Why should physicians have to enter orders in the computer?

PW

C’mon Dr. Leap. Don’t you understand, the computer is the patient! Now we just need Watsons to treat them.

Markus

Nobody hated EHR’s more than me when I was working, and this was because they were designed to be charge capturing and revenue generating rather than doctor helping. Having said that, I don’t think that it is harder to type an entry than scribble it and avoids problems like when my patient got astemizole instead of anastrazole (both dosed at 1 mg) due to problems with writing. Secondly, the EHR can provide useful warnings like allergies that doctors don’t always remember. Thirdly, that patient with the suspected PE has diabetes and a creatinine of 1.9; the ward clerk is not capable of deciding whether the test merits the risks of the procedure. I doubt that entering orders takes that much time. I think that the problem is that the tool is poorly designed.

JustADoc

I have so far refused to do CPOE at the hospital.
Sitting next to one of my partners who is the doc guru for the hospital EMR, I blaze past him in writing orders.
For me to order a CBC, I handwrite ‘CBC’. It takes approximately 1.5 seconds and I don’t have to change screens in the computer that I am referring to.
For him to order a CBC, he has to change screens(3-4 seconds), click on orders and wait for that pop-up to come up(3-4 seconds), type in CBC and wait for the scroll to come up(3-4 seconds), click on CBC and then enter the time/date he wants it(3-4 seconds), then close it all out(5-6 seconds). Total 14-18 seconds to order a simple CBC.
Multiply x an admission order set and it can take 20 minutes to write simple admission orders.
And then the lab/pharmacy/radiology call for corrections on 8 of the things as what he clearly intended is not what the computer interpreted. Or he accidentally hit today instead of tomorrow.
I have never, ever, intended to write the words ‘in AM’ and my pen accidentally wrote ‘today’ NEVER.
W. X. Wall

I hate to come down on you, but every defense of CPOE uses the same examples you’ve provided, and I do not think they make the case for CPOEs.

#1-> doctor’s bad hand writing. Fine. make us type the order. But why can’t an EMR have a natural language parser that can interpret a typed in order? After all, even though prescriptions are ‘free hand’ doesn’t mean there is no structure to them. The fact is that there is a structure to orders that has been developed and refined continuously since literally the days that Rx’es were written in Attic Greek. It’s the height of arrogance for a computer designer to assume they can throw away that cumulative experience of thousands of years of structuring orders and create something ‘better’, or that just because there are no whiz-bang menu prompts that there isn’t already a highly evolved structure.

#2 -> allergy detection. Whenever a vendor is asked to provide one concrete example of the vaporware of ‘clinical decision support systems’ that’s supposed to allow us to write better orders, this is the only one that’s ever provided. We had this with paper orders. JCAHO requires a prominent red warning label with allergies stuck on every patient chart. Furthermore, after the physician wrote the order, the nurse would check it, the pharmacist would check it, and the nurse would check it again when he was administering the drug. Do we really need to spend hundreds of billions of dollars and sacrifice everything else in order to do another allergy check?

#3 -> your example of a diabetic with an elevated Crt. At least this one isn’t an allergy check 🙂 But it points to another problem. Having all these checks in place is good. But the initial step of having doctors write those orders has nothing to do with it. In the recent past of writing paper orders, that CT scan order would be entered into a computer by the ward secretary. Feel free to implement every single medical check you wish at that stage. And if it blares out a warning, then the secretary can call the physician and see what he wants to do.

IOW, having all these clinical decision support systems does not *require* the first step to be automated. When we write a paper order for meds, it gets entered into a computer system that does these checks, which are then followed up by a trained pharmacist who can call the physician if there’s any questions. When we write a paper order for a CT with contrast, there’s nothing preventing the system from cross-checking the creatinine and making a warning that either the unit secretary or the CT tech can follow up on before doing the test. Heck, I’d even be on board with the computer having all of our cell phone numbers so that if it finds a warning, it automatically sends us a text directly, thereby saving the unit secretary the task of calling us.

And that’s all that Dr. Leap is asking. I don’t think he’s saying everything in the hospital should run on paper, just that the initial order entry done by a physician doesn’t need to be on a computer without sacrificing any of the benefits of an otherwise automated process.
Linda

some units don’t have clerks/secretaries 23/7, where I work the secretary is only there from 9 to 5 and if census is low she leaves at 1:30 pm. There is not an evening or night shift secretary, so the nurses have to stop what they are doing to “play secretary” most of the day. W
hich takes them away from their patient care.
- RenegadeRN
  
  SO true! I haven’t seen a unit secretary since 2004! I consider myself a little overeducated and busy to play unit clerk, but I have been forced in recent years.

Hopefool

Great read!

May I also say, it would have also been easier if the names if the orders were intuitive. And numerous repetitive pop ups asking redundant questions did not freeze both the computer and my brain.
Nurses do help if they want to..but between them juggling 8 patients in a single shift and the refreshment orders its heroic when they do. I pity them myself.
The trouble is that now all workflows run ‘in series’ and not ‘in parallel’. Vital processes are held hostage by a click.

This makes me desperate for the old handwritten nurse’s note and a quick phonecall and your ward work was done before you could say ‘dropdown menu’.

Teresa Brown

Ah, yes. How could family members survive grueling visits without being provided turkey sandwiches, potato chips, coffee, soda, ice cream, Italian ice?

Thomas D Guastavino

The answer to this question is easy. Because the government first bribed them to do it, then threatened punishment if they didn’t.

David Gorski

The problem is not so much entering orders. After all, we doctors didn’t use to bat an eye at a different method of entering orders, namely writing them in the charts, because we knew how to do it by that method quickly and efficiently. Once you’ve learned the ins and outs of an EMR, you can enter orders close to as fast as it used to take to find the patient’s chart, find the first blank order, write the order, and flag the charge. The problem is getting to that point, because most EMRs suck so bad. They’re non-intuitive and have a steep learning curve, requiring many, many hours to become sufficiently expert in that the time taken to enter orders approaches the time it used to take with pen and paper. As I like to say, most of them aren’t just user-unfriendly. They’re outright user-hostile. What we need to demand is a better class of EMR.

In Steve Jobs’ biography released shortly after his death, Walter Isaacson described how, after having been ill and spending so much time in the hospital, Jobs had noticed just how inefficient devices and systems there worked. He speculated what would happen if Apple started working on improving the situation. What’s needed is a company like Apple to figure out why existing EMRs are so terrible and fix the problems.

Teresa Brown

If only Steve Jobs had been able to get some skin in the EHR game. The EHR I used defied logic or intuition.

exit 7

My hospital threatens to write up nurses for taking verbal orders. So we just fudge it a bit and enter them as telephone orders.

Teresa Brown

Yeah, I used to do that too, but only for docs I had worked with for a long time and trusted.

Teresa Brown

Yes, nurses really can’t do something until there is an order for it. If we don’t have an order but go ahead and give a med/order a test/etc., we’re practicing outside our scope and veering into practicing medicine. The BON looks askance at nurses who do that.

Verbal orders are frowned upon due to the likelihood of errors being made. And more than one nurse has been burned by “that doc” who gives a verbal order, then turns around and claims not to have given that order.

