Computerized Order Entry: Preventing Spoiled Doctors?

So, there I was yesterday, working frantically to keep myself above the water level of the rapidly rising swamp of patients.  Navigating, haltingly, the onerous and demonic EMR.  So I thought I ordered three nebulizers, but it was only one.  The respiratory tech approached me and informed me that she would put them in, but only this time. That I’d have to do them myself for a while to learn, or I’d become spoiled.  You know, spoiled.  That is, I might spend time with patients instead of the keyboard!

I don’t understand why it’s so much better for me to enter orders than for the secretary, or even nurse in some instances, to enter them.  Other people still vastly outnumber doctors in most departments.  Further, I still work in two places where I check the box on the form, or tell the nurse/secretary, and they enter it into the computer.

Why was that so bad?  Were there that many errors?  Were the secretaries that overworked?  Is the use of language, as in ‘Mr. Schwartz in room 5 needs CT angio to rule out PE,’ so utterly fraught with confusion and uncertainty?  Are physicians of such marginal value that we need to add tasks to the already challenging data entry and (secondary) patient care that we need to be trained to enter orders ourselves?  What’s next, perform our own CT scans, so we get it right?

And in an age of nurse empowerment, are nurses so unworthy of our confidence that they can’t do anything until it’s in the computer?  I swear, I expect to someday say ‘start CPR’ and be asked, ‘did you put it in the computer yet?’

We have crossed the line in the sand, passed the zero moment.  We have jumped the shark and all the other metaphors I can imagine.  Charting is bad enough, but I see nothing beneficial from having me sit at the desk and try to make decisions about life, death and disability, all the while trying to figure out how to enter a timed Troponin level, even as the next stroke victim rolls through the door.

‘Something,’ as my patients used to say, ‘has got to be done.’

11 thoughts on “Computerized Order Entry: Preventing Spoiled Doctors?

  1. I can’t believe what has happened to medicine in the last 10 years. God knew when to get me out of the practice. I could not have been typing while trying to analyze what the patient was telling me. I gave an order and it was done by my nurse or PA.. God help you to do what you do so well. It is no different in Florida.

    • It is sad so many nurses have such an unfavorable and flawed perception of doctors. There is a never-ending discussion on the pros/cons of healthcare before, during, and after the implementation of the EMR and though I have read, listened and experienced only a small portion, I do NOT think it is ideal for MDs to enter their own orders. The longer I work in healthcare the more I feel that something is horribly wrong and the more I feel I am in a constant battle and the angrier I become. I used to get caught up in the seemingly continuous fight between day shift and night shift (Who works harder? Who does more with less? Who is the smartest, most resourceful? Who had the sickest patients? Etc.) For a long time I was angry at the next shift, the other nurse, the doctor, or even the patient. Strange how long it is taking me to understand. Strange how long it is taking me to identify “the enemy” I am really angry with. I am not there yet but I am sure it is not the doctor.

  2. When I was in the Air Force I got in trouble when I called out an order for a resuscitative drug during cardiac arrest and the RN who outranked me refused to carry out the order until I entered it into the computer. When I refused (citing my preocccupation with the dying patient) I ended up spending the next several mornings watching educational videos to avoid being labeled a “problem doctor”. This was in 1992!! Let it not be said that the Air Force was not ahead of the times.

  3. There is no doubt in my mind that I make more errors putting in my own orders than when I had someone else do them or in the pre-EMR handwritten era. The biggest problem is that it is much easier to click on bed 3 and then order something meant for bed 4 than it was to grab a chart and order something on the wrong patient. The constant interruptions to put in urgent orders also leads to the omission of many other orders. This delays care and causes the department to get busier and a spiral develops.

  4. I cannot believe that you think it is a nursing function to do your work for you in this day and age. Nurses are often overworked (yes, they truly are in most facilities) and have to enter their own documentation into computers. They do not expect anyone else to do their work for them. Yes, they could dictate it to a scribe, but we are not given the option (and many physicians do have them now). Nor would we expect a unit “secretary” to do our work for us (they, too, have many tasks besides answering phones and picking up your pieces).

    Do I think it is ideal for MDs to enter their own orders? Resoundlingly I answer “Yes”! Having been on the receiving end of blistering diatribes by physicians on nights about calling for orders and then having to repeat back those orders, being called stupid if I do as I am required (get a grip, we all have regulatory bodies that require us to meet standards and that is one of them), being unable to read any of your orders written sloppily or hurredly (usually both) and having to call for clarification and being bitten for being the messenger.

    Get better writing or enter your own information on the computer. I am grateful that I no longer have to deal with those issues. Another suggestion is to try a speech recognition programme and see if that helps you enter those orders.

  5. A hospital/ clinic can be set up as draconian or flexible- it depends on you administration. I firmly believe all orders should be entered but NOT at the detriment of a patient. We do not require orders to be placed by the docs during emergencies. (For example). Of course some docs try to label all care as an emergency if they can. In non emergent circumstances it is better for the doc (I am an ICU doc) to enter them. IF the hospital has done its work and made the requests reasonable to enter and as efficient as possible. Physician entered orders ensure the outcome is what the doc intended- it gets rid of the middleman where errors can occur. It also allows for the safety systems of the EMR to work. Only the person who enters the orders will see best practice advisories, safety warnings, etc? Do you really want a clerk deciding what to do with these? Having a clerk enter the orders and then call to talk about earnings would make your day more clogged up the. Entering your own. It also delays care to the patient.

    So yes some work has shifted but in the end we had shown that although the doc slows down a little up front, the care to the patient is more efficient and has less opportunities for error. Isn’t that what we all hope for?

