I didn’t become a physician to do data entry

The trouble began when I needed to open the electronic health record (EHR) system for the tenth time that day. EHRs have significantly changed the way we practice medicine. They have completely eliminated the need for storage and transport of paper charts, reduced prescription errors secondary to illegible handwritings of physicians and provided an excellent platform to maximize billing for services rendered. However, in terms of creating a smooth workflow for physicians and in facilitating meaningful face to face encounters with our patients, all EHR systems have completely failed.

Sara, the nurse for Ms. Tucker, called me saying, “Doc, Ms. Tucker is back from the cardiac catheterization lab. She is complaining of a mild headache.”

“It must be from the nitroglycerine I gave her in the lab; please give the ordered Tylenol, it will resolve soon,” I said.

“I don’t have any orders, Doc. All the orders for this patient are on hold,” she replied.

“On hold? What do you mean?” I said surprised.

“Yes. All orders go on automatic hold when a patient goes for a procedure and comes back unless you reorder. It’s the new EHR upgrade,” she said.

“OK, I will do it as soon as possible,” I said, taking in a deep breath and involuntarily rubbing my forehead.

To reorder Ms. Tucker’s medications, I needed to log into the EHR system again. I had to do it remotely, as I was at another hospital in town that used a completely different EHR system, though it was only ten minutes away. I had to enter my username and password carefully and slowly three times in response to three different prompts in addition to entering the secret code that was texted to my cell phone. After what felt like an eternity, I logged into this most sacred, highly-classified, triple-password-protected space of EHR. I wondered if the FBI have to enter their passwords thrice to log on to their everyday workspace. As I was able to log onto the EHR system without seeing the prompt “Incorrect username and or password,” anytime during my three-password entries, I regarded it as my greatest success for the day. The fact that Ms. Tucker’s procedure was uncomplicated and smooth faded in comparison to this success.

I opened Ms. Tucker’s chart. There were twenty-one tabs vertically on the left-hand corner of the screen and eighteen tabs horizontally on the top of the screen. I quickly glanced through the cluttered twenty-one vertical tabs; I clicked on the one I am looking for — “transfer medication reconciliation” in the 19th slot. A new grid showing sixteen held orders opened. I selected each of them separately and clicked on “continue.”

Select and continue.

Sixteen times two: thirty-two clicks.

I was fidgety. I was not sure of even reviewing each order. I just clicked and clicked. Final tab. Review and sign. Clicked. End of my rendezvous with EHR for today. I hoped. The age of “clerical” physicians continues, I mused.

A few weeks ago, when there was EHR system breakdown, patients were still taken care of. Nurses took verbal orders. It was unquestionably chaotic, but for me, it was bliss. I was on call for acute heart attacks that day. Ms. Copper drove her husband to the hospital with sudden-onset chest pain. Mr. Cooper had a cardiac arrest in the parking lot of our hospital. He was revived after a brief period of cardiopulmonary resuscitation and taken immediately to the cardiac catheterization lab. I opened his occluded left circumflex artery successfully, and he was transported to the intensive care unit in a stable condition. No one pestered me regarding entering orders before doing the procedure.

After the procedure, I wrote down the report and all the orders on a single plain sheet of paper in fifteen minutes. Zero clicks. I then went to meet Ms. Cooper in the family lounge. Usually, I am interrupted by messages from the nursing staff that family is waiting for me when putting orders or vice-versa that there is some problem with order entry when I am meeting with the family. This didn’t happen that day. Ms. Cooper had my undivided attention for a full twenty minutes. Her eyes filled with tears of gratitude at the end of our conversation. She hugged me and said, “Thank you for saving my husband’s life.” I didn’t have to rush to correct orders or type in my notes. The bliss, unfortunately, lasted only for twenty-four hours, and once the software was uploaded again, the usual “digital” drudgery continued.

I chose to be a physician to care for people. I value my direct face-to-face interactions with my patients. I want to hear their stories told by them in their own words. I cherish their smiles, their tears, their gratitude, their handshakes and hugs. I did not sign up for screen time with a computer, speed typing or clicking. I did not sign up to type passwords multiple times.

The leading, if not the only, cause reported for physician burnout is workflow issues related to the use of EHR systems. Instead of providing meaningful clinical documentation for easy communication among health care providers, it has evolved into this massive, cumbersome giant with so many interfaces, cluttered screens, redundancy and duplication requiring innumerable clicks, selects, templates and passwords with no added clinical value but only frustration and burnout for physicians. The software has to be re-designed for clinicians to efficiently gather data, enter orders and communicate relevant clinical information without having bloated notes and cluttered screens that are catered for easy billing and coding. Clinicians together with hospital administrators and information technology professionals should be actively involved in the development, testing and optimization of new electronic features to streamline the workflow. For me, there will be no joy in the practice of medicine until my frustrating rendezvous with EHRs end.

