When patient care becomes secondary to filling out the medical record

The policeman was two cars in front of me. I meandered down the road cautiously adjusting my speed a few ticks above the limit. I lamented the forced, measured pace as the road lazily formed a long straight path. The clock refused to slow for my new found law abiding citizenry.

A sports car motored around a curve and flew past us unaware. The cop switched on his lights and tried to pull a U-turn, but couldn’t clear the curb. By the time I realized what had happened, I was screeching to a stop to avoid the break lights that blinked on in front of me.

In the midst of trying to make the roads safer, our friendly neighborhood officer had almost caused a major accident. I wiped the sweat from my brow and reluctantly took my foot off the break petal.

It was a fitting end to a trying day.


My hospital emigrated from paper to an electronic medical record today. They eschewed a stepped approach and went from zero to med reconciliation with the tick of a second hand.

Aware of the chaos, I dragged myself into the hospital at 5:45 in the morning. Nurses scurried back and forth. Already the musical chairs had begun. Getting your hands on a computer was like happening upon a stash of meds long lost to shortage. Superusers walked the floors over confidently with their heads held high, their skills still building towards maturity.

Rounding took and extra hour and a half. No one seemed know how to discharge a patient. The labs were late. After returning to my office, I spent the rest of the day trying to communicate with the hospital staff. Phone lines were busy. Nurses were befuddled and seemed confused about which patients they were taking care of. Some orders were never carried out, others were continued long after they had been stricken from the record.

And somewhere amidst the chaos of this hectic day, patient care became secondary to the process of filling out the medical record. Critical patient decisions were being hampered by confused staff, tardy labs, and cumbersome rules set forth by nonclinical administrators.

While this was just one day, my experience with other hospitals is that things will only improve somewhat. Process wins over product once again. As the sun sets on this exasperating day, I’m still trying to put out a few fires.

I hope as the books close on this gigantic Go Live, we providers remember why we’re ultimately here.

To protect and serve.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://www.facebook.com/profile.php?id=1260516961 Kaye Miller

    The transition could less stressful and safer if, during this time, elective procedures were placed on the back burner. A couple of days would allow the staff to grow EMR legs, gain confidence, and reduce errors. However, administration balks at this idea. Maybe if physicians delayed their elective procedures in the interest of patient safety hospital administrators would be more inclined to provide support.

    Kaye Miller, RN

  • NewMexicoRam

    We can thank the attorneys for all of this. 

    If it wasn’t for them, most of the record keeping really wouldn’t be needed.

    • southerndoc1

      Not a fan of the lawyers, but have to disagree.

      Nearly everything that makes current EMRs so unusable is there because of government, insurer, and accreditation requirements. Our professional societies have been active participants in all of this. We’ve met the enemy, and he is us.

      • http://pulse.yahoo.com/_TJL24CFV4HSOGSKSJSLRBUUTYQ brian

        we did this to ourselves by allowing our out of touch so called professional organizations to run a muck.

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

          Great! The first step to solving a problem is always to acknowledge that it exists in the first place. But what comes next? What are you guys going to do to change the status quo? If you don’t do anything now, the day is approaching when you will no longer be in a position to affect any change.

          • southerndoc1

            “What are you guys going to do to change the status quo?”

            On the macro level, nothing.

            On the micro level, everything I can to keep our private progress thriving. Basically, that means ignoring PCMH, ACO, and everything else the medical societies are pushing, and spending my time taking care of patients.

            When I retire, the practice will either be worthless and unsellable (OK with me), or the entire corrupt system will have collapsed and I’ll be sitting on a gold mine.

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

            I guess adding up all the micro levels should count for something, but I am afraid that without an all out macro level effort, things will get much more difficult than they need to be.
            I am seeing viable practices sold for no other reason than fear. Can’t be a good thing…

          • aj0408

            I came across this article as I was looking into EMR system and their usefulness. There seems to be a lot of resistance to EMR as it is an impediment to the regular job of a physician. There are significant upsides to it as well, in terms of sharing information. 

            Can the users of the EMR system comment on what exactly they would need the system to do for it not be be an impediment to them. Make a list of most useful things. And do not rule out “Star trek” like possibilities within reason. If the physician community can create such a list, I am sure technologists are here to serve and make it happen.

