We must get past the complaints doctors have about EMRs

Any new technology necessarily has a phase in which unnoticed bugs as well as unforeseen challenges crop up. In its early stages, the snail’s pace of a dial-up connection often made using the Internet onerous: before completing an email, one was often interrupted by pop-ups, viruses, cryptic 404 error messages, and a cacophony of sounds from the modem as the line repeatedly disconnected. Yet, as technology matures, the ability to send an email anywhere in the world now rests in our pockets. EMR has often been decried as time-consuming, disorganized, and plagued with errors; these problems are temporary and addressable. Moreover, EMR offers some unique and compelling benefits that are sure to make paper records obsolete.

The most common complaint about EMR is that it is hard to get the patient’s full story. An EMR will only accept what input it is given; it cannot generate its own data. For those pining for the “good old days,” there are blank notes into which one can free-text grammatically correct notes to their heart’s desire. There is also endless customizability in creating template H&Ps for different chief complaints. For example, in my CHF-exacerbation template, rather than a generic HPI I can write:

HPI: *** is a *** year old *** with a PMHx of CHF (last echo: ***, EF: ***%), ***….

This, and numerous other subtle modifications enable me to not only remember to ask the patient important questions (a la Atul Gawande’s checklists), but also remember to weave critical details into the story at precise locations, to shape the narrative unfolding in my reader’s mind.

As far as locating data entered by others, EMR clearly outshines paper charts as well. Sitting at my computer in the county hospital, I can limit the notes I view to the subtypes “H&P,” “Discharge Summaries,” and “Progress Notes.” From my chair, I can view all relevant notes and labs not only from prior admissions, but from the AIDS clinic she visits near her house, the Ophthalmology clinic she visited last year, and the biopsies that were sent out when endometrial cancer was suspected last month. Any, all, or none of these data may be relevant to this particular admission, but having it instantly at my fingertips is a luxury that paper simply cannot reproduce.

Finally, EMR is dramatically more accessible than paper charts. The initial barrier of poor handwriting is immediately discarded. The second barrier of traipsing up n flights of stairs to the patient’s floor, finding the chart, and wresting it away from the poor medical student who is trying to decipher the last consultant’s handwriting is also (thankfully) gone. While I am in an elevator on the way to noon conference, I am able to enter in an order that I forgot during morning rounds from my iPad. And as long as we’re trying to minimize handoffs, what about the handoffs that occur during order entry on paper?

Overcoming these fairly mundane inconveniences is not the only benefit of a full EMR. There are many unique benefits that have already revolutionized patient care. The cardiologist on home call can log in with his laptop and view the telemetry output of his entire ward; the medical team can instantly flip through each X-ray, CT, or MRI done in the past several years to compare a questionable lung spot to a CXR done at a previous admission; the hapless intern can have time to choke down some cereal while scanning his patient’s morning labs, even though he slept 15 minutes late this morning. EMR will continue to transform the way we practice medicine for the better, and the wisest approach to realize that it is just a tool that will reflect what we put in.

Garbage in, garbage out. Clinicians would do well to really learn the ins and outs of the technology so that they can best tweak it to their practice’s needs.

Deepak Ramesh is a medical student.

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  • georgemargelis

    Great insight from a medical student on the true value of the EMR. It is important for us to continue to explore what we can do with the EMR and not just assume it is as electronic version of our old paper notes. As we enter the age of Analytics and big data we must remember that a lot of very useful data has been tied up in paper records for centuries and we now have the chance to liberate that data and put it to good use.

