Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, November 02, 2009

The Emergency Department EMR from Hell

Despite the fact that I am almost always available to my patients day and night, day in and day out, weekends and holidays included, there are occasions when they go to the Emergency Department*. Sometimes they call me first. Once I have ascertained, for example, that what they have is an acute surgical abdomen (I have indeed diagnosed appendicitis over the phone more than once), then they don't need me. What they need is a hospital and a competent surgeon, and the most expeditious way for them to connect with those two things is through an Emergency Room**.

Still, there are several other appropriate circumstances when patients head to an ER without calling me first. In these instances, though, it is a generally accepted responsibility of said ER to somehow let me know that the patient was there. A phone call is way above and beyond for routine problems, although there are occasions when it's appreciated (like when a patient comes in dead. It happens.) Failing that, some kind of written notification, either faxed or mailed, serves the purpose nicely.

The first step in the notification process, of course, is the patient admitting letting the ER staff know that I am their doctor. If the patient doesn't give my name when they check in, all bets are off. Once I am on record as their primary physician, though, the ball is in the ER's court.

I've been on staff at two different hospitals; one during my first decade of practice, and the other for the second. Despite the fact that the first one now has an electronic medical record (EMR), nothing much has changed in the notification process: I get a fax of the face sheet of the chart. What that means is that I get the patient's name, the date and time he/she signed into the ER, and all the contact and insurance information that I couldn't care less about. If they are then admitted to the hospital, I get a second fax identical to the first in every way, except that a previously blank space labeled "Diagnosis" is now filled in. If they are discharged from the ER, I get nothing. No idea what happened, what the problem was, the diagnosis, any prescriptions given; nothing. On the other hand, I do have that original sheet, which I leave in the patient's chart. Then the next time I see them or talk to them I'm able to say, "I see you were in the ER on such-and-such a date; what happened?"

The second hospital is a different story. Back in the olden days, they used a paper system called T-sheets. Every possible complaint had its own sheet, each with dozens of tiny check-off boxes allowing the ER staff to document out their asses in minimal time. They loved it. When the family physicians on staff began demanding requesting that they let us know when our patients were seen in the ER, they responded by faxing us the entire ER chart. This invariably added up to a minimum of 17 pages, of which at least three and up to six were completely blank. (For real; they faxed blank divider pages.) Not only that, but the tiny little print was essentially illegible when transmitted by fax. Usually the only way I could tell what the hell the patient was actually there for was by looking at the pre-printed discharge instructions (that were of course also included in the fax). As has been stated elsewhere, the signal-to-noise ratio of the information in this format was unacceptably low.

Furthermore, there were still many occasions when we didn't even get the 17-page packet of gibberish. The standard answer from the ER docs, recognizing our legitimate complaint, was this:
"Call us."
Um, let me get this straight. If a patient of mine goes to the ER, I don't know about it, and I don't get a report, I should call you. Hmm. So the next time you don't hear a tree fall in the woods, run for cover.

Recently this hospital has spent millions of dollars building a brand-spanking new hospital wing, including a brand-spanking new ER. This brand-spanking new ER also contains a brand-spanking new EMR. Hurrah! Never again will reams of paper be wasted generating illegible notes. This brand-spanking new EMR has the capacity to print out a concise summary of the patient's ER visit, and -- will wonders never cease -- to automatically fax said concise summary directly to little old me. Of course it turns out that although this brand-spanking new EMR can do this, does not mean that it does.

Receiving notification from the ER had been an ongoing issue with this hospital even prior to their multi-million dollar construction project and the acquisition of their brand-spanking new EMR

I recently got a phone call from a patient telling me he had been in the ER three days earlier and was told to call me to schedule a follow-up appointment, which is why he was calling. Because I finally had a situation where I knew exactly when I actually had a patient go to the ER, I called to see what happened to the brand-spanking new report from their brand-spanking new EMR. I actually had a lovely conversation with a conscientious and helpful ER doc, who asked me when the last time was I had gotten an ER report on one of my patients from them.