            A lot of the issues that I see in the discussions seem like training issues (I may be totally off base and let me know if I am). There may be other issues that are related to just inputting detailed clinical information that physicians maybe are not used to doing right now.

            As an example, if we could provide a provider with say an ipad with an application in which he could talk to capture all the clinical information, take pictures to make the record richer, and then let the system take over from there to create and link the health record, get the bills created and filed, do other things that an application such as this does, will that fit the bill? If not what would? What will be your perfect world. As someone said, the time is running out. If you want your life to be better, atleast take some time to let community know what is needed to make your lives easier.

            Just my 2 cents.


          • buzzkillersmith

            For my own self, what I’m hoping to do is retire.

    • http://somebodyhealme.dianalee.net/ Diana Lee

      Burn! We’re always such an easy target.

  • http://pulse.yahoo.com/_TJL24CFV4HSOGSKSJSLRBUUTYQ brian

    transition doesn’t change ANYTHING.  been on EMR for a long time now.. . notes are LONG copy paste pieces of junk with little to no substance and written only to fulfill some arcane billing requirement.  trying to find meaningful information from another clinicians notes is a needle in a haystack, so inter-physician communication has severely declined in the name of “progress”.  is it worse than what we had before?  probably not, but certainly no better and defiantly takes away MORE time from the patients.

    but at issue, is not really the EMR rather the billing/payment system to which the EMR is directly geared toward.  EMR’s serve one purpose: get the bill out fast and capture the highest coding possible.
    patient care is COMPLETELY secondary.an administrative wash at best with yet another barrier to humanity within healthcare.

  • http://www.facebook.com/profile.php?id=1624302541 Bruce Ramshaw

    I think the problem is that current EMR’s are not designed for patient care, they are designed for the various fragments in our current system, especially for coding/billing documentation (not to mention that the software platforms are 20th century technology).  As a physician, I agree we (along with nurses and everyone else who actually adds value to patient care) are the problem.  We allowed this to happen by mistakenly thinking others- administrators, government, or whomever should do things for us to help us, as individuals, care for “our” patients.  Now, I believe we need to recognize the solution will require a transformation in the actual system structure for how we care for patients.  We will need to build teams/communities around definable patient groups and patient problems (and the patient and family need to be included as a primary members of our teams).  By defining dynamic care processes with the patient, software (21st century, agile software) can be developed that actually does add value and can facilitate learning and improving care. 

    • LeoHolmMD

      Soon, practicing medicine will have nothing to do with patients.

  • http://somebodyhealme.dianalee.net/ Diana Lee

    I live with multiple chronic health conditions, and my local hospital & affiliated care partners have an electronic system. It makes working with all those docs (and the ER) a breeze for all of us. I think it’s more about the personality and commitment of the health care practitioner than the technology or lack thereof.

    • Paul Colopy

      A cruelly unfair judgmental response, given the well-documented work-impeding and redundant misleading nature of most if not all EMRs. Glad it looks good from your end.

      • http://somebodyhealme.dianalee.net/ Diana Lee

        Cruel? Inflammatory language like that makes it impossible to take your comment seriously.

        • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

           I think the point you are missing is that the end users (docs, RN’s, staff) of the system are saying the system’s in general  are inpoorly designed and implemented. I am still not nearly as efficient as pre EMR. I still have the same patient load and I certainly don’t see the EPIC superusers around at 20:00 as I am finishing my notes after a busy clinic day.  Do I realize that there is no turning back this wheel and the importance of having accessible EMR from a patient standpoint….of course. But please don’t “blame” the healthcare practitioner for not being “technologically savvy” (most of us are) if you actually haven’t USED the system yourself. There is a lot of crap out there and by and large the docs/Rn’s have limited input compared to admin/billing as to what product is bought. Very simply, if this was strictly about patient care and not billing we should have the VA system nationwide. It is far and away better and more user friendly than any private system I have used (not the crap it spits out to non VA docs though on paper though).  

