A Day In The Life Of A (Reluctant But Coerced) EHR-Using Physician - And Her Patients

A reader, a physician who wishes to be unnamed due to fear of retaliation, writes the following:

Dear Dr. Silverstein,

As you write, there is not a transaction of medical care that does not go through EHR systems.

However, these poorly usable EHR systems stifle creative and artistic thought required to link risk, benefit, and probability of diagnosis with risks and benefits of testing and therapeutics.

Assuring safety and efficacy with pre- and  aftermarket surveillance will maximize the possibility of achieving the potential of the technologies.

Additionally, when I use these electronic ordering systems and  libraries of medical information, they fail to keep up with the agility and nimbleness of my mind as I seek 'random access' to pieces of data to formulate and synthesize diagnoses and therapeutic strategies.

The EHRs are too slow, do not have a robust (if any) search function, randomly and whimsically store key information with ever changing formats, and generally obfuscate what should be simple. They are cumbersome and disable the ability to simultaneously and contemporaneously compare myriad data points.

They get an "F" as enablers of complex diagnostics.

Paper, since it can be organized as needed and set out on a desk to be seen and compared as quickly as the eye registers the data, gets an "A".

The EHRs  are impediments and disrupters of communication.

Example: Just today, I was witness to the fact that a stat EKG was ordered by CPOE  on a heart patient yesterday at or shortly after 4:30 pm. The intended recipient of the order (heart station) never got it because they close near 4:30 pm and there was no warning to the ordering health professional that was so.

Thus, the EKG was never done, and this morning, when the requisition was seen, no one did it because it was ordered stat "yesterday", and the techs asked themselves "what good would it do for a 'stat' to be done now, a day late?"

I do not know what happened to the patient.  I have many other examples of such delays facilitated by the CPOE and EHR systems that I am required to use at numerous facilities.

They facilitate 'stealth' alterations in care.  Also just today, a disease-critical test ordered 3 days ago was not done because it was cancelled in 'stealth' (automatically "expired") without warning to me by the lab responsible for doing it.

There is the "silent silo" syndrome as you've called it.  Also just today, a disease critical test ordered 5 days ago came back with results, but the results were posted in the information 'silo' of 5 days ago. The lab screen default on the EHR only goes back 4 days (so unless I knew to look for it, it would not be seen or acted on), further obfuscating data and delaying treatment.

The EHRs lose data and orders.  Also just today, I found that blood coagulation monitoring tests that were ordered to be done with kidney dialysis (3 days per week) on a patient somehow got "lost" and were not being done for 5 days, putting my patient at risk of bleeds - or stroke if the blood was not 'thin' enough.

I just walked in to examine a hospitalized patient with multi-organ failure and diabetes, on multiple meds including insulin, and recovering from respiratory failure.

The nurse anxiously informed me that the blood sugar was dangerously low. I ordered treatment stat.

I see patients in the morning before labs come back, and depend on nurses to review labs and notify me.

Turns out that the patient was hypoglycemic on yesterday morning labs that arrived in the EHR 'silo' after I left the hospital; and was also low in potassium, but the tests just laid there comfortable in their silos; and were not communicated to anyone like in the old days when a human ward clerk or other undistracted human received them and disseminated them to the appropriate professionals.

Thus, instead of getting less insulin, the patient got the usual dose with near catastrophic adversity.

Misidentifications are facilitated by EHRs.  I  noticed that on several critical clinically significant changes that arose on my patient that were entered as such in an EHR silo by the RN, it was stated that they called attending physician 'Dr X', which was not me...obviously a case of EHR-facilitated misidentification.

Here is a misidentification variant:  yesterday, someone (non doctor but not clear who) ordered a specialist consultation on one of my patients under my name. I did not order it nor was it needed, yet it showed up as an order for me to sign.

Like you, I agree this is representative of a toxic impact of these systems on medical care and I feel like the care environment is foul, like a cesspool, compared to what has been replaced.

These systems of medical devices cannot be trusted in the care of sick patients. Perhaps, they are OK for managing hang nails.

I offer no additional comments other then if I am sick, I do not want my care interfered with in this manner by IT.

Rest assured, though - there are IT hyper-enthusiasts out there (http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html) who would see little problem with this, as any accidents that occur are "anecdotes", "learning experiences" or "bumps in the road."

That's if they don't simply blame the user.

-- SS

How One Hospital's EMRs and the "Experts" Who Designed, Acquired, Implemented And Used Them Ruined Mother's Day

This post is a personal account of a disastrous encounter with healthcare information technology (HIT) by my own mother. This "as it happened" account should put an end to doubts as to the toxic effects that poorly designed and implemented health IT can have on medical care, even on relatively basic issues such as tracking of a mere five common medications.

Today is Mother's Day.

I weep.

It's almost one year to the day when my mother suffered severe and now clearly irrecoverable cardiac and brain injuries due to an EMR-related catastrophic blunder in the ED of a large hospital.

She spent the entire night last night in an agitated delirium, which is occurring more often now, with me, her son, tending to her needs. Not even strong sedatives helped much. It is only now, this morning at 9:30 AM, that she has finally drifted off to sleep, giving me the time to write this.

