A colleague related a distressing meeting he had at the community hospital he works at. This hospital, like nearly every hospital in Cleveland, is owned by one of the two towering medical behemoths. I’m not a businessman, but I have learned that when something owns you, it’s generally better for the owner than the ownee. This meeting was about the hospital’s upcoming EMR policy. Sometimes, these hospital meetings are ostensibly to seek physician input, but the true purpose is to inform the medical staff about decisions that have already been made. In the coming months, this hospital will adopt a computerized ordering system for all patients. In theory, this would be a welcome advance. It would create a digital and permanent record of all physician orders that could be accessed by all medical personnel involved in the patients’ care. It would solve the perennial problem of inscrutable physician handwriting, including mine.
One advantage that computerized ordering aficionados claim is that physicians’ orders can now be standardized for various medical conditions, such as stroke, congestive heart failure and diabetes. Of course, patients are unique and may not neatly fit into packaged computerized ordering templates. Will deviating from these standard order sheets by easy, or will we need a 14-year old beside us to help us over the cyber hurdles? Most of us have been issuing medical orders on paper for decades, without loss of life or limb. When I write an order with a pen for a potassium supplement, for example, I have not found the task to be onerous. Will the computerized system be another example of solving problems that I didn’t know that I had?
One of the physicians at the hospital meeting asked if the verbal order policy would remain. The response suggested that verbal orders would no longer be permitted. The physicians wondered how they would give admitting or other orders at 2 a.m. Would they have to boot up a computer at that time? What if a nurse calls for an urgent blood transfusion order when the physician is in his car? Does this enlightened verbal order ‘reform’ sound like it originated from folks who understand doctors?
I have to hope that the speaker was misinformed, as this aspect of the policy is simply too dumb to survive, at least I hope so.
I am not a Luddite who opposes EMR on ideological grounds. I believe, and have written, that once perfected, it will accomplish its mission. My quarrel is with those who already claim that the goal line has been reached, or is in sight. I also believe that many of these systems were designed by folks who don’t practice medicine or understand physicians’ needs. What’s good for billers and coders may not help physicians in exam rooms with living, breathing patients.
I am sure that most physicians who are retiring now do not regret that they will miss the steep vertical climb from paper to electronic medical practice. Personally, I am glad to be part of it, although I wish that ‘point & click’ medicine was more about medicine than about pointing and clicking.
Perhaps, this approach can be extended to blogging. Right now, it takes me a while to pound out these posts. If I could use a packaged medical ranting blogging template instead, then I could post a Whistleblower twice daily. Point & click blogging. Hmm. I can see the goal line.
Michael,
ReplyDeleteI agree we're nowhere near the finish line. But as you point out, it's hard not to acknowledge the long-term value of electronic health records.
One serious problem in such development is when those funding or doing the development fail to recognize what is involved in (and cost requirements of) good user-interface design. Creating user personas, observing users actually at work, creating prototype interfaces and doing usability tests with actual user representatives---that is essential to any good system, but it's still often not recognized as the critical component of the development effort.
ReplyDeleteMy local hospitals have a two year window on fully implementing a paperless electronic medical record. They are talking about getting rid of medical record and unit secretary personnel. Part of the implementation will be physician order entry on patients within the next year and to discourage verbal orders. Nurses will be available for some verbal orders, but the med directors are discouraging verbal orders currently. No additional pay will come to the physicians who are entering their own orders but helping save the hospital the unit secretary and medical record personnel salaries. This also is going to take additional time away from the patient, although wireless stations are appearing throughout the hospitals. We will be spending more time typing than examining patients.
ReplyDeleteDoc,
ReplyDeleteYou've hit the nail on the head with these salient points:
1) I’m not a businessman, but I have learned that when something owns you, it’s generally better for the owner than the ownee.
(2) Patients are unique and may not neatly fit into packaged computerized ordering templates.
(3) Many of these systems were designed by folks who don’t practice medicine or understand physicians’ needs. What’s good for billers and coders may not help physicians in exam rooms with living, breathing patients.
Until these issues are resolved, both patients and doctors will be victimized at the hands of an industry that has come to regard profitability as the most important measure of success.
Melody
Just putting medical records into a computer doesn't accomplish much unless there is some reasonable system by which the records are organized. Before I retired, I worked as an attorney in the Social Security Administration and reviewed medical records connected to disability claims. Most medical records were in the notoriously illegible handwriting of doctors, each of whom seemed to have his own idiosyncratic method of abbreviating medical terms. An exception to the general rule were records from the Department of Veterans Affairs. They were legible. There were few abbreviations. However, they were also very unorganized. They were full of duplications and it was very hard to figure out what was happening when. If electronic medical record keeping is allowed to evolve on its own, it will probably be a good thing. On the other hand, if it happens the way the Department of Veterans Affairs did it, which seems to be "thou shalt keep all thy records on computer, and we don't care how you do it", then not much progress has been made.
