Electronic Medical Records inElectronic Medical Records inthe Emergency Departmentthe Emergency DepartmentThe downsides…The downsides…

Neal Chawla, MDDept of Emergency Medicine

INOVA Fairfax Hospital

DisclaimerDisclaimer

While this is a talk about the downsides of EMR, in my opinion these downsides are easily outweighed by the upsides

But there are downsides

TopicsTopics1. Information Entry2. Too Much Information3. Allergy Reactions – The 80/20

Rule4. Immature CPOE5. Downtime

INFORMATION ENTRYINFORMATION ENTRY

Information EntryInformation EntryWhat is good?

We can capture more patient information

What is bad?

Someone has to spend TIME entering that information

Information - TemplatesInformation - Templates

And that’s just the HPI!(History of Present Illness)

InformationInformationThere’s also the Physical ExamOn every patient…

Are we done yet???

InformationInformationAlmost. Review of Systems.

InformationInformationA large percentage of the

previous slides has solely a billing function

This is before medications, labs, radiology ordered

This is not a Medical Decision-Making note

How much does all this How much does all this charting help our patients?charting help our patients?

The Most ExpensiveThe Most ExpensiveData Entry ClerkData Entry Clerk

With EMR, it is estimated that physicians spend 15 minutes out of every hour charting

What is the cost?What is the cost?Average ED Physician making

$150/hr$37.50/hr spent on chartingThis just the professional rate

Other costs◦Lost Productivity◦Time away from patient’s bedside

Any solutions?Any solutions?Scribes

◦ Personal Human Assistant

◦ Follow physicians and document at bedside

Macros◦ Quicker

documentation◦ Drop a normal

macro and change abnormals

◦ Potential to over-document

◦ Does this help patients??

TOO MUCH TOO MUCH INFORMATIONINFORMATION

Too Much InformationToo Much InformationEasy to document a lot of

information◦Templates, checkboxes, etc.◦Macros, Scribes

Result is fulfilling insurance requirements for increased billing

Any benefit to patient care?

Too Much InformationToo Much InformationI would argue oppositeLeads to worse patient care

Mountain of medical records which takes a long time to go through

Little of this information is clinically useful◦Needle in a haystack

Too Much InformationToo Much Information

Is it worth my time to even look at all?◦Now I may miss important

information

See sample chart

AutofaxesAutofaxesGreat Concept!

When patient leaves the Emergency Department, automatically fax the chart to the Primary Care Doctor

Seems beneficial..

Small Samples from my Small Samples from my Inbox..Inbox..

Why don’t they want our Why don’t they want our faxes?faxes?They are about 10 pages long

The important information can be communicated in a few lines

Our EMR can’t parse out the important information, so it sends everything

Sometimes you can’t even tell what happened◦ You are reading checkboxes and dropdowns

But many EMR’s can’t autofax at all, so still an improvement, just immature..

ALLERGY REACTIONS ALLERGY REACTIONS – THE 80/20 RULE– THE 80/20 RULE

80/20 Rule80/20 RuleYou know this rule and it has

many applications in the world80% of programming needed for

good patient care software is easier◦The last 20% is much harder, takes

into consideration special circumstances, and takes much longer

◦So it is often skipped

80/20 – Allergy Reactions80/20 – Allergy Reactions Wow! Our system

warns us about possible allergy reactions

Wait a minute! Codeine has no real allergy reaction with benadryl.

Codeine doesn’t interact with Tylenol either

I have ALERT FATIGUE

It feels like the boy who cried wolf

80/20 – Allergy Reactions80/20 – Allergy ReactionsWe get warnings about

significant reactions

We also get many warnings about insignificant reactions

We get a flag but it doesn’t tell us what the actual reaction is

80/20 – Allergy Reactions80/20 – Allergy Reactions2 problems here..

We get alert fatigue and learn to skip thru warnings, so we may miss an important one

We see an insignificant warning and withhold a beneficial medication for a feared reaction that doesn’t exist in reality

IMMATURE CPOEIMMATURE CPOE

Immature CPOEImmature CPOEWhat is good?

We can order labs electronically

No more paper

Immature CPOEImmature CPOEWhat is bad?

The order-set could be betterI only order the CSF tests

together when I do a spinal tap, why are they apart?

Immature CPOEImmature CPOECan we improve?

It was a BIG project to get this fixedWe switched the names so it falls in

alpha order but pointed to the same lab code

DOWNTIMEDOWNTIME

DowntimeDowntimeSystems need to be taken down for

maintenanceOften 2-4 hours at a timeOur ED is never quiet for that longLabs or imaging or other may have

to go to paperThis causes workflow problems and

increases chances of a safety event

DowntimeDowntimeWe have become dependent on EMR

systems

Going to paper in my mind is an internal disaster

Results can get lost, we can’t track our patients as easily, communication breaks down

This is one of the most dangerous times in the ED, even with good downtime procedures

EMR - ConclusionsEMR - Conclusions

I would not go back to paper

EMR has many more benefits than problems

But there are downsides

TRAININGTRAINING

TrainingTrainingOn paper there is minimal training

required

For our EMR, I spend 3 hours with each doc orienting them to our system

The doc takes about 2-4 weeks to get comfortable with this system, and is less productive during this time

TrainingTraining

May have a greater effect on nursing

Especially traveler nurses / locum tenens◦Work for approx 3 months, then

move on◦High cost of training

TrainingTrainingMaybe some day…

EMR’s will be fairly standard and intuitive so only minimum training is necessary

We will be a lot more familiar with computers and EMR’s so training will be easier

But that is not today

TOOLS NOT TOOLS NOT SOLUTIONSSOLUTIONS

Tools not SolutionsTools not SolutionsEMR’s are often sold as “Solutions.”

This is sales..

EMR’s need another 20 years(?) until they are truly mature and robust

Currently, they are tools slowly becoming solutions