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Computer or patient, who do I work for again?

We have a new EMR system.  I like it because I type well.  I’m facile at using a keyboard and touch-screen.  Not everyone in my group is so blessed, and we’ve had some difficulties using the voice-transcription software.  Nevertheless, my gut tells me that in a month or two more, we’ll be getting along with our new system swimmingly.  It’s the sort of thing I have wanted for a while, since I truly hate to dictate; and especially hated dictating the information the nurses had already entered into the computer!

However, I have an issue.  Not so much with our EMR, but with all EMR.  I have an issue with the deeply-held delusion that computerization will automatically improve charting and patient care.

Some time ago, the inimitable, world famous blogger Dr. Wes (who can be found at http://drwes.blogspot.com/ ) told me that his facility’s conversion to EMR caused him to spend far more time at the computer than with the patient.  And true to his great wisdom and insight, that’s where I find myself.  It isn’t the location of the computers.  We have portable ‘tough-books’ that can go to the bedside.

The problem, as I see it, is the attempt to capture far too much data all around.  You see, medicine is at a strange juncture, and I really don’t know what to do about it.  How can I describe the problem… simple physics, perhaps?

We’re pulled in too many directions; there are too many vectors, so no motion results.  We are rapidly approaching a place where we will be unable to do anything and inertia will rule.

Let me explain.  See, in our new system, we chart ‘by click.’  Clicking in available fields charts the data the patient gives us.  So, we have a section called ‘HPI” or History of Present Illness.’  The problem is, it is very much like the ROS or ‘Review of Systems,’ wherein a physician goes through multiple body systems to assess the patients symptoms and problems.  (Not to be confused with the ROUS, for fans of The Princess Bride.

Not the Review of Systems!

Not the Review of Systems!

So, in the history is onset of symptoms, timing of symptoms, then associated symptoms…which is much like the Review of Systems.

Next comes the actual ROS, which goes through ‘constitutional, neurological, respiratory, cardiac, musculoskeletal, OB/Gyn, Heme/Onc, ENT, Neck, Back, genitourinary, etc., asking layers of questions about symptoms and location in the process.

This is followed by the actual physical exam (one of those rare times when we can touch the humans entrusted to us).  The physical exam contains much the same level of detail, and in fact it is easy to forget to chart the exam, if one has just done a thorough Review of Systems, since both sound the same.

Finally, we have the Medical Decision Making, Emergency Department Course and Disposition, where we discuss labs, X-rays, data reviewed, ECG’s, Pulse Oximetry, old records reviewed, consultants contacted, diagnosis, plan and all the rest.  Sure, it may not sound like much, but if done right, all of this takes a significant amount of time:  to talk to the patient and get data, to examine the patient, and most time intensive of all, to input it all to the computer.

Problem is, it’s an ER.  Things move fast.  No one has a scheduled appointment.  Anything can come through the door at any time.  Expectations by patients and frustrations among their families run high.  No one cares about the complexity of ‘the cool new EMR system!’

But I’m not finished.  Our nurses chart in the same kind of detail; and add screening exams for drug abuse, alcohol, immunizations, nutrition, personal safety, physician procedures, admissions reports, EMS reports, etc.  They also do their own history and their own physical assessment!  And of course, I have to reconcile the two and it is my responsibility to find and correct any inconsistencies; lawyers love inconsistencies.

Now, charting is done for purposes of patient care, so that we can be consistent in treatments and subsequent visits.  It’s also done thoroughly for billing purposes.  No good chart, no good reimbursement. But it’s also done for medico-legal reasons.  That’s why our discharge instructions now rise to the level of ‘novella.’ being pages upon pages long.  The medic0-legal aspect drives much of the detail for physicians and nurses, prompting us about safety, about allergies, about dosing, about indications for the tests we order.

And charting is done because, well, EMR companies like us to chart.  It’s good for business!  It sells computers and memory, software and consultants.

In the end, though, I move too slowly and spend far too much time charting unnecessary (but required) layers of information.  I mean, oddities aside, an otitis media chart should take about ten lines on paper, and the discharge about ten more.

I know a handwritten chart is inferior.  But I wonder if the patient feels that the time spent with them is inferior?  If they get a scribbled chart and ten minutes, is it better than a pristine one and two minutes?  After all, the day only has so many hours.

So, to return to physics, I feel myself pulled in separate directions.  One way is the patient, the sickness, my ‘raison d’etre’ as a physician.  The other is the billing direction; chart to get paid.  The other is the medico-legal vector; chart to be safe.  And the final is less clear; it’s ‘chart to chart, because the chart matters most.’  It’s an odd homage to our love of unnecessary information and data.  Do I need this much detail?  Not even for many of my sicker patients!

I wonder in the end if I’m a physician anymore, or just a data entry clerk?  Do I serve the patient, or do I serve the computer, with it’s highlighted, required, red fields, waiting entry of information?  Is it serving me, or am I serving it?

And when all is said and done, I doubt if physicians can move forward efficiently when they are daily pulled to a halt by conflicting activities and overwhelming data, most of which is only useful to a lawyer.

I feel a bad case of inertia coming on.

Edwin

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7 Comments

Ken Campbell

2009-12-22 15:30:37 Reply

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)

WarmSocks

2009-12-22 16:19:48 Reply

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.

Edwinlea

2009-12-22 17:08:30 Reply

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

medrecgal

2009-12-22 17:51:50 Reply

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.

Luis S

2009-12-22 19:54:01 Reply

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.

BoswellEMT

2009-12-24 02:22:55 Reply

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.

drcharles

2010-01-19 20:15:49 Reply

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.

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