  • Lea Sims

    You briefly touched on a critical element here – EMRs must be designed with the option for free-form narrative. No number of customizable text fields and drop-downs is going to accommodate every possible clinical scenario, and beyond that, you lose some important relational elements of the care encounter dialogue when you focus (or are forced by the EMR to focus) solely on the diagnostic elements of that encounter. The nuances of your conversation will be lost to the story, and while the exact exchange of dialogue over a patient’s concerns, poor compliance, interaction with her spouse in the room, etc., may not seem overly important in the immediate, the recording of those nuances has often made the difference in a court of law, years after the fact when your memory of that care encounter fades and the detail of that narrative becomes your legal lifeline. And I would encourage physicians who don’t think they need that free-form narrative or assume that those drop-down menus cover “just about” everything you want to say – USE the narrative section to capture the elements of your discussion that can’t be squeezed in a predetermined field. They just might save you later. :)  And keep in mind that natural language processing (NLP) technologies exist to codify even those narrative sections for consumption by your EMR. You don’t have to compromise detail by shoving your once robust narrative into the restricted square peg of your EMR.

    Beyond that, I think it’s important to keep in mind that meaningful use has introduced an important new patient-centric element here:  Notes captured via your EMR need to become a “human readable” document that your patient can have access to AND understand after that encounter. Have you ever seen the “document” produced by an EMR?  It’s a confusing maze of piecemeal text that is frustrating to read and even harder for anyone other than the physician to understand. And per the example above, it’s worth considering that phrases like “PMHx of CHF” are going to be lost on the patient. 

    If clinicians are mindful of those implications and don’t make the mistake of “throwing the baby out with the bath water” here, the result will be a truly robust EMR that preserves a patient’s FULL story and provides patients with a truly readable record.

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I have an EMR system for eight years now and just recently switched to a newer system ( reasons for the switch detailed in previous posts.). My system is certified and I have met the first phase of Meaningful Use Criteria and have successfully attested. 
    The comments are those of a medical student. That is not said to be demeaning. I have 23 years of medical records on some patients. Upon my initial venture into EMR with a fully certified company and product, I had to decide which of those notes and data should be included and availble for review through the EMR system. The actual work of scanning the document into the system is labor intensive and expensive. It required a data entry person to accurately type in a description of the item entered including the date it occurred. When we purchased our new EMR system we were sold on ” converting ” the old EMR to the new system. All the companies advertised it. We never dreamed that when they finally converted it the vendor they outsourced this to would record every previous entry as a ” chart note” with a ten letter digit ID #.  They didnt label imaging and radiology studies as ” chest x Rays ” or CT Abdomen w/wo contrast”  They were all labeled as chart notes.  Pathology specimens ” right breast biopsy pathology report 1992″ was labeled as a ” chart note.”    Consults were labeled as chart notes. The only thing the author is correct about is ” garbage in garbage out.”  The vendors took no ownership or responsibility for this type of service.
    The stress and strain of learning the new system took a toll on office staff who needed to perform all their assigned day to day tasks well in addition to changing over and learning the new system.
    Once we learned the new system and started using it, we learned that the vendor’s trainers had not been taught which buttons to push and icons to choose to register the audit trail to qualify for meaningful use. Yes we could enter a note and medications and problem lists but if the system had four ways to record data only one triggered the meaningful use criteria so we needed to be trained all over again to do it a different way. 
    The smooth integration between our practice management system and the electronic medical record for billing purposes has never worked correctly. It still does not.

    The government bribe of $44,000 over 5 years for meeting meaningful use criteria will not in any way cover the true cost, emotional stress and strain and loss of productivity the introduction of this system caused. Had the government passed the law differently and offered to pay the vendor $44K when the doctors and offices were trained and met meaningful use then the introduction of the systems would have been far smoother, the call centers would be more responsive and local ( I do not enjoy talking to Nova Scotia, Pakistan, Egypt etc when I have a question and call the Help Line).  If the onus were placed on the manufacturer to get it right or not be paid the transition would have been far smoother.

    EMRs will eventually make transmission of medical data far easier, legible and reliable.  How much wasted time, wasted money, safety related errors and clinical faux pas will occur because of the way the law is structured and implemented should be of concern and worth complaining about repeatedly!!!

    • southerndoc1

      Dr. Reznick:

      Since you’re running a retainer practice, why are you bothering with meaningful use?