To the (ir)responsible people at the hospital, I offer my sincerest ingratitude for what you did to my mother through stupidity. Ignoring my confidential April 2010 warning letter to the CEO and CMO about my observations of your organization's EHR deficiencies did not ingratiate me to your organizational culture, either.

Yet I hope your mothers are healthy and responsive to your gifts and appreciation on this day. I honestly do.

I would not wish what my mother went through (cerebellar hemorrhage) on anyone.

Here's a sampling of how such errors occur due to the toxicity of EHR's:

My mother was placed on a medication, Sotalol Hydrochloride, by this hospital's cardiologists in appx. 2001 to prevent atrial fibrillation.

An ED visit of April 2010 shows Sotalol as a "current medication" (as did multiple ED and inpatient charts dating back almost a decade):

From the ED EHR of April 15, 2010 in an admission for abdominal pain from rectal stricture, resulting in an anoplasty (widening) as an elective outpatient surgical procedure a few days later:

ED EHR of April 15, 2010

CURRENT MEDICATIONS

1) Cozaar: 25 milligram(s) PO Daily. [For high blood pressure - ed.]
2) Albuterol: unknown dose. [For bronchitis - ed.]
3) Restoril: 30 milligram(s) PO Daily. [Sleeping pill - ed.]
4) Humulin N: 10 units in am,8 units in pm. [Insulin - ed.]
5) Sotalol Hydrochloride: 120 milligram(s) PO Every 12 hours. [For heart rhythm, see here - ed.]

PAST MEDICAL HISTORY

MEDICAL HISTORY: Hernia NOS , Atrial Fibrillation [a dangerous heart rhythm that Sotalol prevents - ed.], DMII Wo Cmp Nt ST Uncntr [diabetes - ed], Bronchitis, Urinary Tract Infection NOS, Hypertension.

This is not exactly a complex or taxing medications list or medical history.

Now, from the ED EHR of May 19, 2010, after a Transient Ischemic Attack with temporary slurred speech (aphasia) and narrowed left carotid artery identified as the culprit:

ED EHR of May 19, 2010

CURRENT MEDICATIONS

1) Albuterol: unknown dose.
2) Humulin N: 10 units in am,8 units in pm.
3) Cozaar: 25 milligram(s) PO Daily.
4) Restoril: 30 milligram(s) PO Daily.
5) Atrovent HFA

[Note that something important's missing - the critical heart rhythm maintaining medication, Sotalol. It's simply gone - de-listed - even though WE WERE ASKED on May 19 in the ED if she still took it based on the computer's current meds listing of April 2010, and replied "yes." It then somehow disappeared ... perhaps due to a mission hostile user interface, or quality issues analogous to these ED EHR observations from Down Under? - ed.]

PAST MEDICAL HISTORY

MEDICAL HISTORY: Hernia NOS , Atrial Fibrillation, DMII Wo Cmp Nt ST Uncntr, Bronchitis, Urinary Tract Infection NOS, Hypertension.

SURGICAL HISTORY: anaplasty [misspelling in the original; errors like this make record searching and data analyses a challenge. "Anaplasty" and "anoplasty" are quite different. But what's a little EHR error among friends? - ed.]

PSYCHIATRIC HISTORY: No previous psychiatric history.

SOCIAL HISTORY: Denies alcohol abuse, denies tobacco abuse.

MEDICAL HISTORY: [Obviously repetitious of the above, but this is exactly how the record appears - ed.] Hernia NOS, Atrial Fibrillation, Dmii Wo Cmp Nt St Uncntr, Bronchitis NOS, Urin Tract Infection NOS, Hypertension, bronchiectasis, TGA in 88, post-herpetic neuralgia, possible WPW variant.

SOCIAL HISTORY: Denies alcohol abuse, denies tobacco abuse, lives alone with son nearby. [Also duplicative; a little cut 'n paste action? - ed.]

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Note that the duplicate versions of MEDICAL HISTORY and SOCIAL HISTORY at the bottom contain critical information not in the versions at the top, such as "possible WPW variant" and "lives alone with son nearby."

WPW syndrome (Wolff-Parkinson-White) is a syndrome that predisposes to heart rhythm disturbances such as supraventricular tachycardia (SVT) and atrial fibrillation. I offered that history to ED staff as a reason my mother took Sotalol. I also offered that I once had the WPW syndrome myself, and had recurrent episodes of both SVT and atrial fibrillation, until intervention via the 'catheter ablation' technique in the mid 1990's. The "WPW variant" made it to her chart. The medication did not.

This ED EHR report is a major information presentation faux pas, showing sloppy report generation and poor presentation of information, since people in a hurry -- such as in an ED, or in an ICU where my mother was admitted -- may not scan the duplicate versions below for critical data not in the top version. The repetition with added items in the lower-down versions is inexcusable.

This is the type of IT work done by amateurs. In fact the shabby ED EHR output could be considered an accident of omission waiting to happen. I covered this type of flaw here: http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and.html .

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So what meds actually were ordered after she left the ED and entered the ICU?