Many hospitals have done away with unit secretaries on night shifts/off-shifts. That means nursing staff are having to take care of secretarial duties like answering phones, directing visitors, etc.

Just enter the orders.

David Reinertson

I hope the doctor understands why we want orders written. (Although the incidence of doctors lying about a verbal order is extremely low, where I live. It would have extreme social and professional consequences. Not to mention bringing down the wrath of Asclepius. That would be a good subject for a confidential survey.)

However, the scope of practice ought to change, as technology changes. It’s considerably cheaper, quicker, and easier to check a blood sugar or gastroccult some NG output than it is to calibrate a plasmapheresis machine. I don’t think it would endanger patients or impact MD’s turf if nurses could do these things when appropriate from a nursing point of view.
Letting nurses collaborate would be a lot less harmful to MDs than making them spend all their time locked away from their patients interacting with insurance companies on a computer.

W. X. Wall

Several reasons, Dr. Leap, none of which have to do with patient care:

1) He who writes the order gets the liability if it’s incorrect. The hospital sure as heck does not want the nurse (whose liability falls on the hospital) to be the one entering an order. Hospitals care more that they’re not found liable than they care about whether it’s the correct order or not.

2) Nurses, techs, etc. are paid by the hospital an hourly wage. You are not. Therefore, your time is free for the hospital. A nurse’s time is not. They would make you sweep the floors if you were willing to do it (don’t laugh; I know a surgeon who occasionally mops the floor of his O.R. in order to speed up turnover time).

3) Because we don’t refuse to do it. As long as we continue to acquiesce to their demands, with no counter-demand to be compensated for doing the job of a data entry clerk for the hospital, they will continue to make us do it. They’ll even allow us to continue bellyaching on a physician blog/wailing wall as long as it doesn’t change how we actually do our work.

T H

1. We have the liability regardless of who puts in the order.
2. ED docs are often paid hourly wages. If we’re not seeing patients, we’re not making money for the hospital.
3. Very, very true.

Patient Kit

Whose rule is this? CMS or hospital by hospital, employer by employer? If a nurse or tech can enter an order that you give via the phone, why can’t they enter an order that you give in person? Can a resident enter an order for an attending? What can private practice docs do? Do they have to enter orders themselves or can they have someone on their staff do the computer entering? I guess what I’m asking is: Who is telling you that you and you alone must enter all orders into the computer? Is it a government regulation or an employer policy?

Teresa Brown

Verbal orders have been shown to increase the risk of misunderstanding/miscommunication, leading to errors. Exceptions can be made in the case of an emergency such as a code, but otherwise if the physician is present, s/he can take the couple of minutes to enter the order.
- Patient Kit
  
  Thank you. Thinking about it and considering how much miscommunication happens in all verbal communication, in and outside of medicine, this makes sense to me.
- PaulC
  
  Which bureaucracy or EMR vender do you work for or with?
  - Teresa Brown
    
    None. I’m an RN and have seen how miscommunication can happen when verbal orders are given. Sometimes when nurses get busy, they forget to write them down. Sometimes a “sound alike” drug is mistaken for the drug the doctor actually desired.
    
    I don’t work for any EMR vendors nor do I work for any “bureaucracy.” I’ve retired from nursing due to health issues. Satisfied?
    - David Reinertson
      
      I agree. I note, however, that you don’t mention ever hearing of a doctor giving a verbal order and then denying it later. I’ve heard that given as a reason for refusing verbal orders.
      I’ve only heard of that once in 40 years, and it was a marginal case.
    - Teresa Brown
      
      Actually, it happened to a colleague of mine.
- MsIMDoc
  
  There is a difference between verbal orders and creating a simple way for doctors to type orders in plain text rather than the ridiculous cumbersome way we have to order a chest X-ray or a tylenol with multiple drop downs. We then have to connect each order with a diagnosis in CPOE. So if I want to order a colonoscopy I have to also enter in another form for visit diagnosis of colorectal screening. I then have to indicate when I hope the results to return by, etc, etc. In the past you would just write “Screening colonoscopy”.
  - David Reinertson
    
    In the past, the human reader of your order “screening colonoscopy” could infer meaning from context.
    You want the computer to realize that, since you are a doctor and there is no colonoscopy in the chart, you want one done.
    And, since you didn’t specify a time, you want one ASAP, or you want to know the reason why not.
    And, since you want one done, and the patient is currently in a clinic under your care, the purpose of the visit is now, in part, to do a screening colonoscopy.
    And that, since you used the adjective “screening” before the name of a test, the word “screening” is a rationale for the test, as well as a particular kind of colonoscopy.
    If the ward clerk of old couldn’t figure this out, you’d clarify it, and, in the future, your communication would include an expectation that she could use these contextual clues.
    Communication isn’t just a dictionary and a medium to transport words. The ability to modify and improve communication is part of communication.
  - Teresa Brown
    
    I absolutely agree. Where I worked, the EHR system required you to navigate through five different screens just to note that the patient had no pain.
- David Reinertson
  
  I have heard the same thing. However, verbal communication is extremely valuable, and has been used successfully to reduce misunderstandings for millennia. I think paleontologists consider verbal communication the sine qua non of the human species.
  
  How are we doing in the new age of reduced verbal communication? How many times is a nurse unable to communicate well the subtleties of the patient condition via computer? How often is the medical plan unclear to the nurse? How often is the doctor unable to clearly express what he wants or thinks in a drop-down menu? Do we report these MD-RN miscommunications or misunderstandings to a central database?
  
  I applaud the workarounds you use when verbal orders are given. As they say, the exception tests the rule. How do you decide that a communication is too important to wait for an MD to enter it into a computer? Does it depend on just the type of order, or on your medical understanding of the damage which would be caused by waiting? Does it depend on the importance of the physician? Would you demand this of a surgeon? Would you take a verbal order from a doctor you didn’t know and trust? Does it depend on the importance of the patient? Would you withhold needed care from a VIP because the MD wouldn’t write the order yet?
  
  These are all examples (good and bad) of nursing judgement.
  - Teresa Brown
    
    The bottom line is, whether the order is written or computer generated, it’s less likely to be misinterpreted by nursing staff if the doctor is the one writing it/entering it. There’s no reason for orders to be given verbally, with the exception of emergent situations.
    
    Would I take a verbal from a doctor I didn’t know? If I were still working, probably not. Not when nursing staff get written up by nursing admin. for taking verbal orders.
    
    You’re right that you can lose subtleties with using checkbox charting. That was one of the reasons I wound up using the freeform box and wrote my note out longhand. I could type a lot faster than navigate multiple screens.
    
    The last bit of your comment…yeah. Now you’re being ridiculous. But I’ll try to play:
    
    Would I take a verbal order for Tylenol? Probably. Would I take a verbal order for chemo? No way. Would it depend on the importance of the physical? No. I’m not overawed by doctors, anyway. Would it depend on if the doctor was a surgeon? Is it safe to speculate you’re a surgeon? Would it depend on the importance of my patient? All of my patients were important to me…no VIPs. Would I withhold care from a VIP until the MD wrote the order? Why should it matter that the patient is a VIP? By whose estimation is this patient a VIP?
    