The names used in essay have been modified to maintain anonymity. It is a fictionalized account of true events.

Jaya Mallidi is an interventional cardiologist.

Here’s why you wait in the ER

All have to wait. As is normal with all the busy ER, the ambient sounds of machines, alarms ringing, debilitating moaning, and loudly drunken outbursts permeate the section. It is a controlled insanity.

But, a girl’s scream pierced my spirit. Her baby eight-month-old boy put back in her arms. He is already pale, lips his torso not climbing as it must with breathing — that he is not reacting at all. We wasted no more time. Nothing brings help quicker to a room than a dead kid. We rapidly put a breathing tube, then started pushing on his small chest with our hands to help keep his heart beating, then drilled an IV to his bones, and pushed into all the drugs we could. Ten minutes passed. Nothing. Twenty minutes passed. Still nothing. For every other patient, we might assess heart motion and if it’s not moving, pronounce the time of passing. Not for children. Never for Kids. We spent 45 minutes for this baby. Helpless, the time had finally arrived. We were in agreement. Time of departure: 0205.

The heartbreak isn’t over though. Next is the mother. What would you say? Not much. I could just sit and try to absorb her despair, her skepticism — her remorse.

What’s next? We move on. It’s a hectic night… the damage had ripped into me, but I had more hours to operate; patients are awaiting. The next patient was waiting for two hours. I took a pause, massaging sanitizer involving my cold hands a couple of seconds longer than normal to compose myself. What occurred following etched into my head as far as the tragedy that happened minutes ago.

The patient berated me. Yelled at me personally. “I’ve been waiting for hours to see the doctor! What type of place is that!? You are supposed to treat me, not leave me waiting! I knew I should I’ve gone someplace else!”

Never have I felt this way.

“I’m sorry for your wait. It’s been busy,” was all that I could muster.

Maybe, if this person knew what had happened, there could be some comprehension — when the doctor has not talked to you yet, there is somebody sicker needing attention.

But we can’t say . I can’t say a kid has just expired. I can’t tell you that a seven-year-old girl’s figure, was ripped by a stray bullet. I can not mention that we just consoled a weeping family. I can not.

Our fast-paced culture needs convenience — click on a button to arrange clothes, instantaneous posts on Twitter, receive a hamburger by means of a car window. That which we’ve lost, however, is a tiny comprehension of the human condition — compassion for others. Sometimes we are so excruciating, we can’t see past our own hospital gurney. Nowhere is that more evident than the ER.

Triage must occur. With limited, exhaustible resources we must do what emergency departments are made for: take care of the sickest first. There’s a saying in medicine:”Vitals signs are essential.” That is where we begin.

By way of example, two patients require evaluation.

One is really a 30-year-old man with stomach pain with normal vitals — waiting hours.

The next is a 60-year-old lady with chest pain, quick heartbeat, low blood pressure — waiting ten minutes.

Who’s first? The choice is obvious. Without emergent therapy, patient 2 will perish quickly. Patients #1 might need to wait longer, but patient #2 doesn’t have this luxury. ER physicians will make this choice every single time without hesitation.

We are responsible for the whole ER, its people, and its finite resources. It does not matter who you are, the ER is the excellent equalizer.

For all our patients, we recognize this is among the worst days of their life. We try to deal with it like that. Regrettably, at the ER, somebody else is constantly sicker than you personally.

Admittedly, there are more factors beyond doctor management. The flow of this ER is much like this a five-lane freeway. When everybody goes the exact same rate, traffic flows nicely. When rush hour hits, more automobiles merge in the on-ramps and visitors slows. The ER also slows only by sheer volume. In case a semi-truck crashes, automobiles come to a stop before that truck is cared for. Likewise, we must tend to that gunshot wound to the chest before focusing on the others. The truck must be cleared to permit others to pass. When the destination is outside of parking areas, individuals are left unattended around the freeway. After the hospital is complete, the ER becomes crowded. The patients which need to stay in the clinic? We keep them at the ER, there is nowhere else.

No one likes excuses. If it was possible, we’d evaluate everybody instantaneously. Waiting kills. We know this. That’s why we are constantly developing methods to improve wait times. We’ve placed doctors in the waiting room, acquired blood work and X-rays straight away, streamlined workflow with different specialties and generated different areas to view less critical complaints.

Yet, it is insufficient. Folks will wait. People have emergencies. Doctors fill up. It’s sometimes tough to wear a different patient’s gown and step into their slippers, particularly when we are hurting ourselves. But that is what makes us human — why we appreciate society. As soon as we view a fiery crash on the freeway we expect that nobody is hurt and there are survivors. We understand why we need to stop our automobiles. Our basic instinct would be to wish the best for people.

The ER is an overwhelming place — especially for patients. Several factors contribute to the wait time — many supporting the ER doors, beyond our control and beyond our patients’ sight. We might be in pain and we all might be in need, but our empathy for our humanity can make it more tolerable.