These:

Click to enlarge. Note the remarkable resemblance - or should I say identicality - to the 5/19/10 ED EHR medication list above. These were then entered into the floor CPOE system.

No Sotalol.

Several days later, after my mother was transferred out of ICU to the neuro floor in prep for a carotid stenting, my mother went into uncontrolled atrial fibrillation. In front of my eyes at around dinnertime. Sotalol has a half life of just about 12 hours. After a few days of missing it, it's effectively gone, at a level so low in the blood as to be ineffective.

I immediately asked nursing to call the physician, and asked how this was even possible on Sotalol. All I got back was a puzzled look.

Sotalol had never been ordered.

Long story short, in correcting the iatrogenic atrial fibrillation (the arrhythmia itself a stroke risk), Sotalol was restarted and IV heparin and electrical cardioversion (shock to the chest) were employed.

While initially successful in restoring normal heart rhythm, the IV heparin then precipitated a massive cerebellar hemorrhage around 2 AM the next morning (in an area of the brain entirely different from the cerebral language center supplied by the carotid). IV heparin is a dangerous drug you especially want to avoid in the elderly.

In what I thought might be her last words to me, all my mother could say when I arrived as they were taking her for surgery was a very agitated and frightened-out-of-her-wits "Scot-headache-headache-headache-I'm sick-I'm sick-I'm sick." The headache pain from the bleed must have been absolutely excruciating and horrendous.

She had the pallor of death about her.

The sheer horror of that moment, seeing my mother like that, sticks with me even though I am a physician.

Her CT looked dreadful, much like the stock image below:

Click to enlarge. When I saw her CT scan, I prepared to say my goodbyes.

Emergency craniotomy (brain surgery) was then performed by a neurosurgeon to save her life, followed by months of medical complications and agitated delirium resistant to most medications.

The brainstem sits anterior to the cerebellum, and brainstem compression from the bleed caused paralysis of the muscles of swallowing. A surgically placed stomach feeding tube through the abdominal wall was thus required, which in her delirium she yanked out, thus forcing total parenteral nutrition (TPN) via a central (deep) IV line until the site healed. (She was lucky she did not do herself a major injury by pulling the through-the-abdomen gastric feeding tube, which should have been far better protected with a delirious patient.)

The first ingredient I noted in the initial TPN bag was a medication my mother was allergic to, famotidine, but another EMR defect I uncovered prevented the clinicians from realizing this. It was only my personal knowledge that prevented administration. I ended up filing my own FDA MAUDE report on this EHR defect...to my knowledge the hospital did not, and has not.

The complications of the bleed and craniotomy surgery also forced the re-started Sotalol to be discontinued, as bleeds in the head adversely affect the heart's electrical intervals, and a drug like Sotalol can kill under those conditions (e.g., see Torsade de Pointes).

The forced discontinuation of Sotalol resulted once again in sudden return of atrial fibrillation that is now permanent. Correction or even appropriate anti-stroke treatment would require anticoagulation such as heparin and coumadin, and these are contraindicated due to the bleed.

My mother has been painted into a very bad corner, with irreparable cardiac injury putting her at increased stroke risk, and a severely damaged brain that has resulted in her being an invalid who frequently is in an agitated delirium, and/or no longer recognizes her own son. While her swallowing returned after several months, her mind never recovered.

In effect, the EHR toxicity caused the following personnel (at the very least) to miss my mother's Sotalol de-listing, which apparently propagated from ED to ICU to floor due to lack of any discernible fail-safes or meaningful reconciliation:

• ED triage nurse
• ED physician [who stunningly notes in the record "She had a prior history of atrial fibrillation. However, per her report this has resolved and she is not currently taking any anticoagulation." A true statement - except he forgets to address the first-year medical student-level question: "atrial fibrillation resolved - how?" The answer that I'd related to him was "her atrial fibrillation resolved on Sotalol"; Sotalol is a take-for-life drug. On the NIH page about Sotalol: "Sotalol controls your condition but does not cure it. Continue to take Sotalol even if you feel well. Do not stop taking sotalol without talking to your doctor."]
• ED staff nurse
• Two neuro-interventionalist physicians
• Multiple medical residents
• ICU physicians
• ICU nurses and staff
• Floor nurses and physicians after transfer from ICU to neuro floor

I further observe: it is nearly unbelievable to me that not one person out of all the clinicians who saw my mother during this admission, even when transferring her from ED to ICU to floor, detected this fundamental, major medical error via ED and inpatient histories dating back almost a decade. Is interfacing between the floor and ED EHRs an issue? Are the EHR's too mission hostile for busy clinicians to use? What in hell was going on here?

You'd think that for the $25+ million dollars spent by this organization on HIT, the IT could have included failsafe features on meds and other life-critical data. Has the computer become deified in this culture; its outputs, a Testament that nobody challenges?
I tragically note that one Sotalol pill, worth perhaps a few cents, probably could have prevented the catastrophe if the error had been detected even as late as floor transfer from ICU.

To add insult to injury, the following was added to the ICU H&P sheet some time after the catastrophic brain bleed:

Click to enlarge. A very unwelcome discovery when I asked the neuro floor RN to see the chart a few weeks after the accident. Entry #8 was not present the day the Sotalol error was realized; I was shown the chart at that time.

