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 is not a Medical Decision-Making
note
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 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?

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

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 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