    Your examples had nothing to do with nursing judgement, good or bad.
    - David Reinertson
      
      You gave good answers to my hypotheticals. Knowing when to accept a verbal order may not be nursing judgement, but it is judgement.
      
      If you’re important enough, the hospital won’t make you write orders. Someone else may write them for you. In which case, the important person has given a verbal order, and you’re taking it. Passing the verbal order through a lower doctor or NP to be written doesn’t prevent miscommunication. In fact, you now have even more chances for error, and less ability for the nurse to clarify the order.
      
      I agree that a VIP is any patient I have.
    - Teresa Brown
      
      I don’t know where you work, but in every hospital where I’ve worked there was no such thing as a “higher” or “lower” doctor.
      
      JC, IOM, CMS, AAOS et al have noted that verbal orders should be avoided as much as possible. Of course, if there’s an emergency situation verbal orders may be necessary.
      
      Patient should be our number one priority. If something has been shown to be deleterious to patient safety, I don’t understand why some doctors push back.
      
      I consider it to be no different than people who insist on using cell phones while driving. The data is out there that it’s hazardous not only to the driver, but others on the road. Many areas have enacted laws forbidding use of cell phones while driving, but there are still some people who refuse to obey those laws. Do they think they’re so important that the laws don’t apply to them? Same thing with doctors who, in spite of being told that hospital policy forbids verbal orders in non-emergent situations, continue to try to give verbal orders.
      
      That puts nurses “east of the rock, west of the hard place.” Take the verbal order, get in trouble with management. Don’t take the order, risk getting yelled at by the physician.
      
      We all should be concerned with keeping patients safe. Egos have no place in patient care.
    - David Reinertson
      
      Yes. I agree. All doctors are to be respected for the education and responsibility they represent, but some can be fired, while others can fire the hospital. A doctor can be an irreplaceable rock-star, but not be an expert on the idiosyncrasies of every computer program in every hospital he or she visits. I don’t want to specify which hospitals have formal or informal hierarchies, because it’s a matter of principle, not personalities.
      
      You’re right that there are difficulties with exceptions to the rule about verbal orders. One you listed was “emergencies.”
      
      I just think there are lots of other reasons to take verbal orders. In general, if the alternative to taking an order is to allow harm to the patient, you need to use your judgement.
      
      I agree that texting while driving is unsafe. Imagine if you were required to communicate using your smartphone while driving, because texting is safer than talking.
    - Teresa Brown
      
      Well, if giving a verbal order means the difference between a patient crashing or not crashing, then that’s pretty much an emergency, wouldn’t you think?
      
      I think some of the pushback regarding verbal orders is that some doctors have gotten used to treating nursing staff as their personal secretaries. Times have changed, and nurses are being disciplined in many facilities for accepting verbal orders in non-emergent situations, e.g. “Give Mr. Smith Ancef 1GM pre-op.”
      
      Obviously if you’re in the middle of a code, things are different; you’re not going to say, “Wait, we can’t give that Lido until you enter it in the system.”
      
      It’s not worth it for a nurse to lose his/her job, maybe even license, just to take a verbal order that could have been just as easily entered in the computer.
    - David Reinertson
      
      Good point. I once interrupted a doctor in rounds. He said “Is it life or death?” I replied, “No, but if you don’t deal with this now it will be much worse later.” He trusted me enough to stop rounds and solve the problem.
khrystle

How about this– they’re YOUR ORDERS. If a mistake is made by someone else entering YOUR ORDERS it’s their fault not yours. Its your job.
- Patient Kit
  
  Well they’re not MY ORDERS but I think I get what you mean.
- khrystle
  
  Oops sorry for yelling at you. This was intended to be a general comment but I put it in the wrong place. Which kind of inadvertently proved my point haha.
David Reinertson

I think that the Joint Commission on Accreditation of Hospitals does audits, and will threaten to remove accreditation from the hospital if it does thing which are considered “bad”, like communicating verbally.
If the hospital loses accreditation, Medicare or Medicaid may not pay for their patients. Even though hospitals complain about the low reimbursement rates, these programs do pay for much of the fixed and operating costs of the hospital, so they’d go out of business if they lost accreditation.
I don’t know about doctors’ offices, though. Probably different rules, and different relationships with Medicare and Medicaid. I know some offices don’t take these patients, in part because the limited money isn’t worth it.

Steven Reznick

The EHR or EMR at most facilities is not user friendly. First of all medical staff governance and bylaws have been stolen from physicians by packing the nominating committees with hospital employed physicians. Attendance at departmental staff meetings is next made voluntary so attendance dwindles. The definition of a quorum for a legal meeting is reduced to a simple majority and before you know it the medical executive committee is composed of physicians receiving their pay and benefits through the hospital. Requiring docs to enter orders instead of clerical ward staff is the next step at both the corporate for profits and the indistinguishable so called voluntary non profits.
Our system is tough to use. When you arrive in the ED their notes are on a separate data base. You first have to locate your patient before entering orders. That in itself is a task with the system rejecting full name, birth dates, account and medical record numbers at times.Then up comes the warning that you are unauthorized to access this data primarily because the ED staff is slow converting the patient to inpatient status. Code status, VTE prophylaxis and home to ER medication reconciliation are all they are interested in. The patient could be arresting but unless that data is entered nothing gets done. My patients are older and for every med I enter I get a warning that the med may be dangerous in the elderly necessitating an override choice by me and an explanation. Once I finish the orders I print them out and review them with the patients nurse. Most of the time they are too busy to take the time to review them. We still have to write and sign an admission note AND dictate one as well. The written note must conform to JCAHO standards so when I reach the bottom of the page I must sign it , date it, time it and write , ” turn To Next Page” or it violates JCAHO standards.if I code the dictation as a consult it appears on the chart in hours. If I code the dictated note as a history and physical it takes days to appear on the chart.
The systems suck. If you are in an affluent enough specialty to afford a scribe, or have a PA or NP being used below their level of training and experience you don’t deal with any of this. Regardless of how proficient and experienced you get with the software the process is slow, inefficient and is as error prone with drop down and click errors as it used to be with handwriting errors.

David Reinertson

I agree. If we use scribes, the cost of an inefficient communication system will become visible in the budget.
However, going back to a medieval communication system like this will have social effects, too. You’re delegating communication and adding a layer of bureaucracy.

Was there a change in social structure in offices in the late ’80s when businessmen replaced their secretaries with PCs? Do we have more, or less women in more, or less interesting and powerful positions?
If the scribe is reading the nurse’s notes as well as entering your orders, and has learned all the business rules and “best practices” built into the EMR process, how much is left for the MD to do?
- Steven Reznick
  
  How about spending more than 11 minutes with a new patient and family, which is what house officers and hospitalists have been timed at due to all the computer entry protocols?

azmd

Actually, a careful review of the literature shows that there is no clear evidence that CPOE (computerized physician order entry) system adoption results in improved patient safety or mortality. Although these systems reduce overall numbers of errors, the errors affected tend to be inconsequential ones. There is no consistent finding that serious errors are reduced or that patient safety is improved.