Undated, untimed additions to medical charts with illegible signatures violate Joint Commission, Medicare and State Medical Professional standards of conduct, among others.

I leave it to the reader as to why this chart alteration might have been attempted.

When I saw this, needless to say, I was very upset. I demanded an immediate printout of the eMAR (electronic medication administration record), lest that be altered as well. The eMAR fortunately showed Sotalol had indeed not been ordered prior to the onset of the A. fib. I do not know what it might have showed a week ... or a month ... later, had I not been a nosy and medicine/medical informatics-educated patient advocate for my mother.

As I did not have my Power of Attorney documents for my mother with me, I demanded the eMAR printout and copy of the altered ICU H&P be sealed in an envelope whose glue flap I signed, to be held until I retrieved my POA documents from the nearby bank allowing me to take custody of copies of both these documents.

This is how toxic these wonderful non-FDA approved or vetted, Obama HITECH-pushed Cybernetic Revolutionizers of Medicine can be, when not "done well."

It should be noted that further errors of this type at this hospital system would very likely amount to criminal negligence.

Happy Mother's Day.

-- SS

Candid Nurse EHR Opinions at Facebook Page "Friend a Nurse" Are Not So Friendly

At my Jan. 2010 post "An Honest Physician Survey on EHR's" (http://hcrenewal.blogspot.com/2010/01/honest-physician-survey-on-ehrs.html) I wrote:

I often believe surveys of physicians about EHR's do not present the results candidly, but rather are selective in what is reported - and what is omitted - and generally sugar-coated.

I then presented a candid physician survey on EHR's that was not very complimentary of the technology's value to real-world practicing physicians.

The following candid, informal nurse's survey about EHR's came to my attention the other day via Google.  The thread is on Facebook in the "Friend a Nurse" group pages and can be read at https://www.facebook.com/friendanurse/posts/654085127954821.

Apparently the thread got underway after someone posted the question "What do you think of electronic medical record systems? How was it implemented in your facility? Has it helped or hurt patient care? If so, how?" and a link to the June 25, 2013 Bloomberg News article "Digital Health Records’ Risks Emerge as Deaths Blamed on Systems" (http://www.bloomberg.com/news/2013-06-25/digital-health-records-risks-emerge-as-deaths-blamed-on-systems.html) that mentioned my mother's experience.

The EHR question posed on the "Friend a Nurse" Facebook page at https://www.facebook.com/friendanurse/posts/654085127954821.  Click to enlarge, or click Facebook link, which is public as of this writing.

I note that I had no knowledge of this, nor do I know the responders.  I did add a link to my Drexel website on health IT difficulties at the end of the thread, however, after I discovered it.

Here are the comments from both female and male nurses who belong to this Facebook group.  I redacted the names, however they can be seen at the Facebook page itself at the link above.

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Big problems when you have unexpected "downtimes".
July 15 at 1:10pm · 4

It is an absolute train wreck, I havent seen one record of mine that is not riddled with mistakes. Especially the allergies, they show me taking meds Im allergic too and not taking meds Im actually on.. A true mess!!And now the records are all intertwined. I dont like it at all!!
July 15 at 1:10pm

It is a nightmare!
July 15 at 1:18pm

I retired just in time so I don,t have to deal with this fiasco
July 15 at 1:19pm via mobile

IT SUCKS
July 15 at 1:19pm

I don't like them; my doctors don't like them; how it will affect patient care is still a 'jury out' matter, but we can guess it will NOT help.
July 15 at 1:30pm

our Rural Community Healthcare system is just now switching over to this..along with our hospital switching over to a totally new computer system..the 2 systems do not talk to each other..In my personal experience I find that the "computer" world takes us away from Direct Patient Care.(to busy playing "ring around the Rosie" on the computer..
July 15 at 1:40pm

I like them, but it is frustrating having "downtime."
July 15 at 1:41pm

I hear patients stating things like "my doctors don't know who I am because they don't look at me they are glued to the computer". It saddens me patients feel less valued. I've worked in places where they've had paper charts and places computerized. Seems the computers are redundant and I personally prefer paper charts. Chart one assessment not one assessment 4 different places.
July 15 at 1:44pm via mobile

It looks to me like physicians are cutting and pasting old histories and physicals, complete with the errors. Doctors in a local ER charted complete physicals on me when they did not get closer that 5 feet away. The records are difficult to read, difficult to find information, and not number in chronological order.
July 15 at 1:47pm

I dislike it . Besides the down time find it very impersonal . I don't feel as if I am giving my full attention to my pt, nor do I feel my PCP is hearing what I ' m saying . They are to busy putting in info on the computer . As for the down time you then have to work late to put in the info gathered while the system is down.
July 15 at 1:47pm via mobile

Electronic charting takes the skilled nurse away from the patient and puts them in front of a computer. Its NOT best for the patient or staff - the people who build the programs have not been at the bedside for eons....so the programs are time consuming, redundant, and inefficient.
July 15 at 1:51pm

