Electronic Medical Records in the Emergency Department The downsides…

1. Electronic Medical Records inthe Emergency DepartmentThe downsides… Neal Chawla, MD Dept of Emergency Medicine INOVA Fairfax Hospital

2. Disclaimer • 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

3. Topics • 1. Information Entry • 2. Too Much Information • 3. Allergy Reactions – The 80/20 Rule • 4. Immature CPOE • 5. Downtime

4. Information entry

5. Information Entry • What is good? • We can capture more patient information • What is bad? • Someone has to spend TIME entering that information

6. Information - Templates And that’s just the HPI! (History of Present Illness)

7. Information • There’s also the Physical Exam • On every patient… Are we done yet???

8. Information • Almost. Review of Systems.

9. Information • A 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

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

11. The Most ExpensiveData Entry Clerk • With EMR, it is estimated that physicians spend 15 minutes out of every hour charting

12. What is the cost? • Average ED Physician making $150/hr • $37.50/hr spent on charting • This just the professional rate • Other costs • Lost Productivity • Time away from patient’s bedside

13. 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??

14. Too much information

15. Too Much Information • Easy to document a lot of information • Templates, checkboxes, etc. • Macros, Scribes • Result is fulfilling insurance requirements for increased billing • Any benefit to patient care?

16. Too Much Information • I would argue opposite • Leads 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

17. Too Much Information • Is it worth my time to even look at all? • Now I may miss important information • See sample chart

18. Autofaxes • Great Concept! • When patient leaves the Emergency Department, automatically fax the chart to the Primary Care Doctor • Seems beneficial..

19. Small Samples from my Inbox..

20. Why don’t they want our 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..

21. Allergy reactions – the 80/20 rule

22. 80/20 Rule • You know this rule and it has many applications in the world • 80% 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

23. 80/20 – 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

24. 80/20 – Allergy Reactions • We 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

25. 80/20 – Allergy Reactions • 2 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

26. Immature cpoe

27. Immature CPOE • What is good? • We can order labs electronically • No more paper

28. Immature CPOE • What is bad? • The order-set could be better • I only order the CSF tests together when I do a spinal tap, why are they apart?

29. Immature CPOE • Can we improve? • It was a BIG project to get this fixed • We switched the names so it falls in alpha order but pointed to the same lab code

30. downtime

31. Downtime • Systems need to be taken down for maintenance • Often 2-4 hours at a time • Our ED is never quiet for that long • Labs or imaging or other may have to go to paper • This causes workflow problems and increases chances of a safety event

32. Downtime • We 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

33. EMR - Conclusions • I would not go back to paper • EMR has many more benefits than problems • But there are downsides

34. training

35. Training • On 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

36. Training • May have a greater effect on nursing • Especially traveler nurses / locum tenens • Work for approx 3 months, then move on • High cost of training

37. Training • Maybe 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

38. Tools not solutions

39. Tools not Solutions • EMR’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