We have a new EMR system. I like it because I type well. I’m facile at using a keyboard and touch-screen. Not everyone in my group is so blessed, and we’ve had some difficulties using the voice-transcription software. Nevertheless, my gut tells me that in a month or two more, we’ll be getting along with our new system swimmingly. It’s the sort of thing I have wanted for a while, since I truly hate to dictate; and especially hated dictating the information the nurses had already entered into the computer!
However, I have an issue. Not so much with our EMR, but with all EMR. I have an issue with the deeply-held delusion that computerization will automatically improve charting and patient care.
Some time ago, the inimitable, world famous blogger Dr. Wes told me that his facility’s conversion to EMR caused him to spend far more time at the computer than with the patient. And true to his great wisdom and insight, that’s where I find myself. It isn’t the location of the computers. We have portable ‘tough-books’ that can go to the bedside.
The problem, as I see it, is the attempt to capture far too much data all around. You see, medicine is at a strange juncture, and I really don’t know what to do about it. How can I describe the problem… simple physics, perhaps?
We’re pulled in too many directions; there are too many vectors, so no motion results. We are rapidly approaching a place where we will be unable to do anything and inertia will rule.
Let me explain. See, in our new system, we chart ‘by click.’ Clicking in available fields charts the data the patient gives us. So, we have a section called ‘HPI” or History of Present Illness.’ The problem is, it is very much like the ROS or ‘Review of Systems,’ wherein a physician goes through multiple body systems to assess the patients symptoms and problems. (Not to be confused with the ROUS, for fans of The Princess Bride.)
So, in the history is onset of symptoms, timing of symptoms, then associated symptoms…which is much like the Review of Systems.
Next comes the actual ROS, which goes through ‘constitutional, neurological, respiratory, cardiac, musculoskeletal, OB/Gyn, Heme/Onc, ENT, Neck, Back, genitourinary, etc., asking layers of questions about symptoms and location in the process.
This is followed by the actual physical exam (one of those rare times when we can touch the humans entrusted to us). The physical exam contains much the same level of detail, and in fact it is easy to forget to chart the exam, if one has just done a thorough Review of Systems, since both sound the same.
Finally, we have the Medical Decision Making, Emergency Department Course and Disposition, where we discuss labs, X-rays, data reviewed, ECG’s, Pulse Oximetry, old records reviewed, consultants contacted, diagnosis, plan and all the rest. Sure, it may not sound like much, but if done right, all of this takes a significant amount of time: to talk to the patient and get data, to examine the patient, and most time intensive of all, to input it all to the computer.
Problem is, it’s an ER. Things move fast. No one has a scheduled appointment. Anything can come through the door at any time. Expectations by patients and frustrations among their families run high. No one cares about the complexity of ‘the cool new EMR system!’
But I’m not finished. Our nurses chart in the same kind of detail; and add screening exams for drug abuse, alcohol, immunizations, nutrition, personal safety, physician procedures, admissions reports, EMS reports, etc. They also do their own history and their own physical assessment! And of course, I have to reconcile the two and it is my responsibility to find and correct any inconsistencies; lawyers love inconsistencies.
Now, charting is done for purposes of patient care, so that we can be consistent in treatments and subsequent visits. It’s also done thoroughly for billing purposes. No good chart, no good reimbursement. But it’s also done for medico-legal reasons. That’s why our discharge instructions now rise to the level of ‘novella.’ being pages upon pages long. The medic0-legal aspect drives much of the detail for physicians and nurses, prompting us about safety, about allergies, about dosing, about indications for the tests we order.
And charting is done because, well, EMR companies like us to chart. It’s good for business! It sells computers and memory, software and consultants.
In the end, though, I move too slowly and spend far too much time charting unnecessary (but required) layers of information. I mean, oddities aside, an otitis media chart should take about ten lines on paper, and the discharge about ten more.
I know a handwritten chart is inferior. But I wonder if the patient feels that the time spent with them is inferior? If they get a scribbled chart and ten minutes, is it better than a pristine one and two minutes? After all, the day only has so many hours.
So, to return to physics, I feel myself pulled in separate directions. One way is the patient, the sickness, my ‘raison d’etre’ as a physician. The other is the billing direction; chart to get paid. The other is the medico-legal vector; chart to be safe. And the final is less clear; it’s ‘chart to chart, because the chart matters most.’ It’s an odd homage to our love of unnecessary information and data. Do I need this much detail? Not even for many of my sicker patients!
I wonder in the end if I’m a physician anymore, or just a data entry clerk? Do I serve the patient, or do I serve the computer, with it’s highlighted, required, red fields, waiting entry of information? Is it serving me, or am I serving it?
And when all is said and done, I doubt if physicians can move forward efficiently when they are daily pulled to a halt by conflicting activities and overwhelming data, most of which is only useful to a lawyer.
I feel a bad case of inertia coming on.
Edwin Leap is an emergency physician who blogs at edwinleap.com.
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