epic transition, email Stanford.learning@accenture.com, or call the training Help Desk at (800) 394-7970. For questions about CIS-Epic after launch, call the Help Desk, (650) 723-3333. For questions assistance or comments regarding ABNs, contact ABNfeedback@stanfordmed.org, which is checked several times daily.