ED Physician Executive Slams EHRs

Electronic health records "are not effective communications tools—not effective at all," says a self-avowed technology optimist who holds a dim view of current EHR capabilities, but has hopes for better systems to come.

8 comments on "ED Physician Executive Slams EHRs"
Dr. Cynic (2/7/2014 at 11:07 AM)

It is absolutely clear that electronic health records are good for medicine. 1. They eliminate the horrendous variability in handwriting as an obstacle to reading old notes. 2. They make it very easy to look up old labs, imaging, and notes by subject or date of service instead of wading through piles of paper. Now, which EHR is another question. The field is littered with products from the outstanding ED-Pulsecheck EHR, to the below average Meditech, to the absolutely horrendous Cerner. The problem is not that EHRs are bad, but that people who don't understand IT or medical practice are making these decisions for large organizations which then see suboptimal results.
steve jacobs (1/31/2014 at 4:39 PM)

I'm afraid that the speaker is looking at a conventional EHR as used in most hospitals. The reality for me at Kaiser Permanente is much different. We're using Epic like everyone else, but we're a complete group[INVALID] Inpatient and outpatient docs, labs, xr, etc. How would the speaker like to have instant access to the outpatient ecg done 2 wks ago when he sees a chest pain patient at 2AM? The problem isn't EHRs per se but rather the lack of interconnection. I can see all of my patients' records, even when they're admitted at tertiary centers far away. I can see all the labs, consults, etc. As for usability, Kaiser spent a lot of money and time customizing EPIC for each specialty. So at least for me as a pediatrician, it is far quicker than using paper. And readable. If you are practicing in a hospital ED with no data connections to the referring docs then his point about the documentation being primarily for billing has some merit. But if somehow EHRs can interconnect, then they will really show their promise.
Anne Creamer (1/31/2014 at 2:02 PM)

@cascadia, I don't understand your point. What was the physician's specialty? Did he have any training in workflow, documentation, user interface and functionality issues? And Dr, Geraci, your assumption that "an ideal product for Family Medicine would easily satisfy ER use" is not true. The ER needs documentation structure for all specialties, since we see it all. Do you have the need to document on OB/GYN, trauma, peds, psych, urology, just to name a few? The attendings and residents of all those specialties work in the ER on a regular basis and they need their specialty-specific terminologies and order sets in the ER module. That's what makes the ER unique among all the EHR modules: we need to be able to document for the universe of medical specialties. Therefore, it is very difficult to retrofit an outpatient system, or any other specialty unit for the ER; the ER needs to develop its own module and this needs to be done by ER doctors and nurses who understand its workflow and have at least a basic understanding of database design issues.
@cascadia (1/30/2014 at 8:11 PM)

It is interesting that the largest EHR in the US (Epic) was developed by a programer who is married to a physician.
Anne Creamer (1/29/2014 at 12:35 PM)

First, I want to reply to Corey Edmundson: Many patients come to the ER without IDs or family members who can give a medical history. In those cases the patient is treated based on presenting symptoms and you hope that someone finally shows up who can provide more information on the patient. No one lets them die. I totally agree with Dr. Tom about the poor system design of ER clinical systems; they have obviously been designed by people who do not understand how the ER works. In my last clinical job as an ER RN I was a member of the implementation team for a system-wide EHR. It became apparent right away that this system would not work in the ER. The documentation requirements for nurses (and I assume doctors) were impossibly detailed. It would have taken more time to document than to treat patients. At the same time I was a student in the nursing informatics graduate program at the U. of Maryland and was being taught the importance of documenting at the most granular level so that data miners could make use of it to determine best practices. That's a good thing at the theoretical level but impossible at the clinical level in the ER. My professors didn't understand my concerns but I wrote my scholarly paper on this dilemma anyway. My conclusion was that the competing needs of perfect data collection and clinical reality would never be met using the current EHR systems (I studied several) until we had voice recognition software that could capture data as we worked. That was over ten years ago and apparently nothing has improved much. I, too, believe in technology and the need for comprehensive clinical systems. But the designers need to hire clinicians with real experience in their fields instead of new grads who know nothing of the real world. And unless you have worked in the ER for a while you really shouldn't criticize those who have.
Corey Edmundson (1/29/2014 at 8:40 AM)

This particular statement is very concerning to me, as we as many others. "they can just query the patient and get what they need much more quickly, Tom says". What about the patients that are too young to know, or older patients that don't recall every important detail. More importantly, what about unconscious patients? EHR's can answer very important questions that the patient may not be able to answer. So, he is saying the 5% he does not need to speak to are worth letting die because of a lack of relevant information that is needed to treat a patient safely? It is this kind of arrogance that causes patients to be harmed unnecessarily.
Gus Geraci, MD (1/28/2014 at 3:23 PM)

The ideal EHR would allow for both structured and unstructured history taking. 90% can be structured around the complaint. ER medicine is also different, in that patients don't typically come in for 10 undifferentiated issues, which is part of the challenge for vendors. Each specialty is different. An ideal product for Family Medicine would easily satisfy ER use, but not vice-versa. But the treatment protocols and Clinical Decision Support would be completely different. I do and don't blame vendors for their confusion. The trick is finding clinical users of different specialties who understand database and programming issues well enough to explain themselves to IT folks, and having IT folks understand that talking to one physician to design an EHR is like talking to one woman and thinking you understand women. :-)
Ken Congdon (1/28/2014 at 2:29 PM)

While I agree with many of Dr. Tom's views regarding the clinical workflow inefficiencies associated with EHRs in the ED, I also feel many of his comments in the article come off as arrogant and shortsighted. For example, as much as I don't feel a physician should be bogged down with documentation, I also don't feel the physician should ignore the documentation or rush through patients, which it seems like Dr. Tom is advocating in many instances. I found his statement that most of the information provided by patients is unnecessary to be particularly troubling. Again, while this may be true in some cases, his comment paints a picture of a physician with blinders on, traveling down a predetermined path, without truly listening to the patient or taking all factors into account. Later in the article, he is quoted as saying physicians will often opt to query a patient rather than pouring through the documentation. Again, this may largely be a function of poor technology, but it is also an indictment to physicians who refuse to use the resources at their disposal. It's clear a lot of work still needs to be done to create EHR tools that physicians will actually use.


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