I like EMR very much. The system we use is Allscrips, it is not perfect, but the benefits outweigh the problems. For example, I find most issues are human errors, such as poor spelling, incorrect entry in the proper records, entering incorrect doses. I love the fact that I can actually read and do not spend time deciphering not only the doctors writings, but my coworkers. I like having all the records in one place. There are issues for sure, but some of the issues is from companies who chooses to,purchase low quality EMR packages with poor support. The systems also need to be more standardized and "speak" to each other better. And folks at the end of the day it is your license at risk, do the things you were trained to do in nursing school, the 5 Rs remember those?
July 15 at 1:53pm via mobile

we are starting on it, let you know
July 15 at 1:53pm

In general I dislike it. If it 'goes 'down', you end up being unable to obtain vital information. With the federal system we did have both the computer records and the paper records. This was fine with inpatient informaton. I dislike it when my computer crashes and I can't get anyone to come look at it or fix it. They had a message line which we never had a call back from. I'd have a whole dept be down and non one to repair it. It's very frustrating on a triage line. This made scheduling appts impossible. Lack of vital information could be lethal to critical care patients...Far less pro's than con's. It's just a bad decision all together..
July 15 at 2:01pm

if THE GOVERNMENT CAN GET INTO YOUR RECOREDS SO CAN ANYONE they can hack anywhere now a days and it is scary///
July 15 at 2:05pm

anyone over 25 most likely hates it
July 15 at 2:09pm

I quit 2011...did CPOE no issue but more more is coming seems like q mo. or so keeps adding dig. stuff...hosp. worked with kept changing sys...used to ask myself why fix when not broken also once you got use to it thats when they change...they shld hire more nurses aux. ppl...do not know what to do with their money. Stressout...no more nursing for me . New grads savvy but this boomer did it for 38 yr. Enough is enough!!
July 15 at 2:14pm via mobile

Takes time away from pt care too much:-)
July 15 at 2:34pm

I work in a hospital and I hate it! I feel like I spend more time looking at the computer than at the patient. We have to document the same thing in multiple areas...big waste of time! Also our ER and OR's use a different program and we are not able to access this information when a patient is admitted to the floor. We also use Physician OE and the system we have it is hard to get back to look at an already viewed order. I feel this is dangerous and orders are missed all the time. It is just a ticking time bomb before someone is going to get hurt!
July 15 at 2:35pm

The med was there then disappeared.....software is only as good as the person using it. A PERSON DELETED THE MED! Pharmacies, nurses, and MDs use the computer did it as an excuse. Never understood how I corrected MARs every month and they were worse the next month...the computer did not do it alone. I dislike the MD playing on the computer and half listening to me.
July 15 at 2:38pm

Recently I have had md's not put a patient back on home meds because he/she could put them in correctly. I had to call the doctor on call at night to get these medications in place. The pt was also missing vital medications they needed for their diagnosis. I feel like in some cases emr is not safe. There however some cases where emr is helpful.
July 15 at 2:43pm

it will get better with time...
July 15 at 2:45pm

I worked at a VA until I retired, and I loved it. It is so much easier. Lets face it, anyone that wants your information is going to get it anyway.
July 15 at 2:57pm

I have used EMR in hospitals, home health and hospice for the past 20 yrs. When used within the same corporation w many offices it is very efficient. In that state corrections dept it was very helpful w continuity of care. the medical record follows the inmate to what ever unit they may transfer to. HIPPA is even more important with the EMR systems.
July 15 at 3:14pm

We just changed our system to a new one. It took a large group of staff over 18 months to develop our documentation system. The nursing portion is great. The med ordering part is difficult to use. The docs are all complaining about the system. They want to continue writing their orders.
July 15 at 3:17pm via mobile

We have had epic for over 5 yrs it is a great system.just wish computers worked better always having to shut down and reboot. Has saved us a few times with preventing med errors.covenant healthcare did a great thing when they got this system
July 15 at 3:18pm via mobile

I think it is an injustice to the Patients We are more than a computer file
July 15 at 3:24pm

It helps with a history when a patient is unable to provide
July 15 at 3:29pm via mobile

Plus it may have contacts address patients previous baseline behavior I'm a psych nurse so we utilize this type of system
July 15 at 3:30pm via mobile

Takes time away from patients, goes down too often, difficult when hospitals change systems. There should be a universal system, so info can be shared.
July 15 at 3:40pm via mobile

EPIC is terrible when it comes to outpatient chemotherapy and research. It is cumbersome and takes so much time away from patients. EMR's are here to stay and I think it's a great thing, for the most part, but sheesh make it easy on the provider, will ya?
July 15 at 4:07pm

we fear medication errors because some doctors start up home meds that are no longer correct. getting used to it is the hardest. the younger nurses are much more efficient and comfortable with it.
July 15 at 4:16pm via mobile

I agree with Noelle, it took focus away from the patient because it was cumbersome and repetitious, and because of the environment we had to keep the people moving through recovery....so it was dreadful. I was happy to retire and leave it to others to deal with.
July 15 at 4:30pm

