1. Electronic Medical Records in the Emergency Department The 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 Expensive Data 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