How an EMR can be shockingly inconvenient for prescription refills

Let me start by confessing I’m something of a gadget freak.  I was an early Palm Pilot adoptor, loved the iPod from the get-go, and need to avoid CNET, Engadget, Gizmodo, and David Pogue’s columns for the New York Times when deadlines loom.

Not surprisingly, I embraced the shift to electronic medical records (EMRs) enthusiastically. While I acknowledge that sometimes EMRs slow clinicians down a bit, and have terrible — horrible — interoperability (how’s that for a tech writer term?), I believe the net benefits from EMRs outweigh the problems.  And our EMR has many time-saving and just plain nifty features.

However …

Every so often something happens with an EMR that is so shockingly inconvenient that it makes me wonder whether we’re on a road to EMR purgatory.

Example:  prescription refills.

This is how we used to authorize a prescription refill in our practice:

E-mail from RN or LPN:  “Hi Paul, ok to refill Joe Smith’s Bextrim 10 mg?”
Response:  “Yep, one a day, 11 refills.  Thanks.”
[RN or LPN then refills via our EMR by clicking "renew" and sending electronically to pharmacy.]

Simple.  Time required for MD?  Around 3 seconds.  Plus, easy to manage on a hand-held device — you don’t need a computer.

So here’s how we’re supposed to do it now (physician clicks or keystrokes in brackets):

  1. RN or LPN enters request for refill into queue.
  2. Email is automatically generated that gets sent to MD stating that he/she has a refill request.  E-mail does not include patient name, medical record number, medication, or pharmacy info.  It’s just a notification.  In other words, it’s completely useless on a hand-held device — except as a form of taunting. “You have a task, but you can’t do it until you log into a computer, log into the EMR, and follow multiple steps — nah-nah, nah-nah.”
  3. At computer, MD clicks on email, then deletes it [clicks 1 and 2].
  4. MD switches to EMR [click 3].
  5. MD clicks on refill request [click 4].
  6. Refill screen appears.  Screen looks like it was developed by a web designer who collects mouse clicks the way that some people collect pennies or odd bits of string — the more the better!  It literally has four separate panels, each panel containing various radio buttons, check boxes, drop-down menus, scrolling lists, comment fields — a veritable panoply of web interactive tools.
  7. In second panel, MD clicks on “Renew” [click 5].
  8. At bottom of page, MD clicks on “Mark as complete” [click 6].
  9. At bottom of page, MD clicks on “OK” [click 7].  Yes, there are two separate clicks for “Mark as complete” and “OK.”
  10. “Sign” is now highlighted red in the menu.  MD clicks on “Sign” [click 8].
  11. Sign page appears, with request to enter key.  MD enters key [5 keystrokes] and clicks “OK” [click 9].
  12. Prescription page appears.  MD clicks “Send” [click 10].
  13. Prescription is sent to pharmacy electronically.

Mind you, this is for one patient, and one medication.  More meds and/or patients?  More clicks.

I understand that there are medicolegal reasons for documenting that MDs review and approve renewals.  But there has to be a better way — and of course, there are many, two of them implemented in the commonly-used electronic medical records EPIC and the terrific one at the VA.

But until electronic medical record designers start reviewing “best-of” strategies from their competitors, I’m afraid there will be lots of these one-step-forward, two-steps-back experiences for us clinicians, just like this one.

Paul Sax is the Clinical Director of Infectious Diseases at Brigham and Women’s Hospital. His blog HIV and ID Observations, is part of Journal Watch, where he is Editor of Journal Watch AIDS Clinical Care.

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  • http://www.sufficientscruples.com Kevin T. Keith

    I feel your pain. But this is not really an EMR issue. It is a combination of two things: Pt privacy (HIPAA) and bad EMR form design. Also: note that you haven’t included the extra steps needed to document the Rx in the Pt’s chart after the e-mail – without EMR, you still need to go to the non-EMR record to fully complete the interaction, so using EMR to generate the Rx does not add as much extra work as you say.

    If you could develop HIPAA-compliant e-mail clients for hand-held devices and interface them with the EMR, that would cut out the 2-systems problem. But again, this problem occurs not because of EMR, but because sending Pt info over a non-compliant device is prohibited (which is a good thing, although inconvenient); it’s the handheld, not the EMR, that is to blame.