I've worked with electronic T-system, Promed blue, Meditech, etc and all have their advantages and disadvantages, but the major disadvantage is that we don't do patient care anymore...we do computer care...I could also go on and talk about the fact we also don't get to spend as much time with our patients because of patient ratios and patient loads and the computer charting we have to get back to...
July 15 at 4:32pm via mobile

you are right on target here.....I retired because of this, there is very little patient care, it is indeed computer care !
July 15 at 5:00pm · 1

Nursing Informatics Institute How has nursing been involved in the planning and implementation of these systems? Feel free to share your experiences, it is very interesting to hear about your practice.
July 15 at 5:15pm

I love the electronic records. I do not love all the different styles ect programs out there. So many glitches. Patient's need to be proactive and as involved in their healthcare and that of their loved ones as possible. That means bringing ALL of your med bottles with you to each and every doc visit you go to. I don't care how many times or how many diff docs you see in a week, ALWAYS take ALL of your meds in the ORIGINAL bottles. Where I work there is 100+ doc's in this group, each doc office has access to same record I see when the patient comes to us. Each doc office can ad or make changes to the chart accordingly, so if you don't bring your meds with you to each visit and doc A changed a med and made the notation in the chart we see it but can't verify it. ALWAYS keep an updated list of meds in your wallet/purse for those emergencies when you don't have your meds. Include on this list, your surgical history, your medical history(Diabetes, hypertension ect ect ect), who your PCP is and a #, allergies, blood type, your wishes as far as DNR ...... It will save your loved ones precious time and allow them to focus on you, and not that new pill doc so & so started you on for her diabetes, I think. Anyway, with so many spoons in our medical records here, I catch mistakes all the time where a med has been deleted/added ... By another office. Usually because the patient did not bring the meds, or the patient is a poor historian of their own medical history and the family has no clue. Be proactive people, don't trust us to do it all. Get the dam electronic records fixed so they make sense, and stops all this confusion ..... Why so many different types and formats are needed is beyond me.
July 15 at 6:01pm 

not the systems that cause the problems, staffers that program only what they think is important when making diagnosis.
July 15 at 6:37pm

Love it - but when they go down.....
July 15 at 6:39pm

Mostly like it. Rather type than write. Does take more time than paper note, but overall I like it. I agree when I see patients & when I or my family is the patient, MD hardly looks at you; too busy inputting data.
July 15 at 6:52pm via mobile

No Comment.
July 15 at 6:52pm 

it is a huge improvement! and a potential life saver - no more figuring out what that handwriting is saying.
July 15 at 7:13pm

I generally like EMRs but some programs are so damned redundant (charting the same IV start every time you admin an IV med?) and/or lacking in -- how do I put it? -- intuitiveness. Sometimes I really wonder if anyone actually working with patients was involved in the design or implementation of some of the programs we use.
July 15 at 7:31pm 

Has it's good points and bad points. But I spend more time on the computer, then at the bedside.
July 15 at 7:55pm

I think computer charting has went way overboard and takes the nurse away from the bedside. How does family view nurses that are at the desk on the computer all the time?
July 15 at 8:27pm

it is disconcerting to the patient and or family if the health care provider starts firing questions and then spends the entire visit looking through the chart instead of listening to the patient's effort to provide a history of symptoms. No eye contact diminishes the interaction significantly!
July 15 at 9:15pm

for some things they are O.K. but everything no. Maybe scanned for some things. Now I have not thought out a plan for which, maybe someone with more time than I have could do a better job.
July 15 at 11:36pm

Haven't seen it work too well.
July 16 at 1:04am

It takes a lot of patience to get it implemented into a facility. The inservices that we
have had are few and basically it is a learn as you go. When everyone is finally sure of how to do it, it will be OK but is taking a long time for all of it to be taught to us
July 16 at 7:31am

mountains of paper, I mean mountains...
July 16 at 10:22am

as nurses, we are buried in paperwork... so are the docs... looking for a way out, we all THINK the digital answer with EMR is THE way... BUT nobody has proved it is superior, or really saves time or workload... and now the GOVERNMENT is pushing us into a costly and complex system
July 16 at 11:14am

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I think the comments (largely negative with several "positive but with significant concerns") more accurately reflect EHR reality "in the trenches" than the marketing propaganda emanating from government, the health IT manufacturers, the academic pundits, and other "see no evil, hear no evil, speak no evil" triple-simian hyper-enthusiasts.

On EHRs:  see no evil, hear no evil, speak no evil

Of course, the hyper-enthusiasts will call these opinions "anecdotal", but as one investigative reporter who does work in the EHR sector opined when sent the Facebook page:  

"That's a lot of anecdotes."

-- SS

Some Real-World Lessons for the Health IT Hyper-Enthusiasts

An article was published in Health Leaders Media yesterday by Scott Mace, senior technology editor entitled "Scot Silverstein's Good Health IT and Bad Health IT" at this link.

(Actually, the terms "good health IT" and "bad health IT" themselves came from Prof. Jon Patrick as a result of my discussions with him in Australia about my conviction, presented to the Health Informatics Society of Australia in my Aug. 2012 talk "Critical Thinking on Building Trusted, Transformative Medical Information:  Improving Health IT as the First Step", that to be trusted and do no harm, health IT must be “done well".)

