If it’s not in the computer, you didn’t order it

They used to tell us, as physicians, that “if it isn’t on the chart, it didn’t happen.”  We could protest all day, to billing companies, insurers or attorneys, “I did that.  It’s assumed.  I always do the same thing every time.”  But they would retort, “nope, it’s not in the chart.”  So we learned to detail everything, every time, every movement.  Every consideration and justification.  The idea being, our ‘thought process’ had to be clearly elucidated on paper.

Enter the world of computers.  Not only do all of my thoughts have to be recorded, all of my assessments and intuitions, all of my reflections and prognostications, so do all of my orders.  And I mean all of them. Because, as with before, so it is again.  “If it’s not in the computer, it didn’t happen.”

More to the point, “if it’s not in the computer, you didn’t order it, which means the nurse ordered it without an order, which means she tried to practice medicine which means she broke the law and will likely be summarily terminated.  Or executed.  Whichever comes first.”

I notice, increasingly, that everyone who is my ancillary staff is frantic about the computer.  I say “I need a chest x-ray for this gentleman with chest pain.”

“Ok.  Did you put it in the computer?”

I say, “Go ahead and start a liter of fluid and give him 25 mg of Phenergan for nausea.”

I ask later, “did that get started?”

“No doctor.  We’re waiting for you to put it into the computer.”

Dressings, x-rays, labs, EKGs, scans, splints, IVs and everything else only happens “if it’s in the computer.”

What makes it more real?  Is it billing?  Is it the ability of lawyers to comb through it in litigation?  Is it that we have evolved and only recognize the validity of electronic symbols, rather than the validity of the oral or written word?

I suspect the majority of it has to do with culpability.  If it’s in the computer, and there is evidence I have ordered it before the nurse did it, whatever goes wrong can always be my fault.  But in an age of vastly increased computer use, and the inherent risk of error on drop-down menus or in picking the correct patient from the list of many others (in a chaotic environment), will the data entered always be correct even when the nurse uses it?

And will I then be culpable for a thing I didn’t actually order?  And will we find that tragedies happen more because everyone is so focused on the screen that the computer is actually the customer, not the patient?

There were days when our words mattered.  Now they don’t.  Only our keyboards, or our voice recognition transferred to a hard drive.

And I don’t think we’re better off than before.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test

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

    No, you’re not better off, but may I suggest that to some extent you brought this on yourselves.
    At some point and for many reasons, you relinquished control of your arts and crafts, first to payers and now to Big Data scavengers, and you really didn’t have to.
    For those who work in “systems”, it may very well be too late. For those who don’t, there is still some hope….maybe…

    By pure coincidence, fresh off my presses today :-) http://onhealthtech.blogspot.com/2014/03/health-care-is-like-katzs-deli.html

    • guest

      I think most practicing doctors were not paying enough attention to have consciously relinquished anything. Those of us who spoke up with concerns were informed that we were “disruptive.”

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

        …which brings us back to the AMA, its role and function, and all the etc.etc.etc.

  • Lisa

    So what is the difference between having to write something on paper or entering into a computer? One way or another, it has to get charted. To me, it sounds like you had trouble completing paper charts and now have similiar problems with computer charting.

    This is not to say I think EMRs are all that great; but as a patient I think they have some advantages. It gets old watching a doctor looking through a thick, disordered paper chart, looking for a test result. I like the way some doctors use them, dictating notes in my presence. It reinforces what was said and gives me a chance to correct errors.

    • edwinleap

      This isn’t about completing charts. It’s about doing patient care ‘real-time.’ EMR’s have theoretical advantages, but are well-documented to slow physicians down. They could be vastly simpler and more user friendly, but they’re now used as data-collection tools and billing-devices, and the charts get more and more complex. And if you haven’t used EMR vs writing orders, you have no idea. It’s so much faster to put orders on paper the way systems are now set-up.

