Lessons learned during an unplanned EMR downtime

Lessons learned during an unplanned EMR downtimeA guest column by the American College of Physicians, exclusive to KevinMD.com.

On a Thursday in April, my practice upgraded its electronic health record to the next version, the “latest and greatest” with more features, as well as compliance with meaningful uses 2 through infinity. That was the good news. The bad news was that it meant that our EHR would be unavailable for what was supposed to be several hours, but turned out to be two and a half days.

We prepared for it as best as we could by printing out basic information that we thought we would need to continue seeing patients, since in the world of private practice, you don’t shut the office down for a computer upgrade. We printed the last couple of visit notes and most recent labs. A limited number of users in each office had “read only” access to the old version of the software in case there was an urgent need to look anything else up, plus we could access laboratory information, prescription data, and demographic information through the statewide health information exchange.

Despite all the contingencies and preparations, the bottom line was that we were going into the exam room with paper in hand, just like the old days, and without access to most of our patients’ information. While I don’t recommend an exercise like this one for everyone, it did serve to teach me to appreciate what I had, as well as what I used to have.

It did not surprise me that the thing that I missed the most was the ability to quickly look for old labs, review previous visits, and read consultant notes in the EHR. In the old days, I would leaf through a paper chart, but it was much faster to do so on screen. Similarly, knowing a patient’s status regarding preventive tests was more difficult without the EHR. While we complain a lot about computerized physician order entry and electronic prescribing, the sense of nostalgia for the old prescription pad did not offset the hassle of extra work when I had to prescribe or order tests in longhand.

What I found eye opening was that once I got over the angst about not having the same degree of access to data that I was accustomed to, I felt much more at peace during my visits without the computer in the room. I was clearly multitasking less, since the ability to see and enter more things on the EHR made me look at and enter more things on the EHR, all while talking to the patient. While I am a pretty fast touch typist who can make eye contact with the patient while typing, not having to type at all made even that minor distraction go away. To keep track of what I did while the EHR was offline, I just jotted down the bare minimum on a form that my practice developed for this occasion for use when I documented the visit later. This also took far less time than what I was doing at the keyboard with the EHR.

Instead of waiting to document my visits until the EHR was operating again, I decided to go back to what I did before 2006, which was to dictate an old SOAP note using voice recognition. Later I would cut and paste the various sections of the note into the right places in the EHR. Normally, I would have dictated directly into the EHR, pausing to click in the right place, then resuming my dictation. However, the ability to go through my complete note nonstop without pausing to click in the right box seemed easier and better allowed me to collect my thoughts.

So what did I learn from this unplanned lesson? First, I realized how much I missed the access to data that the EHR provides. While I had other ways to get the information, having it all in one place without my having to log into different places or search through paper was valuable. Also, the ability to track things that I could never track using paper flow sheets and problem lists is another value of the EHR. On the other hand, even for a fast typist, seeing a patient with an EHR adds distraction. Even if the patient doesn’t feel that the computer is intrusive (and many do), not having the EHR made me appreciate how intrusive it is.

Then again, I realized that we weren’t making 100% eye contact in the pre-EHR era either, since I found myself leafing through the few pages of old information that I did have, looking for things while talking to my patient. The ease of dictating a note from start to finish without having to stop to click boxes, as I did for those couple of days, also reinforced my belief that refining natural speech recognition so that one can document a visit by dictating it and letting technology put the information in the correct EHR field would make it easier to document a visit. The new version of the software that we now have is supposed to offer something that comes close to this.

What this experience did not do was convince me that we made a mistake by going to electronic health records. However, it did reaffirm my belief that we have a way to go before it becomes the true helper that it was supposed to be in the first place.

Yul Ejnes is an internal medicine physician and a past chair, board of regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • betsynicoletti

    Informative discussion of the value of an EHR and the disadvantages. The physician office note could be a flat, dictated note inserted into the record. I think we could still meet meaningful using the EHR to collect and record information in structure fields. But, once we get EHRs it’s too expensive to keep the typist as well. I see the irony of that: we have the physicians type.
    You must have a good EHR if you say it is quicker to look at old labs, notes, consultant reports and preventive status in the EHR rather than paper.

    • guest

      Agreed; I would also like to know what EHR Dr. Ejnes is using as I find that with EPIC, the process of reviewing labs has become a very time consuming process requiring lots of clicking, scrolling, and scanning multiple busy screens, many of which do not maintain a consistent appearance i.e. in one encounter the “lab flowsheet” button will appear in a toolbar, but on another encounter, the same button will be hidden in a drop-down menu. Don’t even get me started on finding consultation notes which by and large for some reason, never appear in the consultation section.

      Also, although I agree that theoretically, the ability to view results in a flowsheet is a benefit of EHR, our experience with EPIC has been that the data in the flowsheet is typically presented in small increments which requires a lot of horizontal scrolling and loss of visual continuity, sort of defeating the whole point of having a flowsheet.

      • betsynicoletti

        Isn’t there a mantra, “No one ever got fired for selecting EPIC.”

      • Yul Ejnes, MD, MACP

        I would not say that the EHR’s lab display is perfect, but if one is checking to see if anything’s come in since the last visit, one screen with each lab report date as a line item that can be expanded as needed plus the ability to display a cumulative report for a specified time period is faster than leafing through “x” pages of paper reports. Also, if a question comes up such as “what was my A1c three years ago?” it’s easier to find in the EHR. Keep in mind, that assumes that the results are in digital form, requiring interfaces or manual entry, otherwise one is “leafing” through TIFF images of scanned or faxed documents, which is slower than paper.

        If you contact me privately (Yul_Ejnes@brown.edu) I can share details regarding vendor.

  • Thomas D Guastavino

    The big question here : would you have voluntarily moved to an EMR system without the carrots and sticks?

    • Yul Ejnes, MD, MACP

      We did – in 2006 (before HITECH). The only incentive at the time was the RI Blues’ slightly higher payment schedule for EMR users, but that was not the reason we made the move. We felt it was a good idea to go electronic, and despite the shortcomings, we still feel that way.

      • Thomas D Guastavino

        Thanks. I wonder if thats the prevailing opinion. I would like to take an informal pole. Question: To those that have moved to an EMR, knowing what you know now, would you have moved to EMR without the carrots and sticks?

  • buzzkillerjsmith

    Shorter Dr. Ejnes on EHRs; afferent fairly good, efferent exceedingly bad.

    Uh, everyone knows this. Every stinkin’ physician at this blog knows this.

    Next case.

    • Yul Ejnes, MD, MACP

      Thank you for your thoughtful analysis. I should have consulted with you before reading through the 5166 page RUC meeting agenda – it would have saved me a few days of work.

      • buzzkillerjsmith

        Glad to help. Too bad the ACP didn’t talk to me before locking hands with their co-idiots at the AAFP and jumping off the bridge into the PCMH abyss.

  • Thomas D Guastavino

    Thanks. Thats one yes and one no. Anyone else?

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