Scott Mace observes:

Inevitably, when the subject turns to the pitfalls of bad health IT, you will find Scot Silverstein, MD, ready to comment. He has been writing about health IT difficulties since 1998.

Silverstein is an adjunct professor at Drexel University who I recently interviewed for an upcoming HealthLeaders magazine story on physician resistance to health IT.

A recent Silverstein blog post caught my eye for the following statement: "It is impossible for people, especially medical professionals, to be 'ready' for a system that 'is not ready for them.'"

I wanted to learn about the good doctor's thinking and so I gave him a call. We spoke for two hours and it felt like scratching the surface of issues that healthcare will be facing for a good while to come.

Indeed, the issues we discussed were just scratching the surface.  The real world is ever so complex.

Also noted was my observation that:

... Silverstein says it is wrong to think of the tension in healthcare as being IT modernists versus Luddites ... [he says] "I believe the proper framing of this tension between technologists and physicians is that of technology hyper-enthusiasts, who either are unaware of or deliberately ignore the downsides and ethical issues of healthcare information technology in its present state, versus pragmatist physicians who just want to get a job done."

The hyper-enthusiasts largely ignore the real world. 

Two recent "real world" posts on other blogs by practicing physicians caught my eye, that help illustrate the concepts of health IT's disruption of clinicians and of clinical care.  These disruptions increase risk of error (even under normal circumstances; in an emergency scenario, I fear the disruptions will become far more destructive).

These disruptions need to be thrust in the face of the hyper-enthusiasts as characteristic of a very flawed approach to healthcare improvement.

The real-world observations, courtesy KevinMD blog (who reposted them from the source bloggers), with my comments are in [red italics]:

Information overload for doctors increases malpractice risk
Wes Fisher, MD
January 1, 2013

I have used the electronic medical record (specifically EPIC) since 2004.  I have grown accustomed to its nuances, benefits and quirks.  There are parts about it I really like.  There are parts of it I’d like to do without but accept that they are necessary evils in our current health care climate.  I know that there will always be parts of any modified computer system that will suffer growing pains.  For any new and adapting technology this is understandable.

But there is a little-appreciated issue that I see brewing: doctors (and maybe even patients) are quietly being buried by electronic information overload.  As a result, I believe doctors are being placed at an increased liability risk. [Not just doctors, but all clinicians, and the acquirers and implementers of the technology, and those who force the use of it on the clinicians - ed.]

Let me explain.

In the past era of medicine, nothing happened without a doctor’s order.  Nothing.  If you wanted a medication, lab test, invasive procedure, opportunity to participate in rehab classes – anything – you needed a doctor’s order.   For the years of paper records and independent doctors offices, this work flow assured that doctors (1) knew what was happening with their patients, (2) saw their patients, (3) prescribed the proper therapy, and (4) assumed the risk for the intervention or treatment prescribed.  Information proceeded in a logical linear fashion and the doctor was always at the head of the information line.

But we are no longer in the old days in medicine.  We are in the era of near-instantaneous information flow, multi-directional electronic communication, and geographically disparate order entry by “caregivers,” (think nurses, nurse practitioners, advanced practice nurses, clinic operators, registrars, etc.) who help us take messages, continue care, and order things.  In this electronic process, messages are no longer passed from just one individual to another, but rather are passed to two, three, four, or more individuals simultaneously from any one of several different clinical locations – some of which might be many miles apart.  There is an incredible amplifying effect of all of these messages, orders, and notifications — so much so that even the most tech-savvy doctors are struggling to keep up. [This observation about an "amplifying effect" gives life to my own observation that the terms "EHR" and "EMR" are anachronistic and suggest to the layperson an innocuous file cabinet, when in reality today's "EHR" is an enterprise healthcare resource and clinician control system, with all that implies in terms of potential adverse unintended consequences - ed.]

In fact, it is not uncommon for a doctor these days to work for two hours on a procedure and return to the computer to find twenty or thirty new notifications, e-mails, or orders have been deposited there.  Head back in for the next case and then another thirty items appear.  Pretty soon, it’s an avalanche of items.  Worse: doctors must click on each one of these notifications individually to “verify” he or she has looked at each and every single one.  [Looking at the computer has likely become a source of dread to many clinicians; I used to get the same feeling when facing up to a day's emails in Pharma, sometimes more than a hundred - ed.]

Doctors understand that the reason we have to click on all these orders is because (a) no one gets paid in our system unless a doctor orders whatever-it-is [not the best motivation - ed.] and (b) someone has to be the fall guy if there’s a problem with a nurse, medical assistant, or lab technician that “orders” something on behalf of the physician.  [Ditto; the "social issues" of health IT include factors like these  - ed.]  There is even a trend to auto-order things (like a pneumovax vaccine, for instance) that assure the hospital maintains excellent public reporting metrics whether the doctor ordered them or not with the order later appearing in our inbox to be clicked.  [This observation gives life to my own that the computer is increasingly becoming the intermediary between doctor and patient - ed.]

