Electronic Medical Records in the Emergency Department The

Electronic Medical Records in the Emergency Department The downsides… Neal Chawla, MD Dept of Emergency Medicine INOVA Fairfax Hospital

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

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

INFORMATION ENTRY

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

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

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

Information �Almost. Review of Systems.

Information �A large percentage of the previous slides has solely a billing function �This is before medications, labs, radiology ordered �This note is not a Medical Decision-Making

How much does all this charting help our patients?

The Most Expensive Data Entry Clerk �With EMR, it is estimated that physicians spend 15 minutes out of every hour charting

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

Any solutions? Scribes ◦ Personal Human Assistant ◦ Follow physicians and document at bedside Macros ◦ Quicker documentation ◦ Drop a normal macro and change abnormals ◦ Potential to overdocument ◦ Does this help patients? ?

TOO MUCH INFORMATION

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?

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

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

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

Small Samples from my Inbox. .

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. .

ALLERGY REACTIONS – THE 80/20 RULE

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

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

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

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

IMMATURE CPOE

Immature CPOE �What is good? �We can order labs electronically �No more paper

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

Immature CPOE �Can �It we improve? 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

DOWNTIME

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

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

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

TRAINING

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

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

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

TOOLS NOT SOLUTIONS

Tools not Solutions �EMR’s �This are often sold as “Solutions. ” is sales. . �EMR’s need another 20 years(? ) until they are truly mature and robust �Currently, they are tools slowly becoming solutions