ReplyDeleteI agree with you there, I think using EMR, "It would solve the perennial problem of inscrutable physician handwriting, including mine." Anyway, I enjoyed reading this informative post. Thanks for sharing.
ReplyDelete-krisha-
I've always thought that the VA system (CPRS) was the best online medical record system in existence. Its easy to use, does what you want, gives you access to anything, and allows access to any records from any VA anywhere in the world, at any time. Its a case study in a great EMR.
ReplyDeleteAs for templated orders -
Honestly I think these are very good. As Atul Gawande argued in "The Checklist Manifesto", checklists are very effective ways of improving care in a complex world. Templated orders for common issues are exactly that. They make sure that every important step is followed, while still leaving room for modifications when needed.
Ie, a template for a stroke admission guarantees that every patient gets an aspirin in the ED. I once audited that particular data point, and found that 30% of the patients with this complaint did not get aspirin, despite the strong data to show improved outcomes with this simple intervention.
Nick,always nice to hear from you. I guess this is 'not your father's VA Hospital!'
ReplyDeleteMany doctors often have undecipherable handwriting, which can lead the the one carrying out to mistakes. ;) However, some doctors may have a significant learning curve when these programs are first employed. Confusing for the most part, and one may not be alert to one's patients needs.
ReplyDeleteAs the saying goes by Max Frisch, technology..the knack of so arranging the world that we don't have to experience it.
Freelance MD
The EMR is the worst invention, cannot take care of my patients the way I used to or the way I should. Then when there is not enough staff ( EVERYDAY ) it is worse. It is not user friendly and if you are an older generation Nurse or Dr. who has to look at a keyboard to type hahaha worse even more less eye contact with your patient!!! When computers are down..or to even find one that works or how about one someone is not using!!!!!
ReplyDeleteYour Favorite Nurse I am SURE you know who!!!!
Love Ya
My favorite nurse? I have some idea, but a hint would be great.
ReplyDeleteStudies by RAND Health and other groups are noted to have recognized problems with the quality of health care in the United States together with gaps in the deliverance of preventive and chronic disease care. In order to address these inadequacies, primary care physician practices could possibly be encouraged to invest in various types of structural changes intended to promote improved quality and adopting the electronic health records.
ReplyDeleteMy main concern is for the security of the medical records. We have seen time and time again that no system is fool-proof, and I am concerned about such sensitive information being accessible.
ReplyDeleteHow about computer systems that drops orders? I have been accused, falsely, of drug diversion. I am a travel nurse and work in PACU. I was accused of drugs not given but taken out of the Pyxis and some amount wasted but not charted. Possibly given but never charted, highly unlikely in my case. I am a type A personality and I never gave a medication with out scanning it first because the the way that our orders and charting were done, it was very difficult to find out if there actually was an order or if it just was in an order set. To avoid giving something that was just in an order set, rather than actually ordered, I scanned it and if it was in the medication profile then it accepted the scan. Some where after these patients where discharged from the PACU, the order was lost into oblivion because I was told that in 5 or 6 patients had no order for the narcotic that I gave. I was told that I could have over ridden the rejected scan. Not true in my case because I had never been shown, nor did I know how to over ride a rejected order. Other accusations were, "you gave more of the drug than was ordered", not true, once you reached the limit of what that drug was ordered, it wouldn't let you scan it anymore. That order went into the discontinued section. Other accusations that fall in line with the "I couldn't have scanned it and given it if it wasn't there, or ordered". Every day this computer system had a temporary fail glitch/down. Constant hiccups in ability to chart. Calling doctors and telling they didn't put orders in the computer when they swore up and down they put orders in. They weren't there. After updates, issues with ability to initiate doctor's orders. One day after an update on the computer system, no PCA orders could be initiated by the PACU staff. If you tried to initiate the orders, there was some glitch or another. So NOW I face the BON because of this hospital's EMR or their actual computer system. Yes my urine drug screen was negative but I was accused of "giving or selling" these missing charted narcotics to someone in a town that I had never been to before and didn't know anyone! THANKS EMR!!!! Also, thanks to the largest hospital system in Tn. How do you fight a corporation on a nurses salary, or lack thereof because no one will hire me until this is settled by the BON.
ReplyDelete