What we do know is that CPOE systems increase physician cognitive workload, and lead to fatigue, which can actually increase medical errors. A study I am doing showed that prescriber error rates in our institution TRIPLED after adoption of CPOE. Overall errors went down, but the rate of medically serious errors which resulted in patient harm stayed the exactly same. So, doctors made more mistakes, and there was no improvement in patient safety.

Saying that “It is more work, but we just need to do it,” completely misses the points that are being made here. Physicians are cognitive workers. Doing our jobs well requires time and also the ability to concentrate on clinical issues. The extra work and constant interruptions imposed by poorly designed EMR/CPOE systems, and by the need to do extra clerical work that used to be done by unit clerks and nurses, has unquestionably affected the quality of care we offer our patients.

Just look at the steady drumbeat of complaints here on KevinMD by patient commenters describing rushed physicians who spend the majority of time with a patient staring at a computer screen, and how often diagnoses are missed these days.

joehospitalist

I’d be really interested in seeing the results of your study. I can tell you anecdotally that CPOE absolutely increases the number of errors that I make. They often include putting orders on the wrong patient, forgetting orders (because the system is designed so poorly), or putting in the wrong order entirely. I don’t think these events get captured because they are usually fixed (one hopes), and it is falsely making CPOE look better than it is. If a patient requires a lot of orders, I have to write them out on paper and then put them in one by one so I don’t miss anything. And like MsIMDoc mentioned earlier, I grew up with computers and am fairly competent with them.
- azmd
  
  Yes, I had noticed the same issues myself when my hospital went up on CPOE. After I apparently complained one too many times, the chair of the Research Committee for my department assigned me the task of studying the numbers during my research time. I was unsurprised to see an increase in prescriber error rate, but I was a little surprised to see how big the effect was. I am presenting the results in a poster at the AMIA Annual Symposium in November, and could share the specifics after that.
- Chloesbrother
  
  This is just one study that I have handy at the moment. I’m sure that azmd has more.
  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC353014/
Merv

“Doing our jobs well requires time and also the ability to concentrate on clinical issues. The extra work and constant interruptions imposed by poorly designed EMR/CPOE systems, and by the need to do extra clerical work that used to be done by unit clerks and nurses, has unquestionably affected the quality of care we offer our patients.”

This also applies to nursing. All of our charting has to be done with these poorly designed systems, so how do you expect us to take on your extra clerical work above all that we are required to do? And provide “Excellent Care” 24/7?

Chiked

More reasons to unionize…..just saying.

Captain Lurk

You seem disruptive, physician.

Chloesbrother

Keep it up. We need many more disruptive doctors, and many less docile lambs to the slaughter. Good for you!

Chloesbrother

have you read the literature showing that CPOE is NOT safer than handwritten orders? That mistakes caused by computer entry are more common, more harmful, and harder to prevent than the isolated indecipherable doc written order? I also have to smile at you comment “saves me time, improves the quality of my note which provides for better CODING ACCURACY. Enough said. Oh, and PS, talk to any malpractice atty. EHR does NOT provide for a better defense.It makes you even a bigger target. So many pages of useless crap, so many ways to trip you up.

LesCarter

Many excellent comments already.
Having used CPOE for 5 years, I’m not convinced it’s faster. And every day or two I need to order something that I seldom order that takes several minutes to figure out. Then I enter several orders at once and forget to start this new daily drug today, so no dose is given for 18 hours. Then I must choose the reason for a prn laxative from a drop-down menu that includes items like asthma, pain, headache.
In the hospital, EMR serves those that require them (the Feds) and those that pay for them. They collect data and divert liability.

Hopefool

You have ward clerks!
Where I last worked the junior resident had the honour of being a sort of form-delivery person.

W. X. Wall

At my hospital, we don’t any longer. Since physicians now do the task of entering orders that ward clerks used to, they fired most of them. Now the “charge” nurse gets to also be the ward clerk, while still taking care of her quota of patients.

joseph badolato

This type of article is why I go nuts when I hear, “we need to get everyone to practice to the full extent of their license.” Really? Funny, I don’t remember anywhere in my training or in taking the Hippocratic Oath where it says anything about me being adequately licensed to perform hour upon hour of clerical work. It seems that the only member of the care “team” NOT practicing to the limit of their licenses are the docs.

JustADoc

Upvote x 1000 if I could.
The comment that the docs are the only ones not being paid by the hospital and therefore our time is free to them is also +1×1000.
- PW
  
  It’s a huge waste of resources. My wife is a radiologist. Because of the lousy dictation system, she spends valuable time correcting reports when she could be reading more studies. On top of this her group is graded on TAT (turn around time).
David Reinertson

Not only is it a terrible waste of your expertise and judgement, it means you are getting only half the hands-on experience with patients.
In ten years, you’ll be twice as “tech-savvy”, but your clinical education will be ten years older in your memory.
You guys need a better union.

logicaldoc

“I swear, I expect to someday say “start CPR” and be asked, “Did you put it in the computer yet?”” LOVE IT !!!
Spot on! I run into this everyday and feel the same way. For some reason (liability and lawyers; along with Corporate stooges of course), things can no longer be communicated verbally to get done; they have to be in the computer. It’s paralleling exactly what Society is doing: children and adolescents no longer have communication and coping skills; but hand them a Smartphone, and they can communicate with anyone (including finally their Parents).

KM

As a nurse, not once have I refused a verbal order for a critical patient…or really a verbal order in any circumstance. In fact, the majority of the time the nurses are the ones notifying the physician of the critical patient. There is a gross over exaggeration here. The only reason I ask the doctor if he or she has entered an order is to know whether I should do it. To accurately document care given to a patient, whether it be medication or some other intervention, there first has to be an order.
- David Reinertson
  
  Have you ever had to document on a paper towel, then crowbar it into the EMR after your shift? Painful.
- logicaldoc
  
  I believe you missed the point of the obviously sarcastic but somewhat truthful statement of mine; along with the point of the article. The article is not just about “critical” patients.

Chloesbrother

I’m serious when I say kudos to you for figuring out a way to actually save time rather than waste it while using EHR. I just don’t think that is the case with most of us, as evidenced in this blog. And as for minimizing malpractice? I guess there are lots of opinions out there, but here are just two examples from the legal literature. Oh, and none of the authors are associated with corporate or academic med, health plans or government agencies. I don’t know, this just makes my skeptical, cynical mind more accepting of its truth.

http://www.thelegalintelligencer.com/id=1202720405290/The-Malpractice-Risk-of-Electronic-Health-Records?slreturn=20150706160502

http://www.jetlaw.org/wp-content/uploads/2011/05/Carter-FINAL.pdf

David Reinertson

Would we the achieve the safety of EMRs while allowing old-fashioned surgical technique if there was a voice interface?

“Hello EMR. Choose Surgical. Enter username John Smith. Enter password “E4.**tnfR”. Caps lock off. Enter password “E4.**tnfR”. Enter account #298347. Confirm account #298347. Open CPOE window. Go to blood screen. Choose order. Choose now. Choose PRBC. Choose volume order. Choose defined rate. Choose ml/hour rate. CHOOSE, MILLILITERS, PER, HOUR, RATE. Set volume to 20 ml/kg. Set rate to 999ml/hour. Set initial BP to 75/25. Set initial HR to 115. Set initial T to 35.9 C. Override BPA warning. Reason for override: “Not appropriate.” Choose “Start”. Choose “Submit.”