  • buzzkillersmith

    But wait, at least you can console yourself with the knowledge that all this will massively IMPROVE quality of care and make you PRODUCTIVE beyond your wildest dreams. Of course it hasn’t happened yet, but just wait!  Death rates from pneumonia, MI and diabetes any day now will plummet because of the selfless efforts of our specialty societies, the vendors, and those wise heads in government that have encouraged us to upgrade our clerical skills. You’ll be leaving the office at 2 pm with all the i’s dotted and t’s crossed and your patients happy, healthy, and cured.
     As an extra special bonus, you are also well qualified to be a medical transcriptionist should that medicine thing not work out.  Yes indeed,  you’re on the team and coming in for the big win. Maybe you’ll even get a free t-shirt!  Can you smell it? That’s the sweet smell of success, young man!  We’ve got our eye on you. 
    And by the way, can I interest you in bridge? 

  • lv2bike

    Working with EMR is indeed a nightmare. We have had Epic EMR for over one year, and I still come home from my ED shifts feeling totally drained and feeling like I short -changed my patient care. Instead of discussing  pt  flow and care problems in our emergency dept, our monthly staff meetings focus increasingly on better documentation in the EMR. I find retrieving basic information and labs on pt increasingly difficult and , rather than alert the ordering provider that the test they want was JUST DONE, it allows the same imaging study to be done over, and over, and over…how many times does a  B12 and VDRL need to be checked on a confused 80 year old, anyways?
    Patients medical histories have now been condensed into lists…lists that may be duplicitous (ie, hypertension, high blood pressure , elevated blood pressure can all occupy the same list.) and frequently in error (One patient told the nurse she had a problem with “high platelets ” so HER  medical condition list mentioned “thrombocytopenia” instead of “thrombocytosis”. It will be there forever, I suspect.)
    We have created and have been sucked into this monster. We have blindly accepted what the IT and computer software engineers roll out as the “best” systems. But  all the systems combined  fall short of a good, cogent, well thought out , gramatically correct dictated note. And the systems  leave we physicians scrambling to sign on to computers all shift to write for that antibiotic, that IV fluid, that pain shot…and wade through countless fake “drug interactions” and hard stops.
    Keep Go-ing Live!

    • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

       EPIC products are awful. They are user hostile and the organization appears to have no interest in what the end user has to say.about what is wrong with their products. The sad thing is this is one of the “big boys” or EMR. 

  • buzzkillersmith

    So I sent a guy with nasty epistaxis to the local ENT and got back 4 single-spaced pages of notes, which included such choice tidbits as the pt did not have seizures or depression or skin rashes or a family history of chronic diarrhea.  Diagnosis: epistaxis.  Plan:  I have no idea.  I guess he forgot to type it in or his fingers cramped up or maybe he got so frustrated with the EHR that he said to hell with it and hit the local bar.

  • http://www.facebook.com/profile.php?id=22607257 Shannon Wilson

    In my opinion, you get what you pay for when it comes to Electronic Health Records. Of course in the long run when patient records are the norm, it’s going to be the easier and less stressful option. However, many healthcare professionals are being forced to transition over to electronic health records. The key is, you get what you pay for. It’s as simple as that. If you purchase a cheaper system or try to use something that is free then you are going to be stuck figuring out how to do most things yourself, scrambling around to find patient’s records, spending more time filling out all of the necessary notes than you should be doing and basically doing everything but focusing on patient care. However, if you purchase something that is possibly a little more on the expensive side, you have a much better chance of working with a vendor that cares about your needs and is determined to ensure your staff goes through as seamless of a transition as possible. It’s important to remember that there are always going to be bumps in the road just as there are with a new car purchase or buying a new home. When researching EHRs, make sure you are taking the time to not only find an EHR that will perfectly suit the needs of your staff but to find a vendor that will be there to support your staff whenever and wherever you need. Try finding someone that can log in remotely to your system and a vendor that will offer a complete support package, training, implementation and project management. The key to a successful EHR implementation can lie specifically during the project management stages! While I know this may be too late to suggest these ideas for your staff, hopefully others reading this post can recognize the importance of finding a vendor that fits all of your specifications. In the meantime all I can say is best of luck to you and your staff and you are most likely correct in your situation, it may only get a little bit better but it seems like you and your staff know enough about taking quality care of patients that you will be able to still provide the best care possible despite all of these technological difficulties.

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