Because the answer was, "Never," I instead asked, "How long have you had the new system?"

Answer: "Since May."

Okay, then; at least five months.

After some rooting around on the part of the conscientious, helpful ER doc, it turned out that the only way their brand-spanking new EMR system would send me a nifty new easy-to-read report was if all of the following things happened:
  • If I was in their system (I am)
  • If the system had my correct contact information (it does)
  • If the doctor clicked on my name from a pick list while he was writing the discharge instructions. Note: Not before (ie, the information wasn't carried over from the sign-in process when patients are asked who their doctors are); not during the visit (while the doctor was in the process of diagnosing and treating the patient), but SPECIFICALLY while the doctor was typing the discharge instructions.
Maybe that doesn't seem particularly onerous, but I think it's ridiculous. How many other things would I rather have an ER doc thinking about while discharging the patient, especially when MY F*CKING NAME AND OFFICE NUMBER ARE ALREADY IN THE GD CHART!!!

It turns out this brand-spanking new EMR has a few other little minor shortcomings:
  • It doesn't let the physician access the nurses notes
  • It doesn't let the physician access notes from triage
  • It doesn't let the physician access the past medical history, family and social history already gathered earlier.
Um, excuse me, but isn't a computer's major strength its ability to eliminate repetitive actions? Hell, any time I want to order something from a catalog, there's this nifty feature that lets me check off a box that says, "Billing address same as shipping?" instead of having to enter my address again. (Not only that, but once I've done it, there's this thing called auto-fill that allows me to just point and click.) I thought that's what computers were supposed to do best!

But no. Here we have this brand-spanking new EMR -- did I mention that it's one of the largest and most popular EMRs (almost certainly among the most expensive too) nationwide? -- that basically makes the doctor duplicate all the nurses' charting.

Can't they fix this little bug? Surely it can't be all that difficult from a technical point of view.

Actually, it's not. The problem is that because it's such a large, widely used EMR, they can't make changes for just one user. They have to change it for everyone.

So...Why not do that? While they're at it, what's with having to make sure I'm "in their system"? We have these really cool new things called NPIs. The letters stand for "National Provider Identifier". Last time I looked, that first word ("National") pretty much applied to the entire country. So why can't they just incorporate the national NPI database into the system. That way, any time one of my patients went to an ER anywhere in the country, there's an easy-peasy way to identify me as the person waiting with bated breath to read the ER report.

Sorry, came the answer from the conscientious, helpful ER doc. We can't do that right now. So I'll just keep trying to remember to click on your name when your patients come in. I'll also make sure the other docs try to remember to do it too.


* Happy now, Whitecoat?
** Sorry; old habits die hard.


At Mon Nov 02, 08:30:00 PM, Blogger Wade said...

Question from an EMR-IT type guy -- would it help if the system you can't change showed up in a window that you COULD at least put yellow highlighting, circles, arrows, yellow-sticky-notes, etc. on, so every time you go to that screen on the expensive-but-inflexible-system, your notes-to-yourself also popped up? That might be a place to put notes like "Ignore the manual, hit option C", or "we always use code 381.27 here", etc.

Maybe another optional panel would show such notes that many doctors agreed made sense to add at that point ,such as "Check for referring here" or whatever.

If the underlying system is incapable of learning, maybe an enveloping meta-system could have a role and learning curve.

It would seem to have a role as well when you learn some obscure, low-use part of the system and wonder "How the *&&*& am I EVER going to remember this bizarre twist here?", you could put a note to yourself, and whatever other PC you accessed it from, the note would pop up, for you.

At Tue Nov 03, 12:49:00 AM, Anonymous Anonymous said...

EPIC WTF: is this a clue?

At Tue Nov 03, 09:15:00 AM, Anonymous Anonymous said...

"So I'll just keep trying to remember to click on your name when your patients come in. I'll also make sure the other docs try to remember to do it too."