Seriously, if the EMR is only used after a visit to personalize a pre-recorded template, perhaps it would be quicker than having a file cabinet with pre-printed forms. That is a special case, however.

azmd

I don’t see anyone here, including myself, arguing that medical errors should not be reduced. So that’s really not the debate, and I hope it was not your intention to suggest that those of us who are a little skeptical of the benefits of CPOE are anti-patient safety, as that seems like a somewhat ad hominem arguement. In terms of my personal thoughts on reducing errors, it’s my opinion that giving clinicians more time to spend with their patients would greatly reduce medical errors and improve patient satisfaction. EHR, which is the solution that has been forced on our industry (by powerful corporate interests who could afford to aggressively lobby our lawmakers, by the way), has decreased patient satisfaction while not clearly improving patient safety, and in many cases appears to be used to task physicians (who are not paid by the hour) with clerical and administrative chores that used to be done by paid workers and now consume a lot more of our time and energy than is compatible with providing thoughtful care.
The studies showing most positive results for EHRs, by the way, were the studies done on “homegrown” EHR systems, that is, systems which were developed within an institution by and for its own clinicians. The commercial EHR systems in widespread use today have had significantly less impressive results, when studied.

KM

azmd, what is your opinion on what the solution is? You seem out of everyone on this thread to be the most well versed in research. You have made your point time and again that poorly designed EHR’s are detrimental to the quality of care physicians are able to provide. Do you have any solutions to offer?…There is not going to be a magical revolution that occurs where a physician user friendly system is developed and universally adopted…there is too much big money and politics preventing logic. But reverting to written or typed orders and trusting that overworked nurses or non-medically educated secretaries can always interpret and enter orders is moving backwards and adopting a known risk of error.
While we wait for the powers that be to create and adopt a more user friendly, intuitive, and acurate software for EMR’s, I truly belive the temporary solution lies in education and training. Physicians need to be properly trained (and receptive to that training) on the most effecient use of the system at hand. Nurses have adopted into their practice the technology knowledge and tasks surrounding the EMR. Ask any nurse if she/he thinks scanning medications saves them time or truly prevents a significant amount of medication errors? You will probably get an eye roll in response. Like one commenter here pointed out, 4 shifts of nurses made a med error.
Good nurses focus on patient’s needs first and managing bureaucratic and “CYA” tasks second. But somehow we manage to juggle both and often seamlessly. I think it is a bit of a cop out to blame the computer or software for a physician’s lack of thoughtful care.
I really am hoping to hear your response, azmd, as to what your proposed solution is to this order entry conundrum.
- azmd
  
  Sorry, but I have no interest in being drawn into a physician-nurse exchange of hostilities. If you reread my posts, you will see that I entered this discussion in response to another physician’s statements about medical errors and CPOE. I have made no comments about nurses entering orders, nor do I plan to. My post immediately above this one will give you insight into what I think some potential solutions would be, if you are genuinely interested.

Chiked

So let’s solve the problem by implementing a $29 BILLION program that still cannot guarantee that if I happen to be on vacation somewhere, the local hospital will have access to my medical records. I thought that was the whole point.

David Reinertson

That was exactly the problem Al Gore saw when he was in the Senate. He’s not a programmer, but a politician. He knew that the little email and social networks of the time were making more money from incompatibility than they would from compatibility. The Internet was a government standard, tasked with compatibility first and foremost, since they had to connect widely disparate military and research networks with a minimum of burden for the services and labs. By legalizing, subsidizing, and promoting the TCP/IP protocols, the US government increased the growth rate of connectivity from single- to triple-digits.

We could have an interoperable healthcare system in one day, where you would just type in your Social Security number and password from anywhere, and get all your records. Call Google, Yahoo, and Microsoft, and have them compete. Offer them the ad revenue.

Well, maybe a month. Someone would have to scan and upload all the paper records. Everyone would have to upload your medical records in some standard format, like Ascii, pdf, jpeg, mpeg, etc. Anything entered into an EMR would be unreadable at first. The printouts are hopeless. That could be fixed, but imperfectly, by translators.
Insurance companies and auditors would have trouble figuring out if your treatment fit into one of their covered categories. They’d have to actually read the doctor’s typing. You’d have to compromise somewhat on security and secrecy. But then, you don’t have security or secrecy now. The insurance industry has full access, and wants to deny you coverage if you come down with a pre-existing condition.

Chloesbrother

No, Linda. That’s not what I mean. If you have a chance read the articles linked above. Not what I mean at all.

guest

I don’t believe I actually said anything about nurses entering orders. Maybe go out for a long walk to work off some of that hostility? It’s not good for your cardiac health.

azmd

Hopefool

If only it were a standardised tool that helped in doing the actual job instead of being a carelessly designed instrument that only comes in the way.
A physician will be happy ti enter their own orders. The author’s point is that the software makes the job more difficult and could stand to be improved.
“Delegation” is seen as a hallmark of a good “teamleader”…why cannot a clerical task be delegated?
People often get confused between cognitive work and the act of entering an order generated by doing that cognitive work into an EMR. Trust me, doctors actually do a lot of work in a very unstructured and unpredictable environment, even if they do not appear to be typing all the time.

Joe

Because The Man said so.

W. X. Wall

#3) Which is why I said I’d even support the system automatically sending a text message to the doc with the alert so he can decide while sparing the secretary or nurse the task of making a phone call. I’m genuinely curious: if you’re a nurse or have studied nurse workflows, have CPOEs increased or decreased the number of calls nurses need to make to clarify orders? On the receiving end, I can tell you in my experience it has increased the number of calls I receive.

#2) That’s why I’m all for automating the rest of the order process. Even if both the doctor and the nurse miss the allergy, there can and should be a computer system that does that allergy check before dispensing the medication. FWIW, even with an EMR, a physician can override an allergy alert (especially when it’s buried among 10 useless alerts), and a nurse can override the pyxis. So that error mechanism doesn’t go away just because you force a physician to click through ten menus.

My assertion is that perhaps current computer entry systems are not the best way to accurately capture the initial order a physician wishes to make. Quite frankly, I’d go even further and state that it enables new mistakes (e-iatrogenesis) that we are only starting to analyze now, so on balance, IMHO, we don’t yet know if it’s even safer (although we do know it’s more time consuming for most physicians). But I’m not against automating the rest of the process.

This may sound like I’m letting doctors be lazy while forcing everyone else to work more to deal with our mistakes. It’s not. I liken it to producing a car: The initial designs are usually often still done on paper with clay models. Then the engineers get involved and it gets translated on CAD software to a bunch of rigorous design specifications, complete with automated testing modules, etc. Then the production supervisors get involved and turn the final CAD specs into the automated instructions the CNC machine uses to cut the final part. Each step is done with the best tools to enable that process, and even now, the best tools for designing may be pen and paper. Do pen and paper enable the sophisticated stress-testing, etc. that CAD does? Or the path conflicts that CNC machining software will point out? No, which means if something fails testing at those phases, it gets re-designed. But if you force a designer to use CNC machining software to design the car, do you think you’re going to get the best design? No.