      • Lisa

        You’re right that I only see EMRs from a patient point of view, so I don’t see all of the problems. Thank you for the explanation. It gives me a better idea of what you are saying.

    • guest

      Here is what Dr. Leap is talking about: previously, if we needed something for a patient like a medication, iv fluids, an EKG, etc, we could give a nurse a verbal order and co-sign it later if we were in the middle of something and couldn’t get to the paper chart.
      Now, with EMR, nothing at all can happen until we excuse ourselves from what we are doing (seeing another patient, talking to a member of the staff about another patient, driving home from work, having dinner with our family, etc, etc.), get to a computer, spend 1-2 minutes logging on, and then another minute or so writing orders. It sounds petty, but when your workflow is constantly interrupted by requests to log on to a computer and enter an order, it does get difficult to concentrate.
      Also, I notice that with EMR, there is a perception on the part of some nurses that we are with and logged onto a computer all day long, so that when I am paged at night on my way home (at 6 pm) about an order, I have actually had nurses express some surprise and annoyance that I cannot instantaneously produce an order they want (say, for mag citrate, or for an EKG that didn’t get done and the order needs to be rewritten because it expired.)
      All of these little interactions work to erode the basic civility that it is so important to have for good teamwork.

      • Lisa

        Thank you for a better explanation.

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

          Lisa, the sad thing is that you could have everything you like about EMRs, without making your doctors miserable, because all these problems are due to administrative processes.
          In this example here, if administration allowed nurses to enter verbal orders in the EMR, noting who the ordering physician was, there would be no problems, and there are dozens of other things like this one example.

          • guest

            One of the main stated aims of CPOE at many facilities, including mine, is to eliminate “verbal orders.”

          • Josy Coke

            eh, that is really is a problem – not one I think can be fixed with any EMR modification

          • LeoHolmMD

            If you could just have your admin log in and enter that stated aim at the beginning of each business day, that would be very helpful. Otherwise let’s not go around setting “verbal” aims.

          • Josy Coke

            we have the worst, most un-user friendly emr ever, and we can enter notes and write whatever we want. I always put in an order, and then notate, like I commented above, V.O. Dr. XYZ “whatevertheorderis”

          • LeoHolmMD

            Only a physician with 11 or more years of post graduate training is capable of doing the advanced data entry you are suggesting.

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

            Are you sure 11 years is enough? :-)

  • Dr. Drake Ramoray

    At one time the tech people at my residency program thought we were gonna run codes using the EMR for med administration. Was a running joke for months.

  • guest

    EMRs created all kinds of problems when I worked on the floor. Another problem is the system goes down, and then no one has access to the chart – which means the nurses don’t know what has been ordered, no one knows when the last dose of drug x was given, etc. The stat order that was just put in sits there for hours while the EMR is nonfunctional, because the nurse doesn’t know the order is even there. They create real safety concerns.
    If I am hospitalized one of the first questions I will have for my nurse is if the EMR goes down, how do you handle medications – how will you know when the last dose was given, when the next dose is due, etc. Scary.

  • ninguem

    And you wonder why doctors drop hospital “privileges” as soon as they have the chance.

  • Josy Coke

    we have EMR, but we still have “verbal orders” V.O. Dr. XYX Chest Xray. Later, Dr. XYZ signs it. problem solved.

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

    Agreed. It seems that at some hospitals, things have gone a tad too far…

  • TheresaWillett MDPhD

    I wish I knew. I think we need to hold our CIO, CMIO, etc accountable for the choices they make in the EMR, from ‘options’ purchased to hardware setup. They, in turn, need to hold vendors accountable. Maybe withhold payments when support or features do not work as promised. The EMR ‘market’ is far from free or competitive in the classical sense, There are so many string attached that once an office or institution buys in, they are often effectively trapped. As individual physicians, we can use our voices. If we have blogs, tweets, whatever, they can be outlets for examples of unacceptable products, workarounds, and expectations. They can also be ways of conveying practical suggestions for improvement. Hopefully someone will listen eventually.

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