Comments on: Computer or patient, who do I work for again?

By: drcharles

drcharles — Wed, 20 Jan 2010 01:15:49 +0000

Good post. I’m interested (and somewhat afraid) to see what happens to my clinical decision making as our office transitions to an EMR from paper. I wonder if thought processes change as a reflection of the way data is collected. Of course I worry the process will overwhelm the purpose of each visit. We’ll see.
Thanks for the point of view.

By: BoswellEMT

BoswellEMT — Thu, 24 Dec 2009 07:22:55 +0000

Ed,
100% I agree. We are more data entry clerks sometimes than providers. Of course you can pencil-whip a chart for the minimal content needed to process it, however then you start hearing about all these “low-level” pt encounters, which remember, the acuity ends up being in relation to the complexity and depth of the charting!

On our system, I counted once, the number of screens I had to go through just to discharge somebody:
1)Dispo screen: enter primary Dx and disposition (home vs admit)
2) Rx Screen: pick the Rx and write it (hopefully it’s already in my “short list”)
3) D/C instructions screen (home care, wound care, f/u timeframe etc)
4) Medication reconcilliation screen (of course this is only valid when the RN enters the pt’s home meds!)
5) Dr’s Notes screen: It isn’t needed, but I always make a short 1-2 sentence note here about “stable for dispo”, any pertinent clinical points, note any consults, why I did/didn’t give ASA and Lopressor for an AMI (cause it wasn’t an MI!!!!!), etc.
6) The “Work Note” screen (sheesh)

that’s SIX screens just to get someone outta’ my ER! There are many places between each for pitfalls, system “hangs” and possilbe “critical failures” in windows….This is NOT the same system as when we bought it 5-6 years ago; it has morphed over time to our custom needs.

I went to the annual Stanford EM conf in Maui last year and one speaker talked about using scribes in this type of setting. It sounds VERY intriguing of a concept – we piloted it once with 2 med students; it didn’t pan out well – but I think that was because the “pilot” attending ER MD was thinking too much of good “learning opportunities” for the med students for later on in their training, AND, the scribing was being done back at the desk and not simultaneously at the bedside.

By: Luis S

Luis S — Wed, 23 Dec 2009 00:54:01 +0000

I think many of us have been down this road. We have used scribes pre EMR and post EMR and they become even more valuable in recording the patient encounter documentation. Not all ERs have access to develop a scribe program. There are other benefits as well. Hopefully you will experience the value of the EMR at some point, but there is a learning ad adaptation curve. Best. Merry Christmas.

By: medrecgal

medrecgal — Tue, 22 Dec 2009 22:51:50 +0000

I think you’ve managed to capture here why I sometimes feel like I ended up in the “wrong spot” in the whole system of medical care; I was a wannabe physician who couldn’t hack the chemistry and ended up in medical records, and I stare at an EMR all day long. There are so many things that get lost in the process of trying to make things streamlined and “efficient”. (Note the use of quotations here…sometimes the EMR is actually LESS than efficient!) The upside is no crazy handwriting to deal with.

But I still find myself a bit surprised by the things docs and other providers write in a patient’s permanent record; the basic human relationship doesn’t change all that drastically even when constrained by things like time and technology.

By: Edwinlea

Edwinlea — Tue, 22 Dec 2009 22:08:30 +0000

Hey guys,

Thanks for the comments! It isn’t actually first generation. And on a real level, it does some cool things to prompt safety and good record keeping. But you’re right; it isn’t intuitive and data doesn’t automatically flow. Some of that may be to avoid the accusation that the computer is charting for us, rather than us paying attention to the patient. I don’t know; there are lots of little rules like that in medical charting/billing. Some folks use scribes, whose sole job is to follow the doc and do data entry. In fact, I saw Dr. Jenkins (the optometrist) today, and he does exactly that!

Merry Christmas to both of you and your families!

Edwin

By: WarmSocks

WarmSocks — Tue, 22 Dec 2009 21:19:48 +0000

Sorry to hear that your system isn’t working as well as it should. Any database that makes your job harder instead of easier is a poorly designed system.

There is no excuse for a database to require duplicate entry; data should flow automatically from the entry field to every other place it needs to be in the system. If it doesn’t flow automatically, at the very least, it should be possible to easily copy from one field to another.

Someday somebody is going to make a ton of money by listening to the people who use EMRs and creating the kind of system that would be most helpful to them. My two cents.

By: Ken Campbell

Ken Campbell — Tue, 22 Dec 2009 20:30:37 +0000

Very interesting. It sounds like the software really fails to recognize the fast-pace environment of a hospital ER. Going digital with records will obviously take some time and will be labor intensive in the beginning, but I’m guessing some of that going to be an “investment” of time that will returned later – when you walk up on a patient and with a single click can pull up their entire medical history.

Sounds like a situation where the “first generation” of a software app is a swing and a miss, riddled with overlap and bugs. I’m curious to know if the software designed for emergency room care, or is it used in all wards of the hospital?

(Say hello to Jan for Alice and I…. hope the Leaps have a great Christmas holiday! KC)