And that’s what’s happened with physician orders. I can say anecdotally, based on my experience (and I’m not a tech luddite) and that of many of my peers. After clicking through 10 screens of post-op orders that go against the way we learned to think about orders, most physicians are actually not sure exactly what they’ve ordered. And if you ask them to write down on a sheet of paper everything they think they’ve ordered, it will be vastly different.

When your mind is focused on getting through the clicks on some huge order sheet designed by a committee of nonclinicians who are deciding what ‘best practice’ is, and dealing with nonsense alerts, then I guarantee your mind is *not* on what are the best orders for this patient. IMHO, this is a classic case of choosing precision over accuracy. You might as well ask a car designer to design a car body using CNC machine code. I don’t know if it’ll look good or pass aerodynamics, but at least the CNC operator will cut the exact parts the designer wanted!

Captain Lurk

Well, that escalated quickly.

azmd

Lots of angry nurses here!
- Teresa Brown
  
  Who’s angry? I’m not angry. Unlike a few people here, I can state my POV without being snide or condescending.

Captain Lurk

Actually if they’re not legible they provide no defense. But thanks for playing.

W. X. Wall

That’s because most of these “opportunities to weigh in” don’t lead to actual change. They’re pro forma sessions designed to get “physician buy-in” on decisions already made. And physicians correctly perceive this as a waste of time. Give them a chance to actually press for changes they want (rather than serve as rubberstamps for decisions already made), and you’ll find no end of physician engagement.

Not sure what your position in the hospital is (physician, other clinician, administrator (congrats for braving kevinmd if you are :-), etc.) but at the hospitals I work at, not a single one even had a simple survey asking us physicians which EMR we prefer before deciding on theirs. So much for “opportunities to weigh in”. Most physicians in private practice work at multiple hospitals, which means most have seen other EMRs. Why not just a simple survey at the doctor’s cafeteria asking “1) Which EMRs are you familiar with [might lower training costs] 2) Rate the following 5 options if you’ve used any of them”. That’s it.

Of course, once the decision has been made, there are tons of “opportunities to weigh in” complete with “physician champions”, and go-live consultants, etc. etc. Sure, once the fundamental decision has been made, we can comment on the periphery. Such power!

Captain Lurk

Unfortunately necessary career survival advice: Pretend you are in the army. “Keep your head down.” “Never volunteer.” “Don’t attract attention.” And get out when you can, cause I don’t see you changing anything from the inside. “All in all, you’re just another brick in the wall.”

buzzkillerlmsmith

If you find yourself in a hopeless situation, might as well give up hope. Dealing with Reality 101.

W. X. Wall

Actually, he’s not the only one saying that. The entire fields of human factors engineering, user interface design, etc. etc., is based on the foundational principle that if a user makes a mistake using a system, redesign the system, because you can’t redesign the user!

If you’re actually interested, you should read the bible of user design, called The Design of Everyday Things, by Donald Norman. He was hired at Apple because of his reputation. And it’s surprisingly readable. For example, Norman actually states that he has problems using doors, and that if he walks into a door, it’s the door designer’s fault, not his (as the user).

In a nutshell: a door is supposed to communicate three things to a user:
1) It’s a door (not a wall or a window)
2) You have to push or pull it (discard door knobs or locks for now)
3) Where you have to push or pull it (left side, ride side?)

If you can’t communicate those three things to a user, and therefore he walks into a door, or pulls when he should push, or pushes on the wrong side, then you as a designer are at fault. Not the user, since he actually wants to use the door in the right way. And he uses doors precisely because most people feel stupid, or are laughed at when they can’t use a door, and his point is that *even* in this situation, where the user usually blames himself, it’s the designer’s fault.

So yes. No doctor wants to write orders on the wrong patient. If an EMR (or paper system, for that matter) enables a doctor to do it, then the system is poorly designed. Blaming the user will never improve the system.

It’s an incredibly insightful book that leaves you convinced that at best EMR designers never read the book, or at worst, read it and decided to do the exact opposite deliberately.

Hopefool

It is easier to “take ownership” for being thorough about tools that help you do your actual job. Like surgical instruments for a surgeon. Or pharmacotherapy reference softwares for physicians. Why a physician, or nurse, for that matter, “take ownership” for learning how to use poorly built softwares that just dump billing work upon them under the guise of electronic reduction of human error?
We all do what we have to do. If losing our minds while using an EMR is what it takes to treat a patient, physicians will do it. But one cannot help feeling overqualified and underutilised typing up stuff for ten minutes we wrote in three, when we could be seeing another patient. Yes we could use help for the clicking.

Cait

When I was in residency I pointed out dangerous flaws in emr . I went to a few meetings regarding fixing it . Truth was it wasn’t really fixable so again each time I brought up that things would be better if we did x, y,z I for slightly labeled as a pain.
I’ve worked at places that have a lot of computer support and some that don’t and it makes a difference. If it’s not gojng to change best to be quiet and look to go somewhere else later

David Reinertson

Great response.
As you point out, EMRs are mandates, and we can not stop them. Not doctors, nor nurses, nor patients. You, as a nurse, take full responsibility for getting orders. If you think the doctor has time, you are responsible for making the correct doctor write the order. If they can’t, you are responsible for for doing the right thing without a written order, in a probable violation of your hospital policy. You help people like the author above when the delay and complexity of the mandatory EMR threaten imminent harm to the patient. Once the doctor orders the care, you take responsibility for making sure the order is correct. You make sure, using phone or personal contact, that the doctor has the information you think he needs, since he is on the computer, and not with the patient. The EMR programmer does not have any responsibility for communicating what’s important to the doctor, (when, for example, a patient with symptoms of Ebola comes in after a trip to an Ebola zone).
You and the doctor are a team.

SJ

Where I work (in Canada) it is out of nursing scope of practice to enter a doctor’s verbal orders in the computer. Nurses do it all the time, but are not covered for doing so.

David Reinertson

The current EMR is intended to replace calling the doctor. The doctor in on the computer, not with the patient or nurse.

If they used a Wikipedia or Google or blog or even a comment stream like this one, they could have added your correction immediately. If they used paper charts, any nurse could have called the doctor, and put a post-it note on the incorrect page of the chart.

There’s lots of room for improvement. I agree.

David Reinertson

Assume that doctors are now spending 1/2 of their time on the computer. That’s conservative.

You’re suggesting some kind of after-hours training or practice which would be more effective than the time they now spend actually using the EMR. How much time would it take for them to increase their click-speed or order-search speed to speed up their EMR by 10%. A semester? Five years? Is there any data on this?

azmd

Nobody has studied that, although it’s an interesting and valid question. Here’s why: these systems are developed by engineers, working for corporate executives, who are selling a product to non-clinical administrators. These administrators enjoy a captive workforce of highly educated professionals who are apparently too stupid to unionize and are amenable to suggestions that they have to expand their workday into the evening in order to get training on an inefficient EMR with a poorly constructed user interface. What is the motivation for anyone, other than the physicians, to study the data? The system is working great for everyone except us.