      Thanks

      • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

        I like the idea of my patients having access to important parts of their medical history through the patient portal. The clinical summaries prepared now are very meager and frankly garbage but as the technology advances the summaries will be inclusive and worthwhile and the systems will talk to each other. I am working with a group out of Miami that is pioneering that. Of course our patients can travel and receive their records in hard copy, on a disc or USB Flash Drive now but being able to access it from anywhere aids communication. I can not tell you how wonderful it was to have a patient develop atrial fibrillation while traveling in Vietnam and she had her records with her on a USB Flash Drive. The cardiologist in Ho Chi Minh City faxed me her EKG and labs and we discussed the case by phone. I was able to speak to my patient and tell her just how sharp and well trained  her local treating physician was and it gave her a great sense of comfort. The technology will allow many interactions like this. It is a value added service that I believe enhances the concierge services as well.
        On a practical level it is nice to recover some small portion of the financial investment we made eight years ago in an EMR system. 

  • http://www.caduceusblog.com/ Deep Ramachandran

    Very nIce article. I think you are correct, as I posted previously here, once physicians get used to the idea that you must adapt the way you do things to the emr and not the other way around it gets a lot easier. There are also going to be horror stories like the one below which should not be discounted in the march to modernize paper charts. My biggest complaint is the systems are not compatible and can not talk to each other. To borrow your email analogy, it’s like gmail not being able to read messages sent from hotmail.

  • wahyman

    It is not clear if the values cited are hypothetical, or the attributes of a particular product that the writer uses. It is probably correct that a well designed EMR COULD do some or all of those things. The problem is that so many of them can’t.

    • http://www.facebook.com/profile.php?id=3003997 Deepak Ramesh

      My experience is with EPIC, which is able to do all of the things I wrote about.

  • http://twitter.com/Erin_Tolbert Erin Kadeg Tolbert

    I agree that with the EMR system, it can be difficult to “get the patient’s full story”, however the same can be said of paper charting and probably to a greater extent.  I have found EMR to be most useful in my own practice to compare a patient’s current and past lab values, review old X-Ray and CT reports etc.  When patients present with a stack of paperwork- MRI reports, lab results etc. I dread looking for the information I need.  Hopefully in the near future we will have systems that can synchronize with each other so we can get existing electronic information on patients who have information stored in multiple EMR systems. 

  • http://www.thehappymd.com/ Dike Drummond MD

    Doctors since the beginning of record keeping have demonized whatever system they used for charting. It is part of our culture. AND the responsibilities of documentation are a MAJOR contributor to the burnout rates we see on physician surveys of one in three practitioners every day worldwide regardless of specialty.

    The tragedy is that we allow our hostility to keep us from proficiency. Instead of complaining, do what it takes to become skilled and fluid  in your particular EMR interface. Think “YoYo Ma and his cello” or “Eric Clapton and his guitar” … like that. Instead most doctors remain hostile critics spending more time on complaining about what the system can’t do than working to learn what it can.

    Here is what I teach my clients. If you HATE your EMR go right at it and become an expert. You can’t hate the system if you don’t understand its capabilities. You HATE CHARTING … your system could actually make that easier if you learned how to play it well.

    My two cents,

    Dike
    Dike Drummond MD
    http://www.thehapppymd.com

  • LBENT

    I have used EMRs for patient care in my office for over 15 years. They are good for keeping track of meds and allergies and PMH.  They are lousy at really getting into details and understanding the illness and the patient.  The important information is not in the record like the relationship you build. 
    ]I am very proficient in the EMR, and I am a surgeon.  I can type and talk and type and listen. 
     EMRs will not save money, make care better, or solve all our problems.  We document to get paid fairly and for the lawyers.  Let’s be honest. 

  • http://profile.yahoo.com/YZGUU5I4THLVZHQWYHEPOVB7NY ben

    Would it help if you could have transcribed notes put directly into the text boxes meeting meaningful use requirements?  My medical transcription company has this capability and we are building a few interfaces now with a couple of different practices, but it is the exact opposite of what the EMR sales people tell their prospects.  They sell their products based on never having to pay for transcription again.  Does anyone have any thoughts on using transcription in conjunction with your EMR?

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