EMR conversion doesn’t always help physician communication

by Stuart Sutton, MD

Our very large and very integrated health care system is plowing ahead with EMR implementation. All the offices are gradually converting from paper charts and all the hospitals have completed the process.

As a member of one of the last offices to be converted to the EMR, I’ve had the pleasure of patients being assured that the notes were sent to me (albeit via the EMR we are not yet using). I’ve come to accept that notes which I do receive from consultants who use the EMR (or indeed their own and different EMR) will be voluminous reams of boilerplate intended to maximize reimbursement and provide optimal medical-legal protection. The notes may also contain information of use to me in coordinating my care of the patient although such data may be so well hidden as to escape detection.

Regardless of the advantages claimed to exist within this Bataan death march of coerced changes in our practices, one subtlety of the paper chart is gone forever; the expectation that your note will be seen by the next physician who writes in the chart.

When I round at the hospital, I have immediate access to all the notes on the patient but may or may not opt to review them. Furthermore, as I previously indicated, the usefulness of these has been seriously degraded by their original intent having been hijacked by other priorities.

With a paper chart, of necessity, I will have to see the note of the physician who documented their visit just before me. And the same will be true of the physician who comes after me.

Resourceful note writers will have taken advantage of this by boldly writing as well as underlining any points they want to be certain are seen by those coming after them. This might relate to a diagnosis, a new symptom, or a suggested test. Indeed, even just the parts of a note in your peripheral vision will catch your attention with a diagnosis or some other finding that has been documented that may be highly relevant to the patient’s care. This unique aspect of communication is lost when working with an EMR.

With an EMR, the need to consciously choose to view a note actually discourages physicians from the process. Wanting to merely “glance” at a previous note requires signing on, selecting the patient, opening up the relevant screen, selecting the pertinent note, and then scrolling through the documented information to find the desired section. Not really a system that optimally facilitates physician communication.

This train has left the station and I don’t expect to be able to get off; there is too much of a commitment from the powers that be who hope to achieve their goals with an EMR. Sadly, the initiative seems to impair rather than improve many aspects of health care delivery.

Stuart Sutton is an internal medicine physician.

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  • http://www.neilmehta.com Neil

    Terrific post.
    In all the quantitative evaluation of EHRs and their potential benefits (e.g. reduction in errors due to CPOE and Clinical Decision Support, reduction in cost due to decreased dupication of labs etc) the qualitative aspect of how this affects the physician in the trenches has been overlooked. I posted about this recently with a concept map of where EHRs cause problems for docs here

  • http://glasshospital.com John Schumann, M.D.

    I, too, recently posted on the qualitative aspects of being ‘tethered’ to our EMR system–albeit in a narrative fashion. I like the idea of a concept map. I’ll check it out!

    You can see my post here: http://goo.gl/fb/ui5n

    -GlassHospital

  • http://drpullen.com Ed Pullen

    It is quite possible to make notes readable and yet also contain the jibberish needed to get paid and not get sued. At our office the forms to enter data ordered in a way that the key information is easily visible on the first screen. More of an APSO format than a SOAP format. We also have designed an initial screen to view most of the relevant information on one screen. I think having current problem lists, medication information, and essentially never having a lost or misplaced chart, as well as info available from home or hospital when on call outweigh the problems mentioned in this post. It sounds like administrators designed and rammed this system down your throats. At our smaller private office we molded the EMR to work for us.

  • http://www.neilmehta.com Neil

    Great to read Ed’s comment.
    In large centers with students and residents and multiple specialties getting customization in EHR is difficult; even more difficult is to maintain standards in documentation like your APSO format, etc.

    Ironic that the adoption of EHRs is mostly in these large centers and lags behind in small practices. Your story should give heart to non-adopters. Glad it is working well for you!

    My complaints about some of the large EHR systems relate to this lack of customization of user interface, workflows, and functionalities that are achievable.

  • http://EHRtv.com Nicole

    The EHR can have tremendous benefits in gathering quantitative data, and yes, it can lack in the ability to gather qualitative data. However, I think there is a shift towards developing integrated technologies that will assist in enriching the ‘patient story’ within an EHR. Many EHRs are able to integrate with speech recognition software, and one of the more exciting technologies out there is speech understanding, from M*Modal. This technology translates physician dictation in real-time into a searchable, structured document.It is esentially translating the rich qualitative data into distinct data points. EHRtv recently interviewed Dr. Nick van Terheyden, Chief Medical Officer of M*Modal, at HIMSS10. It’s a facinating interview that can be viewed here: http://www.ehrtv.com/mmodal-nick-van-terheyden-mar-2010/

  • http://curbside.posterous.com Nuclear Fire

    Great post. I completely agree.

    In order to make my own writing more relevant, I’ve taken to writing my assessment, discussion and recommendation sections at the top of my note.

  • Tamara

    I represent an EMR solution that is customizable with the ability for stylus entry. However, as healtcare worker it is clear to me that it is far more important that we have leaders that will listen to the American citizen with actual expertise before jumping in on mandates.

    As a person who loves technology it can be beneficial for all if we ensure fair and ethical (and I hate saying that because those words have lost all meaning) treatment of not only the patient but the respect for their privacy. Then I look to other applications, and I want to go to France, or Scotland for the summer, then a down load into a thumb drive attached to my key chain, is a cool benefit of seeing a physician who provides EMR. That is of benefit for anyone just wanting to travel the US.

    The ability to spend more time with the patient is possible if you are really looking to automate your office going paperless. Your patient wants to make an appointment or request a refill, or make a payment, an integrated online reception page with secure features will sure create a different atmosphere inside the office.

    There are definitely pros, and cons……..I say make it bend to your will….;-)

    I have questions for you as well. Has EMR/ EHR consolidated billing and coding