    In summary-EMRs are not medicine. They are a tool only. How that took is set up, when and how it is used will determine its benefits or failures. Set up right and used right it can improve care. Set up or used wrong and it can be a disaster.

  6. It is sad so many nurses have such an unfavorable and flawed perception of doctors. There is a never-ending discussion on the pros/cons of healthcare before, during, and after the implementation of the EMR and though I have read, listened and experienced only a small portion, I do NOT think it is ideal for MDs to enter their own orders. The longer I work in healthcare the more I feel that something is horribly wrong and the more I feel I am in a constant battle and the angrier I become. I used to get caught up in the seemingly continuous fight between day shift and night shift (Who works harder? Who does more with less? Who is the smartest, most resourceful? Who had the sickest patients? Etc.) For a long time I was angry at the next shift, the other nurse, the doctor, or even the patient. Strange how long it is taking me to understand. Strange how long it is taking me to identify “the enemy” I am really angry with. I am not there yet but I am sure it is not the doctor.

  7. In my ED at night we will have 4-5 nurses, one MD and who knows how many patients in any and every condition. It’s stupid for the provider to have to stop and enter a cardiac or septic w/u when any of the nurses could do this.

  8. News flash: nurses are professionals with their own scope of practice and endless list of responsibilities. I’m not sure why there is a physician mentality that we need to do your work for you? We don’t work FOR you, we are a team. And we certainly have enough on our plates with all the hospital assigns us. We also have to assess patients, record our assessments and carry out the orders that you do not want to enter. I gather that you would be very upset if a nurse didn’t care for your patient properly or in a timely manner and there was an adverse event? We don’t exist to serve you. We serve our patients, and you should be doing the same as ONE of our team members.

    The healthcare world has changed dramatically in the past several decades. There are many high-level, well-educated professionals (PT, OT, Dietician, social work, RN, APN, PA, etc…) that are integral to quality patient care. That doesn’t include the countless ancillary staff that – God forbid they should all decide to leave one day- make your (and our) day run. Period. You are part of that team now.
    The days of the physician autocracy are long. Nurses are tired of this and in 2015, we are more empowered and this simply isn’t going to fly. It’s not as simple as entering a quick order. There are often decisions to be made when entering that order that should be made by the doctor. I have experienced physicians not wanting to enter order sets for surgery the next day- what is the excuse? They are not coding someone. They either don’t WANT to do it, or they feel they are above “sitting at a keyboard”. Or both. In the end it doesn’t matter what anyone wants to do, because every governing body is moving toward PHYSICIAN CPOE- with verbals and phone orders as a VERY RARE EXCEPTION.

    Please stop asking us to operate outside of our scope of practice to do your job.
    Please stop asking RNs to do your job…. and then saying APNs are not good enough to do your job.
    Please stop treating us like we are inferior. We know you are doing it. It’s rude and disrespectful and it’s going to earn you ghost-pages at 2am.
    Lastly, please do your job. You went to medical school. You are compensated well (unlike RNs). You are professionals. Act like it.

    • Nurse Julie,

      For your information I think very highly of the nurses with whom I work. I recognize that I’m a team member. I wasn’t suggesting, in any way, that I sit on my bottom and boss you around. What I mean, and it affects you too, is that computerized order entry is very cumbersome and interrupts patient flow, frequently forcing all of us to spend too much time staring at screens and not enough time at the bedside. What bothers me, as I wrote in the column, is when I have to stop seeing patients and sit down, navigate the complexity of many poorly designed systems, and enter the order. It’s often the wrong order because hospitals have loaded every imaginable order in these lousy systems. Thus providers (nurse and physician alike) have to sift through far too much hay to find the needle, that is, the correct version of the right order. It also bothers me when a nurse says, on a busy shift, ‘Bed 5 is nauseated, can she have some Zofran?’ I say, ‘sure,’ and before a blink the nurse says ‘did you put it in the computer yet?’ ‘Not yet.’ ‘Well, put it in and then I’ll get it.’ I feel even more this way about orders that a secretary could (and for years has) entered. It’s so fast to write them on a sheet and hand them to someone, who then enters them far more effectively and quickly than I can. I know, I know, secretaries are really important professionals who have things to do. Right. Like help me, and you, to do our job which is patient care! I’m not above sitting at a keyboard. But it’s not the best use of my time or yours to be well compensated data entry clerks. Now: Please stop assuming I want you to do my job. You can’t do my job, any more than I can do yours. And APN’s can’t do my job. And I don’t think you’re inferior. I wish we could all be liberated from the inefficiency of poorly designed EMR systems which only benefit administrators and billing companies.

      Really, Nurse Julie, I have no reason to think you aren’t an excellent nurse. I find it unfortunate you seem to assume I’m a lazy, entitled, bossy jerk of a doctor.

      That doesn’t help our common cause in a complex world.

  9. I can see the reasoning behind both arguments. I think having the MD putting in the orders makes more sense for patient safety, but it’s very time consuming & confusing systems developed by people outside the Healthcare community. I also think there’s a huge difference between “hey can I get an order for Zofran? And “make sure you enter ALL the orders for this patient you admitted 3 hrs ago.” I have zero objections to entering orders when I call you in the middle of the night, bc I wouldn’t expect you to have to enter every single order for the five million calls per night. My ex was an attending & when he was on call the number of pages he got a night was astronomical, & some of the dumbest reasons I might add. BUT I completely agree that many times secretaries & data entry clerks would make both our lives much easier.

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