Saturday, November 18, 2017

When Electronic Medical Records Crash

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era.   The paper medical chart I used during most of my career never ‘crashed’.  Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed.  Although I appear to the patients as a breathing and willing medical practitioner, I might as well be a storefront mannequin who appears lifelike, but cannot function.  We cannot access the patients’ records, write a prescription or enter a new office visit. 

Mannequins appear lifelife but don't function well.

Of course, like any business who faces this crisis, we expect instantaneous rescue from our IT professionals, as if we are their only client and they are permanently stationed in our waiting room just waiting for us to sound the alarm.

This is among one of the most frustrating aspects of EMR for medical professionals.   We simply don’t have the time or psychic reserve to absorb unexpected loss of computer service.  We are not playing computer games (although sometimes it feels as if we are.)  We have a live patient facing us as we face a blank screen.  It is frustrating and awkward.   The patients understand this reality as they undoubtedly have endured similar frustrations in their own lives.  

Yes, we resort to writing a note in longhand and scanning it into the EMR later, but this is problematic.  First, a scanned document cannot be ‘read’ by our EMR as this document is not ‘part of the EMR family’.  It can’t be tracked, as we do routinely with laboratory and x-ray data.  More importantly, I will be offering medical advice without any access to the prior medical record, which may span years.  If the patient has a complex, chronic condition with a history of extensive testing and medication changes, moving blindly could lead me into a blind alley or through a trap door.

I propose no solution to all of this.  No technological system can perform perfectly.  It’s another example of our ever increasing reliance and dependency on technology – more than we really need, in my view.  I have no choice but to accept EMR in my professional life.  But, there are opportunities when we can stand up and push technology back.

Do we really need Alexa to turn on our lights?


Unknown said...

Dr. Michael Kirsch has provided several ways in which electronic medical record software lowers physician efficiency. These technologies are designed to improve overall patient care by boosting efficiency and safety. Yet, many physicians are hugely dissatisfied with the software’s performance and I find it hugely ironic that some believe we would be better off with the original paper medical charts.
We thus need to critically examine the factors that have contributed to lower EMR efficiency. Dr. Kirsch mentions how software malfunctioning is a huge hindrance on worker productivity. We should also discuss the huge role of human error and its contribution to EMR inefficiency. Medical practitioners are making far too many avoidable mistakes with patient records. Since its implementation, there have been new forms of patient safety errors, such as ordering a medication dosage that is far too large. Additionally, doctors are more likely to miss crucial patient information because of the confusing software display. It is thus no coincidence that the error rate has skyrocketed since the emergence of these electronic technologies, becoming the third-leading cause of death in the United States. This begs the question of why providers should even expect to be satisfied with the software’s performance when we have not truly found an effective means of implementation.
There are a multitude of ways in which we can improve EMR efficiency. One option is the implementation of new technology that could detect and avoid human-related medical errors in practice. Additionally, perhaps voice recognition software could be designed and incorporated in the near future to reduce error associated with data entry. Although this would not help reduce software-associated glitches, the technology could ensure that information is uploaded to the correct patient file. In addition, perhaps the software could correct for improper measurement units, thereby ensuring for more accurate patient history documentation overall. This could also save time for the physician, which in turn would reduce time spent on administration work and enable them to see more patients throughout the day. Another mode unrelated to improving software design would be to hire scribes, who could improve data entry accuracy by catching physician errors. Some disadvantages of this option, however, are that a third person in the room might reduce overall patient comfort and there could also be difficulties acquiring enough money in the hospital budget to hire the scribes.
Interestingly, studies have actually shown that payouts for claims reduced when errors are divulged to patients and their families. More recent approaches have included Communication and Resolution Programs and the Disclosure, Apology & Offer (DA&O) approach, which is designed to disclose, investigate, and explain what happened. This system is set in place to prevent the recurrence of such an incident, where appropriate apologies offer fair financial compensation without the patient feeling like he or she needs to file for legal action. Additionally, error disclosure training could give providers the opportunity to practice talking about these mistakes. In general, these approaches could encourage transparency and honesty by protecting the rights of patients who have been negatively impacted by the increasing error rate associated with EMRs.

Unknown said...