But worst of all are the silent notifications sent from fellow physician colleagues buried amongst the other notifications. They tell of an important story, one that needs fairly urgent attention, but because people no longer pick up the phone, are not immediately noticed or highlighted. It’s like a landmine sitting in a doctor’s inbox waiting to be stumbled upon.

* Click* *Click* *Click* * Click* *Click* *Boom*  [The "silent silo" syndrome, as I called it, also affects lab results reporting.  It should be clear that health IT does not "automagically" improve communications over Alexander Graham Bell's invention - ed.]

With all these people and devices ordering and sending, the limited number of doctors out there are being bombarded from multiple directions.   It is getting harder to keep up these days.  Orders and notices come to us on names we don’t recognize or have been long forgotten.  (Computers don’t forget that you saw the patient eight years ago).  [These observations should put an end, once and for all, to the oversimplifications of comparing health IT to, say, mercantile or banking IT - ed.] And once an order is placed and acted upon without our knowledge these days, we click on the order to clear our notices and thereby assume all the legal risk for the care. The legal buck still ultimately stops with us.

Doctors need to speak up about this problem.  [I could not agree more - ed.] We are not in the old days any longer.  We are in the fast-paced, electronic medical record era where things happen (literally) at the speed of light.  We need the electronic medical record companies, payors, hospitals and legal community to come together to help us find a solution to this current information overload crisis that maintains patient safety and improves efficiencies while limiting legal risks to the doctors who are doing their very best just to keep up.

Wes Fisher is a cardiologist who blogs at Dr. Wes.

The above "anecdote" (I use that term somewhat satirically, see here) is likely characteristic of the lives now lived by most clinicians using today's health IT.  Hyperenthusiasts, take note.

The second real-world illustration of the naivete of the hyper-enthusiasts is as below.  I'd observed most of the points made in my own writings after my CMIO period in the late 1990's, which I highlight.   It is quite interesting to see these same points come from others without Informatics expertise, directly from the clinic:

Explaining the epic failure of EMRs
Kiran Raj Pandey, MD
December 19, 2012

It is no news a lot of doctors like to stick up a rather snotty nose to EMR. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. [In reality, the tension is between the hyper-enthusiasts or 'Ddulites' vs. pragmatist clinicians with real-world patient care responsibilities and obligations - ed.] But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia [the path to Utopia usually has very bad unintended consequences, and Utopia never reached - ed.], and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there. [As I've opined, we're on a speeding bullet train on a quarter-mile track - ed.]

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS [and the Lords of Kobol - ed.]), I complained to the IT guy that the thing barely works! The guy was sympathetic and said, “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs.” [Hospitals and clinics, as I've written, are NOT the proper place for software alpha and beta-testing - ed.]

But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with,” he retorted. “Computer records do take a longer time than paper, and there is nothing I can do to change that.” [This reflects healthcare IT culture's of arrogant acceptance of bad health IT, largely ignoring ways to ease human-computer interaction - ed.]

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. [The reverse is also true - ed.] Add to that the inertia people have about their old ways and you have a deal breaker right there.

That’s not all. Driven by the constant government whip to adopt EMR, and an EMR industry that is hell bent upon imposing itself on healthcare [long ago I began writing of a territorial invasion of healthcare by the IT industry - ed.], a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.The constant juggling not only made the patient encounters time consuming and cumbersome [and surely tiring - ed.], it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. [And increase risk of cognitive overload and error substantially - ed.] Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.

What’s wrong with the current adoption of EMR? Why are even the converted like me questioning EMR? [Converted to what? - ed.]

I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. Second how the EMR tries to impose its will on to us instead of the other way around. [I've written that HIT should work like the clinicians work, not the other way around.  Again, the IT has become the cybernetic 'governor' or 'regulator' of care, and is not just an innocuous records system - ed.]  A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty.

... On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes 10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better [when bugs and 'glitches' due to sloppy industry practices don't cause faulty output such as occurred here - ed.] , but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper. ["not possible with paper" is a theme I've written about as well - ed.]

Trying to impose a ready made architecture on to health care will not work. “It works for retail and banking,” some people seem to offer cluelessly [Business/mercantile computing and clinical computing are two different subspecialties of computing, I've long observed - ed.]. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they force things you to do things you wouldn’t otherwise do. [Hyper-enthusiasts don't really seem to care; if it's a computer, it must be better - ed.]

Such forced behavior modification may make the administrator, the insurance company, and the government happy [it does - ed.] but I can’t understand how selecting a dozen pesky radio buttons while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamored with the EMR, just because the government said so, or that it made the IT companies a few million dollars richer. [Doctors are just supposed to obediently accept this technology by the hyper-enthusiasts and profiteers - ed.]

Kiran Raj Pandey is an internal medicine resident who blogs at page59.

I feel "anecdote" #2 is also quite common, and the sentiments shared by a large number of clinicians forced into using this technology in its present state.

Hyper-enthusiasts and other health IT promoters and grandstanders need to read the above accounts well.  They need to understand that the real-world effects of the technology, recklessly pushed, can be toxic, and not result in the utopia of better care and cost-savings they naively believe will deterministically occur. 

-- SS