We need more people studying these sorts of things so we can actually have data to back up our complaints.
- David Reinertson
  
  If the computer requires you to log in, and logs you out automatically after a short idle period, there’s probably an actual “log” file somewhere. It would be pretty easy to total up the logout-login intervals and see accurately what percentage of time doctors are “on the computer”.
  Without such access, someone would have to look once per hour over a few days and add up the number of times they saw the physician on the computer versus interacting with patients, nurses, or other doctors.
  - guest
    
    Oh, I think that’s already been studied, and we know that in fact docs (and nurses) are spending a huge amount of time on the computer and limited time interacting directly with patients. What would be a little harder to do would be to set up a study where you provided some sort of organized training to one group of clinicians and then studied their EMR efficiency to see if it improved. All of that sort of begs the question of why we are introducing EMR systems with poorly designed user interfaces, then suggesting that the solution is for physicians to spend their personal time on training so that they can use the system as optimally as it is possible to do.
    
    We like to compare the healthcare industry with the airline industry when matters of patient safety are being discussed. I think it’s interesting to note that pilots are unionized workers and their union has been successful in insisting on such things as paid time for training to enhance skills and safety, as well as the “sterile cockpit” which means that the pilot cannot be interrupted while engaged in such critical maneuvers as takeoff and landing.
    
    I think we could take a page from the airline industry’s book, but only if we take the whole page, including the part of the page where the actual workers responsible for patient safety are provided with the tools they need to do their work safely. Naturally, healthcare “thought leaders” don’t appear to be too intrigued by that part of that page…

David Reinertson

Good point.
However, it is much more efficient for someone to write an order with a pen or by typing. The reason is that we all have 5,000 to 100,000 words in our head, and can choose the best one pretty instantly, in cases like this.
A drop-down menu is seldom quicker than typing or writing or talking, If you had to include every possible item, the drop-down menu would take forever to navigate. If you limit the items to what you think the doctor wants to say, you’re bound to be wrong sometimes, even most of the time. If you want to force the doctor to choose one of your items for reasons of your own, like money or standardization or your own global judgement, then you’re not just programming a record system, you’re micromanaging doctors without an MD of your own.
We may not care about efficiency for the doctor. But we all want the healthcare system as a whole to be good. We can’t completely separate efficiency from quality.

David Reinertson

Changing the items in a menu might take only a few hours of the doctor’s time, assuming the hospital has good and expensive IT and a good relationship with the management of the EMR company.
Meetings, explaining things to people from the computer company, making sure no one objects, etc.
There’s not guarantee the doctor will win, however.
By the way, this is one of the big obstacles to interoperability. It’s easy to send a text prescription to anyone in the English-speaking world. Trying to capture the underlying intention of a doctor filling out a database input screen, learned by trial-and-error, requires special knowledge.

David Reinertson

However, not only are you forbidden to take verbal orders, you are also required to take verbal orders.
You have to save the patient, regardless of whether the computer is slow or broken.
Managers must have fits trying to reconcile those two mandates in a coherent policy. Calling everything a “telephone order” when it’s not is a great solution. JACHO probably won’t catch on for a while.

David Reinertson

True. However, the time you take to chart reduces the time you spend actually doing the things you’re charting. When is charting not worth it?
If charting 10% of the time improves communication with the following shifts and other professionals by 50%, I would say it’s worth it.
But if charting 50% of your shift doesn’t incrementally improve communication at all, I would say it’s not worth it.
Assuming you were doing something useful with the 40% you lost.

azmd

I would like to echo the very astute response that W. X. Wall has made to your suggestion. As a bright, engaged physician with an interest in quality improvement, systems thinking and healthcare policy, I re-entered the medical workforce in 2008 with a lot of interest in participating in medical governance. What I very quickly realized is that few administrators are interested in what physicians have to say about how things could be improved. Administrators tend to come from a corporate perspective where “efficiency” and expediency are valued. Neither of these attributes lend themselves to thoughtful analysis of systems issues. Money is also a driving force, and quite frankly, one which looms larger to administrators than does patient safety. Physicians in most cases are invited to join these committees and “teams” in order to provide a medical gloss on administrative decisions. On several occasions during EMR training meetings I have made suggestions for improvements. The response: “But a PROGRAMMER would have to do that.” Oh, right. So let’s just stick with something that’s inefficient for the physician and potentially dangerous for the patient…

The bottom line is that physicians who persist in pointing out opportunities for improvement and making suggestions for optimizing processes are very quickly labeled “negative” or “disruptive.” You just learn to keep your mouth shut.

azmd

Finally, a thoughtful and balanced comment from the nursing side of this debate.

David Reinertson

Dear Doctor: In the first place, you can write very legibly if you take the time.
Secondly, I’d much rather have a doctor spend 60 full seconds writing the order with a pen, even if there’s a potential for misspelling “sodium dioctyl sulfosuccinate”, and spend the other 14 minutes talking to the patient about what to expect, and what to watch out for, after discharge.

David Reinertson

Nowadays, the Lab isn’t going to suggest an expensive addition when it sees an order for a CBC. I think it would be OK if a lab tech added the differential in cases where she thought it was appropriate, but they can agree on a local definition of CBC that doesn’t require further elucidation.

logicaldoc

I believe you missed the point of the obviously sarcastic but somewhat truthful statement of mine; along with the point of the article.

WarmSocks

Has your physician group considered hiring scribes? My niece is an ER scribe and loves it. She’s getting some very good experience in what the practice of medicine is like. What would be more important from your perspective is that it helps the doctors tremendously. The scribe, rather than the doctor, does the bulk of the data entry.

guest

“Make good templates and good order sets and get entering.” Interesting suggestion, not very respectfully phrased, by the way. Do you actually have any experience at all with what is required to construct a template or an order set? It sounds like maybe you don’t. Let me tell you my personal experience with making ONE order set, about two years ago.

Our CPOE didn’t have an order set for opioid withdrawal, sort of a critical one to have in my specialty. I naively volunteered to create one. How hard could it be? It was actually more time-consuming than I had expected to construct the actual orders, but I got it done. The order set itself then took ONE YEAR to pass through the various nursing, administrative, pharmacy, EPIC build team etc, etc, committees that apparently needed to sign off on it. I lost track of how many meetings I had to sit in to discuss the very minutest aspects of the order set, and how many emails I received and had to respond to with stupid suggestions from non-clinical administrators for “improvements.” At one point I had to EMAIL the UCLA professor who created the opiate withdrawal scoring algorithm (which is in the public domain) to get his written “permission” to use the COWS in our order set.

The number of moronic hoops I had to jump through was staggering. Meanwhile, there was no sense of urgency from any of the administrators on moving the order set through the approval process, so they drove the schedule at a leisurely pace, while on the clinical side, I was blamed for the order set not yet being available since I was the one who was publiclly identified as being responsible for it. All of this on my own time as I have a full clinical schedule without protected time for administrative work. On a slightly more positive note, the experience gave me valuable insight into why our healthcare system is such a mess: a big part of it is because administrators have little to no accountability for the work they do being done in an organized, timely or accurate fashion. They don’t have to, because we physicians are the face of the enterprise and we are unhealthily willing to accept responsibility for all sorts of things that we really shouldn’t be responsible for.

