The Bitter Fruit of EMR

I recently worked at Medium Community Hospital. It’s a lovely facility in a desirable location, and full to the brim with vacationers in the summer. Actually, it’s pretty full all year since it’s such a nice place to live. In fact, it’s also a pleasant place to work. The emergency department is modern, and staffed by skilled physicians and nurses, all committed to giving the best care to everyone. And yet…

The staff is hampered, weighed down, hamstrung. The staff is oppressed, enslaved, constrained. Like Vonnegut’s Harrison Bergeron https://archive.org/stream/HarrisonBergeron/Harrison%20Bergeron_djvu.txt , intentionally handicapped by earphones, glasses and heavy weights, the good doctors and nurses struggle every day with an ever worsening handicap of their own.

Can you guess what the problem might be?

Yes! It’s the EMR! The Electronic Medical Records system at Medium Community Hospital is abysmal. Of course, while I don’t usually ‘kiss and tell,’ I will say that it’s one of the most widely used systems in America.

But why is it so widely used? I can only assume that the sales-force does an outstanding job of convincing administrators that it is truly the Holy Grail. ‘Oh, yes Mr. CEO, it’s an industry standard!’ It certainly isn’t because of ease of use, or efficiency of effort. You see, the EMR at MCH is click intensive. Click, click, click ad infinitum, ad nauseum. And the operating system is old enough, and layered enough, that every action requires for the computer to think, and process while the tiny clock spins and mocks. It takes just enough time to drive you bonkers on a busy shift.

(This in an era when your cat can play a game on an iPad, and my phone can track the movement of the stars across the heavens real-time.)

One must move from page to page to complete the chart, and pedantic, dull things like medical history, medications, vital signs and discharge instructions are not located in simple, intuitive places. Every action must be saved individually, and despite signing in with username and password, every order has to be subsequently individually signed again. And the complex discharge process is a total black-hole of time, which leaves patients standing by my desk, tapping their feet and saying things like ‘I thought you forgot about me,’ or ‘do you know how long it will be?’

I estimate that the average chart involves somewhere around 7 minutes from start to finish, with some more, some less. Now you may be thinking, ‘that’s not much!’ But if you see 30 patients in 12 hours, that’s 210 minutes of charting time. That’s 210 minutes of clicking and dictating (or typing) that doesn’t go toward thinking, reexamination, reading or researching a problem or even (gasp) talking to or comforting a human being. It’s just data entry.

But that’s all that really matters, it seems. Even though we want a culture of safety, a place where patients can really be heard, a hospital where customers are ‘satisfied,’ what seems most important of all is the charting. I know, I’ve beaten this drum before. We all have. But nobody seems to listen.

The problem is that when I work at MCH, I sit and log into the system, see the tracking screen, scurry off to see a patient and then scurry back to my little doctor den, (a packrat carrying a little bundle of data) where the really important work of charting happens. We always thought the emergency department was about caring for the sick, about diagnoses, procedures, interventions. But I can scarcely spare the time for all of that antiquated claptrap. There’s a chart to generate! So I, and the others at MCH, and all the other large and small hospitals everywhere, are less and less free to engage in patient care, but more and more in bondage to keyboards and screens.

The EMR at MCH is popular because it captures a lot of data, and data makes for thorough billing and tracking. This is undoubtedly the reason hospitals and hospital systems love it. Because I’m confident that many a physician has gone to the CEO, CMIO, etc. and said, ‘we tried it, and it’s bad’ or ‘my friends from residency use it and it’s very difficult and time intensive.’ And they’re answered with ‘oh, don’t worry. You’ll get used to it.’ Pity.

The fact is, a good EMR (and yes, there are a few) makes things easier. But most make things not only inefficient, but miserable. The result is that physicians, and nurses, spend more time with screens that the sick. And equally awful, they spend long periods of time after shift, and at home remotely, completing the ridiculous requirements of the systems imposed upon us.

I have worked in locales that still use paper charts. No, you don’t get as much data. Yes, they might be harder to bill and defend in court. But I’d love to see the patient outcomes compared side by side. I suspect they aren’t that different, considering the EMR chart runs 15-50 pages or so and is almost uninterpretable by the subsequent physicians.

But even if the outcomes are better, there has to be a drop off in quality with use of EMR systems like the ones at MCH.

Because it’s hard to do a good job when you spend far more time with the chart than the patient. And that’s the bitter fruit of modern EMR.