EMRs can slow medical charting by requiring too much information

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 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.)

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 Leap is an emergency physician who blogs at edwinleap.com.

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  • Classof65

    Could this situation be remedied by the creation of a new job? EMR Data Entry Clerk? They could chart while you work, you could review, then both sign off…???

  • http://www.mmfemr.com Leor Feder

    I suggest you continue filling in the forms in paper and have an assistant put in the data for you to the EMR system. This is what many of our customers are doing quite successfully.

  • Pauline Sweetman

    The problem is that we have reached a stage in the development of technology where people have realised that it they capture all this information they can make use of it. So just because it is possible to capture it they do. The result is an explosion of collection of material, most of which will possibly not be used.
    We need a period of learning during which
    1. people learn that just because you can doesn’t mean that you should.
    2. With every new technology there is a need for more, not fewer, staff resource.
    3. As has been stated already, tasks need to be assigned to the most appropriate person, which may mean data entry clerks, or it may mean highly paid clinicians, depending on the clinical significance and complexity of the entry being made.
    As new systems are developed the user interfaces will be much more user friendly, and also the people specifying the design will have realised that you can have too much of a good thing, i.e. data gathering has its limitations.

  • http://www.practicefusion.com Glenn Laffel, MD, PhD

    Edwin is to be commended for what appears to be infinite patience and the resolve to forge ahead, but it sounds to me like he’s got a bogus EHR on his hands.

    Who designed a system that would rob a physician of his most valued asset–his judgement, and time with his patients?

    Newer EHRs offer far superior methods to input information at the bedside…and yes, they accomodate actual physician thought processes and workflows.

    In addition, EHRs which are web-based enable rapid updates which originate with suggestions from actual physician users. It becomes a community design project.

    Glenn Laffel, MD, PhD
    Sr. VP Clinical Affairs
    Practice Fusion
    http://www.practicefusion.com
    Free, Web-based EHR

  • jsmith

    Yup, Dr. Leap gets it. I have been almost literally screaming about this issue at work and on the internet for some time now. EHRs are the incorrect treatment because the diagnosis is incorrect. The diagnosis, first made after the 1999 IOM report, was that EHRs would help pt care. This report correctly stated that lots of people are hurt and killed by medical errors. It also noted that computerization was primitive in medicine. Unfortunately, the post hoc ergo propter hoc mistake was made. If we computerize, then care will improve. Would that it were true.
    The Big Problem in Acute Care, as Dr. Leap knows, is not lack of communication or that we as docs don’t know what to do. The Big Problem in Acute Care is that we do not have the time to do what some others, who do not do what we do and therefore suffer from an informational deficit, think we should do.
    Of course the EHR, which soon takes on a life of its own, worsens this problem.
    If you must use an EHR, keep it simple. Minimal template foolishness, dictate if you can and get someone else to enter the data. Delete all unnecessary check boxes. Doing this will not harm pts. Indeed, you will spend more time listening to them and examining them and thinking about them.
    Good to see real front-line docs pushing back on this important quality of care issue.

  • R Watkins

    “I know a handwritten chart is inferior.”

    Supporting evidence, please.

  • gerridoc

    Right on Dr Leap! And it is not as if you don’t have any computer skills….but just try to get one of the IT gurus to listen to your point of view, and try to improve the product.

  • http://www.ahdionline.org Lea M. Sims

    Dr. Leap, I read the above and had to smile when Classof65 above suggests that the solution might be the creation of a new role to help alleviate the documentation burden you are struggling under. The reality is that healthcare already has highly skilled and qualified people to assist in this capacity – medical transcriptionists. These professionals have spent years immersed in the diagnostic process and understand the organization and accurate capture of patient stories better than anyone else in HIM. But healthcare is so anxious to eliminate the cost associated with transcription that it prefers, instead, to transfer that clerical and quality support role to the already overburdened shoulders of its practitioners (at arguably greater cost in the long run – MTs make $20-25 per hour; how much is it costing healthcare to have a physician assume this role?). While you are not alone in your aversion to dictation – many physicians have long grumbled about having to dictate – I would point out that narrative entry is still considered the fastest way to get a great deal of information into the record. What you used to be able to dictate in 3 to 4 minutes is now taking providers 10 to 15 minutes to capture through point-and-click methodologies. I can’t believe that such an exchange is saving anyone time and money.

    The solution is for healthcare to embrace a hybrid model of documentation where historical data (HPI, ROS, PMI, etc.) is captured once on the front end, verified by the physician, and then automatically imported into subsequent reports. Highly predictable and repetitive information could be selected from point-and-click menus. Then there should be a narrative option for the physician to quickly dictate the unique and variable contributions to the record. A traditionial transcriptionist could be redeployed to ensure quality of all of these integrated pieces, including the accurate transcription of any narrative.

    I recognize ERs are unique and abandoned transcription for template charting a long time ago, but I can’t help but wonder if ERs were better off, after all is said and done, when its visits could be documented in 2-3 min and signed off on at end of shift.

    Either way, the scenario you describe is what we are hearing repeatedly from physicians….”When did I become a data entry clerk?”

    Lea M. Sims, CMT, AHDI-F
    Director of Professional Programs
    Association for Healthcare Documentation Integrity (AHDI)

  • http://www.ahdionline.org Lea M. Sims

    I thought I would add to the above that one of the reasons healthcare is anxious to abandon narrative entry is the erroneous assumption that it can’t be codified and converted to consumable data, and this is simply not true. I would encourage those who are interested to explore what is happening through the Health Story Project (www.healthstory.com) who is working via charter with HL7 using HL7′s clinical documentation architecture (CDA) to reach this goal:

    So for those who prefer the quick and comprehensive method of narrative entry, it is possible to codify and abstract that data.

    Lea M. Sims, CMT, AHDI-F
    Director of Professional Programs

  • jsmith

    A good transcriptionist is essential infrastructure if you live in EHR world.. I dictate and then she points and clicks, filling in the often silly but required boxes. Before the EHR, documentation took me 2 minutes or so. Now it’s up to 3 minutes maybe. It’s certainly not 10 minutes or more.
    If you don’t have a good transcriptionist, you are lost. My advice is to find a new job before you are driven insane.

  • http://drpullen.com Edward Pullen MD

    We have used an EMR for 13 years, and the key is to have the forms to enter data designed by a physician in your specialty who can make the form intuitive. Our forms have places to enter data, but checks left blank just disappear. I work in primary care though, and can see how in the ER setting this would be more problematic. I bet it could be solved if an ER doc designed the forms. We use GE Centricity,

  • Sean

    Sounds like you are in EMR no-mans-land. If you don’t have a lightning fast EMR that was built around exactly how you work and think, you’ll end up fighting it and giving up. A good emr needs to anticipate what doctors will do next and what information should be at hand, but far too many EMRs fail at this.

    Sean Ross
    Mitochon Systems
    http://www.mitochonsystems.com
    Free EMR
    “It’s not EMR. It’s FreEMR.”

  • http://www.nehealth.com/Medical_Care/Physicians/Primary_Care_Network/South_Troy_Health_Center/ Wally Litwa,DO