All of this for just ONE order set that should have been high-priority for our department. So, when someone working as a HUC suggests that we “just make order sets,” that’s a suggestion coming from a position of ignorance, sorry to say.

guest

I am not so sure that I think a system where the doctor give verbal orders for an entire set of orders on a routine basis is a good thing. And certainly, although CPOE systems are inefficient, it’s important for us to have some degree of proficiency with using them Also, it’s true that a high rate of verbal orders to nursing is a red flag to regulators. Having said all that, I do think that some of this anti-verbal-order rhetoric has gone a little too far.

In my hospital system, we have apparently arrived at a point where because of the cult of “the doctor must enter the orders herself,” it is seen as completely acceptable for: a nurse to call me when I am off duty, in my car on the freeway, to request an order for Colace on a patient, then act frustrated when I respond that I happen not to have computer access at the moment, but am happy to give a telephone order. Or for a nurse to page me when I am in the middle of an emergency with another patient to inform me that the original admission orders for an EKG on a patient have not been carried out by nursing for 48 hours and so the order has expired and they need me to enter a new one. The latest iteration of this outlook in my facility is the night-shift “chart-check” where the night nurse doesn’t have a lot to do and has been assigned the task of going through charts and leaving notes for doctors asking us to remove orders that nursing hasn’t carried out yet, apparently so the chart with look prettier. Really?????

As with anything in medicine, doctors and nurses are on the same team as we care for patients as best we can. We need to be respectful about the fact that we have the ability to enter orders on patients and nurses have their own clinical tasks that they need to complete. On the other hand, nurses and other medical workers need to be sensitive to their tendency to start to see the physician as some sort of order-entering automaton who should be available at all times to immediately enter orders for whatever comes up.

guest

Here’s why you should care about making the doctor’s work day more efficient: your 15 minutes costs the hospital a certain amount in salary. Where do you think that money comes from? It comes from the money that the doctor makes by billing the INSURANCE COMPANY for his services. His work is earning revenue which goes straight to the hospital and is used for paying the hospital’s expenses, including his salary and yours.

To the extent that you assist the physician to work more efficiently, the hospital will make more money and can be more generous with your salary, benefits, etc. If he can see two patients in the same 30 minute time slot and bill for those services, because you helped him with some of his tasks, that benefits you. If he can only care for one patient in that 30 minutes because you and others no longer see a function of your job as being there to support his work, he is generating half the revenue that he could, and there will be a trickle-down effect to you and your peers when the hospital is financially strapped.

Just something to think about…

leslie fay

Let me first say that I completely agree that all entries in the EMR are seriously more difficult than necessary and whoever designs EMRs have never practiced medicine in any capacity. That being said as a retired RT I think that the physician order entry speeds up/streamlines the whole process of patient care, and after all that should be everyone’s goal. Physician penmanship has certainly contributed to more than a few errors. When three or four RNs and RTs plus a unit coordinator have to take 5-10 minutes to not only debate what the order appears to be but who the ordering physician could possibly be(since now you have to stop, call him and wait for his reply) because his signature is pretty much one scribble it’s not very efficient. Remember, the patient is waiting. And anyone who is looking for a chart after 5am can attest that 90% are in a huge stack in front of the unit coordinator where it can remain for hours while she’s trying to keep up. Then it goes to the huge stack in front of the charge nurse for double checking. I could go on… Finally, everyone has a license to protect and both hospital administrators and physicians will throw those of us at the bottom of the heap under the bus in a heartbeat if we make an error.

Hopefool

If you actually knew what doctors did probably that silly statement about doctors being comfy in bed at night would not have made it to this forum.
Good physicians respect nurses and the job they do. Good nurses respect physicians and the job they do.
Due to some unknown(to me) reason, ward systems have been abolished. Physicians have to run from floor to floor to finish their rounds. So while some professionals have the “luxury” of having all their patients on the same floor, and the facility of having the same team to work with everyday, some others do not.
So since out of sight is out of mind, some nurses may believe that just because the attending physician is not visible,s/he MUST be asleep. That doctor may actually be in the ER, or handing over a floor patient to ICU, or performing surgery, or down in the labs to get a headstart on results before they are online, or looking at another patient elsewhere, answering another page from some other floor, breaking bad news to some patients, teaching residents, doing research,looking at out-patients or also getting told off for not clicking a microscopic box on an EMR.

RenegadeRN

Buzz, we are ALL doing too much computer work- versus the patient care we are trained for and the reason we ALL went into healthcare! Glad I have left hospital care.

buzzkillerlmsmith

Thanks.

Teresa Brown

No, but it’s not in my scope of practice to order labs/procedures that haven’t been signed off on by the physician.

And since my hospital’s policy forbade verbal orders except in emergency situations, it wasn’t my responsibility to write verbal orders.

buzzkillerlmsmith

As I said.
- Teresa Brown
  
  If you can’t be bothered to enter your orders, why not hire a scribe to tag along with you and do it for you? If you want a personal assistant, hire one; nurses aren’t your personal secretaries.
  
  You don’t want to actually discuss this, do you? You just want to be antagonistic.
  - buzzkillerlmsmith
    
    I see a discussion of this with you as pointless. My comments are more directed to others here.
    - Teresa Brown
      
      You haven’t even tried to have a discussion, unless you consider sarcastic one-liners “discussion.” David Reinertson and I were able to converse about this, and while we don’t see eye to eye, at least we shared our POV in a civil manner.

T H

I did participate for the 1st 3 years: no one wanted to listen to the MD who made suggestions about making the MD’s job easier: they wanted to make the coding, data mining, and billing easier at the expense of everything else. They started having meetings without me.

JustADoc

Well the ward secretary does what she always did and puts the orders in. She knows the system better than I and she is, after all, a ward secretary.
So it gets done just like it always did.
Keep in mind that 2 years ago, no one at my hospital did CPOE. I didn’t notice a rash of missed/delayed orders before then. I have heard numerous(hundreds) of complaints about orders done via CPOE being done not as intended. And it takes much more of the physician’s time.
Ward secretary $12/hr
Hospitalist $100/hr.
Who should the hospital want to pay to do clerical work?(hint, the answer is in the question)
The person who does it hundred of times a day and is there.
Or the person who is supposed to be figuring out how to get the patient better and isn’t in front of the computer all day(or at least shouldn’t be)

JustADoc

Well, if I write ‘CBC’ it gets done then.
If I write ‘CBC in AM’ it gets done the next day
If I write ‘CBC QAMx3’ it happens the next 3 AMs.
And I just typed all of that faster than I could have ordered the first CBC in a CPOE system.

PaulC

Make ONLY the “providers” with bad handwriting do the CPOE.

PaulC

I’m in a specialty with a considerable national shortage, as the locums companies are always telling me. Because of the inefficiency of just about all EMRs, I will not any longer work for hospitals who do no provide a skilled scribe to interface between the thinking decision making and the time wastingly poor EMRs. Just so you know there’s a cost to your dismissive point of view. Further up the comments, a physician explains what happens when we try to “fight that battle”.

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