Tuesday, April 28, 2015

Dr. Orthochick: Problems with EMR

So in our EMR (Electronic Medical Record), you can just copy and paste the note you wrote from the previous day and add or subtract as needed. Which means it takes 3 seconds to write a note, because generally not much changes over the course of the day. The downside to this is, if I want to read someone else's note, I'm stuck sifting through three weeks of respiratory culture results and discontinued pain meds until I actually get to the "plan" section, because all of that stuff carries over. Plus when the note is copy-pasted, I get the feeling no one else can find the stupid plan either, including the person writing the note, because it is not particularly helpful since it doesn't get updated all that often. Don't get me wrong, I love being able to see what everyone else is writing from my computer at home, but i would love it even more if reading all this gave me some grasp on the overall plan for the patient, instead of 5 days worth of sodium values.

Anyway, the other day I got paged down to the ER at 4AM to evaluate a lady who was having arm swelling and numbness after falling. I had pretty low suspicion for compartment syndrome but I had no idea what it actually was, so I checked her compartment pressures, they were normal, and I discharged her with a prescription for Norco. As luck would have it, she came back, (again while i was on call) and I still didn't know what was wrong, except by this point she was also having numbness and tingling in the other hand as well. I did a CT of her cervical spine (normal) and then gave up. She got admitted to internal med, I wrote a note saying I had no idea what she had but it wasn't a surgical problem.

I was on call on Wednesday and I got paged to do a consult. I spoke to the consulting physician and it turned out it was for the same patient during the same hospitalization.

Me: I've already seen her. Twice. We didn't really know what she had, but it didn't seem like a surgical problem since her nerve symptoms were diffuse and she didn't have compartment syndrome or a drainable hematoma or something like that.
Internal med doc: Oh, I'm sorry. I didn't realize Hand Surgery had already seen her.
Me: If you want, I can see her again to see if anything's changed.
Internal Med Doc: No, you don't have to do that if you've already seen her. I don't think anything's changed.

See, the thing is, everyone's note, from the initial internal med doc who saw the patient 4 days before that to the internal med doc who consulted me, contains the phrase (and I quote):

Hand surgery has evaluated the patient and feels no surgery is indicated. Appreciate hand surgery input.

Seriously people, you don't have to read my note, but you could at least read your own. I'm sure that was just carried forward from the last guy to write a note, and I know it's a pain to write your own note, but I'm not going to be too impressed if your own note acknowledges that I've already seen the patient you consulted me on.

I'm not saying the EMR is a bad idea, because I think it has a lot of potential, but I'm not sure it's working out quite the way it's supposed to. There's no point in having easier access to records if we're not reading them to figure out what they're saying. And i say this every month, but if we can't get two hospitals in the same city to use the same EMR, I'm not sure how we're supposed to get everyone in the country to use it.


  1. I think part of the problem is the level of documentation we're required to have, as well as the standard progress notes that we're used to writing.

    For example, take the medication list and lab values. Using paper charts, due to time and space constraints, we generally include new lab values. I like to include the previous day's results for comparison, but it's extra work. I like to write a medication list indicating anything that's changed (meds started/stopped, dosage adjustments, etc.) but most people don't write the med lists anymore.

    Here's the thing: the EMR can easily punch those values in, and depending on the system, it can even generate a small table with previous values for easy comparison. But does it make sense to include that information in a note? It did with paper charts, because the medical administration record (MAR) was usually in a separate binder or folder, and lab values may have been scattered elsewhere in the chart. Including it all in one note made it easier for others to follow, including yourself when looking back through it. Yet with the computer system, pulling up lab values and the MAR no longer requires a trip around the ward to find them. You just click some other icons, and you're there.

    Aside from including potentially extraneous information, there's an information overload because the chart still covers two purposes. First (and ideally), it's a communication tool between healthcare providers and staff. Second (and unfortunately), it's a legal document. The first goal benefits from brevity, while the second benefits from being overly thorough and including more information than others really need.

    The benefit of being able to copy and paste notes from day to day is an increase in speed, but the downside is that people get used to ignoring most text because they assume it's just a copy-and-paste (which, admittedly, can happen with paper notes as well, but probably isn't as common). I suppose we could take to putting text into bold, italics, and underlining in order to catch people's attention, although I don't know how professional that would be regarded as... it might also be nice if the EMRs could recognize a copy-paste, and then do something like change the color to blue for any edits made. That way, at least people would be able to see what parts of the note were actually written that day.

  2. From the other side of the world we envy you guys for having a "record" in the first place. I work in a third world country and most of our hospitals here don't have any sort of records (no paper record). The only thing we have in the place I work in is paper med recs (updated daily in patients' charts); and paper labs carried by patients themselves (often missed, and disorganized). No H&Ps, no outside meds (neither prescription nor OTC), no past medical records. Residents sign out H&Ps from their own personal notes/scrap papers.

    I spent 4 months in US hospitals during my final year of med school, and having EMR was such a privilege I couldn't believe it. I completely agree with you though on blindly-copy-paste-everything thing, but still, EMR is a bless

  3. Sadly once a lawsuit happens, you might see this changed.

  4. You can lead someone to a sentence, but you can't make them read it.

  5. From a (very recent patient's) perspective, this makes me something like 70% less nervous at having requested a copy of my own complete medical records, to go over the tests and doctor's perspectives. Because something was just not right, and while we were all vaguely agreed at, "Ehhhhh, epilepsy????" it's very probable I actually have a heart condition that keeps making me pass out and have seizures, when said condition is actually misdiagnosed with epilepsy all the time.

    But when I saw the EKG reported I had long qt intervals, I nearly facepalmed myself into next week. Couldn't ANY of the half dozen medical practitioners who had access to my file said, "Huh, that looks bad, let's see if her heart keeps doing the thing."

    So I took it into my own hands to ask the least scary of the medical professionals I've been seeing and ask, "Uh, should I do something about this?"

    Here's hoping all of these professionals will not now saddle me with the label of a kind of repeat offender jockeying for attention or some shit. D:

  6. Not only does the copy-paste feature make lives hell for providers, I can tell you as a medical coder, I am constantly downcoding (taking credit away from) visits to level 1 or 2 because although the documentation is present, it was not the rounding provider who did the work.

    It takes an enormous amount of time to sift through this crap from the billing aspect to quantify a note for reimbursement.

  7. The you get into the medical/leagal aspect of notes from medical, NP and PA students getting carried foward in to attending and residence notes.