Monday, April 4, 2011

EMR Follies, Part 2

The other day I posted a story about one of the pitfalls of the Electronic Medical Record (EMR). Here are a few more.

1. In some versions of the EMR it is very easy to copy and paste. This leads to the creation of duplicate progress notes such as the following passages which were buried in a pair of nearly identical 500+ word notes:

03/09/2009 “Patient underwent tracheostomy yesterday. Is more comfortable.”
03/10/2009 “Patient underwent tracheostomy yesterday. Is more comfortable.”

2. The ability to copy and paste coupled with the ease of dictation results in voluminous notes. As you may know, coding (directly linked to reimbursement) for visits is based on the extent of the care given. “If it’s not documented, it didn’t happen,” goes the saying. But now we have the inverse. It is so easy to document that notes are easily puffed up to “document” extensive encounters with every patient.

3. Because they are so long, they are difficult to read and the black-on-white appearance of the words on so many screens causes the reader to skim over most of the note and go straight to the plan or recommendations.

4. For privacy reasons, most of these programs shut down if one does not touch the keyboard or mouse within a minute or two. This means if one gets a phone call or other distraction, one often has to log in again. Again for privacy reasons, passwords must be changed frequently. I am unaware of massive attempts by hackers to access medical records. Most of the time they really aren’t that interesting.

5. Nurses’ notes have become very easy to write thanks to pop-up windows. In addition, regulatory agencies have mandated “documentation” of multiple nursing interventions and screens (likelihood of falling, skin condition, pain assessment, nutrition, etc, etc). Not only is the nursing record unreadable due to its size, the zeal to document has taken the nurse away from the bedside. They are so busy documenting that they have no time for patient care.

6. This is analogous to the lament from patients that their doctor no longer talks to them but rather sits facing the computer monitor so he can document his comprehensive visit.

7. Reviewing a record for assessment of quality of care is almost impossible as it is no longer possible to “leaf through” a medical record. And if the record is printed, one gets a two-foot high pile of paper with every iota of information about the patient’s admission. And it’s all black text on white paper so important items cannot be distinguished from garbage.

Yes, I know I have omitted references to the good features of the EMR, (instant access—while sometimes cumbersome—to old records, legibility, etc). But it is my blog after all.


Anonymous said...

I agree. I have made the argument that using an EMR in Anesthesia is akin to texting while driving. Most of the medical software is similar to Windows NT while we live in an era of cloud computing...cutting edge medicine in anachronistic software.

Vivdora said...

This may not be entirely on topic but I'm saying it anyway!

An awful lot of note taking is done to avoid getting sued. Everybody the patient encounters takes a history, apparently they never read it again and no one reads anyone else's! I have personal experience of this as a patient. I started nursing (England) in 1975.

Last time I was in hospital, I was given a form to fill in with the question "date of death". i wrote " to be arranged" no one noticed :(

Computerised records have some advantages but print-outs are not good to read. My late husband was a GP, he used to write "Back yet again....." in the notes sometimes :) He hated computers.

Skeptical Scalpel said...

Vivdora, I agree that many notes are written with the possibility of legal action in the future.

I also agree that no one reads most notes. I wrote about this last month. If you'd like a laugh, please read it. Here's the link

Anonymous said...

I agree, the record is unreadable and *(insert your deity here) help you if you have to obtain a record from annother location or group. Even the simplest encounter pulls a wall of text on white (at least 10 pages ussually) with all kinds of bs scattered throughout. (who needs a cage questionaire on a kid with an ear infection?). The other doom is communication overload, once everyone discovers that they can send you questions quickly and easily (from PT to lab to scheduling to nurses etc) you start answering an couple of hundred things a day (all recorded for the lawyers to hang you with. If you were to do a proper chart review to answer all of these questions you would not have time to do anything else. EMR technology is a rope that is choking us all off.

Skeptical Scalpel said...

Good comments. I agree 100%.

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