Electronic medical records could also be improved by remodeling the structural efficiency of the provider system. In general, most cost and quality problems are related to lack of coordination among the divisions within the general health care delivery system. More integrated delivery systems that coordinate quality improvement programs could help to boost EMR efficiency. This might include improving communication and collaboration among physicians by implementing organizational learning into patient safety practices. There are three dimensions to this process, including creating a supportive learning environment that instills team-oriented learning processes and practices. Health officials should consider adopting collaborative models, integrating electronic records while simultaneously prioritizing communication across interdisciplinary teams. This might include huddles, team meetings, as well as routine communication through paper and electronic modes of information flow. We require structured communication so each member of the team functions at the top of his or her practice. This would create an enhanced learning environment that incorporates intra-professional team communication.
This team-oriented proposal highlights an important problem in which we desperately require more communication among clinicians, patients, consultants, and healthcare workers. If a team of physicians was working together on a day-to-day basis, I am confident that the error rate would be reduced dramatically. However, the broader issue here is the existing physician shortage. If we figure out a means of increasing collaborative practices, however, then there would be a dramatic drop in error rate.
Alternatively, perhaps we could allocate more funding towards committees or councils where there could be a platform to address these issues. Currently, providers tend to cover up their mistakes. If we can create more intentional spaces for conversations about improving patient safety, then perhaps people might be more willing to change their habits. The Massachusetts healthcare system has piloted a full DA&O program and while this is a good first step in increasing transparency and trust, we require perhaps a nation-wide program that can effectively reduce ligation, thereby cutting costs to the health care system through this model. We also need a more informed understanding of whether the error took place due to a user issue or a software issue.
Ultimately, we need to critically examine these technologies to brainstorm ways in which we can learn to use EMR software more efficiently. In general, we require more transparent interactions among doctors and patients regarding medical errors. The error rate has skyrocketed and the current malpractice system encourages providers to remain silent, covering up their mistakes. I find this to be hugely ironic. Human error in general is unavoidable and this system does not allow providers to learn from their mistakes. Instead, they are trained to cover up these errors; in turn, more and more mistakes are made and tensions among providers and patients continue to escalate.
By considering all of these factors, maybe provider systems can adopt new solutions so that the EMR interface is better for the general public. Perhaps these digital technologies actually hold more promise than we realize.

Michael Kirsch, M.D. said...

Many thanks to Laura for her thoughtful and comprehensive response, which I suggest politely, was also an opportunity for her to 'vent'. Yes, the current EMR universe, with many benefits, is a source of frustration for many of us. Realize that EMR was not designed primarily to assist physicians with respect to patient care. It was crafted to assist billers, coders and all others who mine our charts for documentation purposes. It is mind blogging that in our mature digital era, hospitals and physican practices use different or proprietary EMR services that do not easily communicate with each other. If I am seeing a patient in my office, shouldn't all of this individual's medical data be in front of me? How often are physicians unaware that their patients have had CAT scans, lab work or specialty consultations at other venues? Is this a 'physician error' or a system defect? I am uncertain if errors are the 3rd leading cause of death, as Laura asserts. I agree that the medical malpracticce system is dysfunctional and I refer readers to the Legal Quality category of this blog for add'l thoughts. I entirely agree that communication among all parties particpating in patient care is often less than ideal. Hiring a scribe is cost prohibitive, especially for a small private practice like mine.
I do believe many of these deficiences will be worked out as EMR advances, but it is frustrating that it has not happened yet. It will happen when the various EMR systems and others will have incentives for doing so.

Common Sense Medic said...

Dr. Kirsch,

I see your point about the frustration that EMR can cause and how *systems* that doctors build to "help" them with their work can actually harm their efficiency. I think it is truly a physician defect but that the coders who are actually building the software which you use are combating these problems. The aforementioned comment which mentioned voice recognition is a good example. AI, especially in the use of EMR, can be used to fix your problem. A natural language processor can actually take the words which you say into your phone and input them in the correct text fields, using an algorithm which is standardized across systems. It is a better way to get back to the patient and a good application of AI rather than the narrow scope which it is used for now, mainly drug delivery. I expand on this more in my blog post at

Add this