electronic medical records in the emergency department the downsides… neal chawla, md dept of...
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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
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