    As for the weird EMR design, that’s just silly, but it’s an issue with the EMR GUI, not EMR as such. There must be better EMRs, or at least, if you’re a big enough institution, you can go to the vendor and tell them to cut the crap out of their application.

  • http://www.yourneurodoc.com Pete

    No, no, no – it’s an EMR problem. That same process takes me 11 clicks with my EMR. Then God forbid my sig is more than 140 characters, that takes another 20 clicks to fix that. After using EMR’s for the past 15 years or so there is one thing I am sure off, EHR programs that are written by doctor’s or have a doctor high up on adminisration (a chief medical officer), are significantly better than those that do not. I think this is why people absolutely love programs like Amazing Charts and Practice Fusion. That aren’t the faciest by any means, but they get the job done like a doctor thinks, not a programmer.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Yes, the UI described in step #6 is rather insane, but something else triggered this chain of events.
    Somewhere, someone has decided that the prescribing MD must sign each prescription, and that someone was most definitely not the EMR vendor.
    You should take your EMR vendor to task for the UI foolishness, but the main complaint should be directed to whomever created that new regulation, because now you have to do for yourself what your nurse used to do for you.

    BTW, two questions:
    1) Did you not delete the email in the olden days?
    2) Are you sure that all your nurse did was click “renew”? Surely she needed one click to log in, another to get to the patient, another to get to the med list (unless already in queue from surescripts, in which case she would have gotten the same crazy screen you describe in #6) and at least one more click to renew, assuming nothing changed from the original script.

  • Anon

    I work at the VA and renew rxs all the time. When my PCP affiliated with a UC med school started using their EHR it became untenable for me. Just about every refill was wrong, the #pills changed, the # refills was wrong. I left his practice and found an independent internist in the community. Maybe the kinks are worked out now, but when you have several long term chronic meds and it is a hassle to get correct renewals, sorry, I’m not staying with your practice.

  • soloFP

    refills for 1-2 meds are usually easy with most systems
    try 20 meds on a diabetic/hypertenisve/thyroid/chol etc who also has sinusitis and who needs a short term local rx on all meds, a 90 day supply for chronic meds but only has 1 day’s worth of meds left, and antibiotics. Also try entering meds on a new patient. I have not found an easy system yet.

  • http://briarcroft.wordpress.com Emily Gibson

    Another reason for refill requests coming through an EMR associated password secured patient portal, then approved and sent electronically to a pharmacy. The entire process is much more efficient, private, accurate and recorded automatically in the med list and in the progress notes. A far cry better and less fraught with opportunities for error than the phone message/email/hand written/faxed/called process of yesteryear.

  • http://e-patients.net e-Patient Dave

    ARGGGGGG! We need to OUT these systems! Name and shame! This is disgraceful!

    > Screen looks like it was developed by a web designer
    > who collects mouse clicks the way that some people
    > collect pennies or odd bits of string — the more the better!

    Seriously: hearings are underway this month in Washington regarding usability of EMRs. Check out last year’s post on the Cream of the Crap, as one hospital described the BEST system they could find (after ditching a worse one).

    As long as vendors are allowed to conceal their CRAPPY user interface, they’ll get away with selling crap.

    I keep thinking of Ralph Nader’s early work in cars – his watershed book “Unsafe At Any Speed,” which finally woke people up to the dangerous crap that manufacturers were selling us. The vendors swore it wasn’t possible to do better; then Japan did, and we have safer, more efficient cars. What will it take to eliminate EMR vendors who say it’s not possible to make a system that works the way users want it to?

    Why do I care, “just a patient”? Well, hell: aside from the above, if a system is hard to use, it’s more likely to cause errors. See slides 6-10 of this excerpt of a talk I gave last June to the Agency for Healthcare Research & Quality.

    I’m reminded too of an article in Consumer Reports, years later, about the Yugo, saying that it had big engineering problems (e.g. front wheel drive that oversteers) that others had solved long ago. Good info!

    So c’mon – let’s OUT these crappy systems. Warn others.

    And thank you for speaking up about this, in detail that everyone can understand!

  • doctor1991

    Even in the “good old days” scenario, why did you have to go through an RN or LPN?
    You also have to ask yourself how much of the “inconvenience” is from need to comply with government regulation, how much is from tech designers who don’t know medicine, and how much is actually from the technology itself? I think most inconvenience is from the first two.

  • Jon Appelbaum

    Paul:

    Good to see that LMR hasn’t changed in the two years since I left!! I feell your pain.

    Jon