And isn't that EXACTLY what we want ER docs to be thinking about while they're making life and death decisions.

Medicine is often compared unfavorably to the airline industry in its failure to use checklists to avoid mistakes. Well, I'm pretty sure there's no checklist that requires a pilot during take-off to go into the cabin and ask who ordered the fruit plate.

But the forces that run modern medicine (including our professional societies) feel that there is no administrative task too trivial that it should not be allowed to interfere with the doctor's interaction with his patients. This trend is only exacerbated by making an EMR the focus of the physician's concentration.

Basic point: anything that reduces the time and mental energy a physician has to bring to direct, one-on-one patient contact is BAD.

At Tue Nov 03, 04:18:00 PM, Anonymous Anonymous said...

This is just another example why I am totally baffled by the belief that EMRs are going to save money/medicine/the world. The people actually involved in providing health care have, apparently, zero input into the development of these ridiculously kludgy pieces of software, and the software companies developing them have zero clue what clinicians' needs are. We are all about to be subjected to the PowerPoint version of medical recordkeeping, which will be a disaster.

At Tue Nov 03, 06:53:00 PM, Blogger Midwife with a Knife said...

Um.. we use epic at my current hospital and you can actually make changes (our IT dept does it all the time), and there are ways to send notes prior to doing the discharge instructions, and I can see any notes or any other info entered by any person taking care of the's actually a cool EMR system, I think. I like it.

Unless the hospital got some sort of cheesy Epic knock-off... maybe made in China with the lead that they can't put in childrens' toothpaste any more?

(word verification was reams... seems oddly appropriate in so many ways)

At Wed Nov 04, 09:20:00 AM, Anonymous Anonymous said...

Our company produces an EMR, and we hear this all the time from systems we replace, that you can't see the rest of the record from the physician documentation. We also take the primary physician across an interface during the stay, so we always (ALWAYS) get the record to the primary after discharge, or even (if they specify) during the visit!)

I love this article. Most of the systems we replace have been settled on by comittee on which the primary care physicians are represented. They force a system down into the ED in the name of integrating a record, and what they find too late is that good ED management means good ED service to the patients and the primary care physicians, and integrating with the hospital turns out not to be that hard. The "difficulty integrating" seems to be simply an anticompetitive tactic by a couple of big vendors out there.

We would all get better service if Harry Reid would simply call his antitrust people and put them on a couple of large HIT companies.

At Wed Nov 04, 12:14:00 PM, Blogger MedInformaticsMD said...


I share your concerns. However, it's the IT world that is the dinosaur, not you. They are stuck in the paradigms of the 1970's.

See the posts that appear at this link for more on the travails of EHR's in ED's and those who challenge the common wisdom that Doctor + Badly Designed Computer Program = Marcus Welby.

And while at it, see this link as well.

At Wed Nov 04, 03:42:00 PM, Anonymous Anonymous said...

All your suggestions are possible with EPIC. It seems your real issue is with your hospitals I.T and policy departments. All this can be done (don't let them tell you it cannot) and should be done with EPIC, and most other EMR's.

At Thu Nov 05, 10:02:00 PM, Anonymous Anonymous said...

"All your suggestions are possible with EPIC Systems."

I talked to my ASAP TS today and she said it wasn't possible, get the facts straight from the company next time.

At Tue Dec 01, 12:19:00 PM, Anonymous Anonymous said...

As the doctor is forced more and more to create the record himself and thus take valuable time away from thinking about the computer program instead of treating the patient, we hear about the IT department this and the IT department that. Has anyone paused long enough to assess just how much money it is costing the medical facility to pay the burgeoning costs of the IT personnel versus how much they are saving in transcription costs? I don't think so. Were it all to be revealed, I think we would find that the doctors are being asked to do more work and thus see less patients while the cost of the handy dandy EMR point and click program combined with an expensive IT department have sunk the medical facility into a bigger financial hole than it ever bargained for.


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