I have a unique perspective as a physician. Having traveled to many hospitals in the past two years, working as a locums emergency physician, I can comment on a variety of issues with a reasonable amount of experience.
One of those issues is EMR, or electronic medical records. I have spent plenty of time writing about this in the past, and I will continue to do so. Because all across the country the same problems, the same frustrations are evident. And the institutional lack of concern is well-entrenched and well understood by everyone affected.Whether working in an academic teaching/trauma center or a small community department, one theme emerges.
EMR is so inefficient, and patient volumes and acuity so high, that charting isn’t done real-time. Unless it is accomplished with scribes, or by dictation, doctors stay after their shifts, or chart from home, or come in on their days off in order to complete their documentation. Needless to say, this is unlikely to create the best possible chart. Not only is this true, I have watched as nurses sat for one to two hours after their busy ED shifts, catching up on the ever increasing documentation requirements in their EMR systems.
Weary from a long day or long night, they sift through notes and charts, orders and code blue records, trying to reassemble some vague estimation of what happened in the chaos of their 8 or 12 hours on shift, when they were expected to function simultaneously as life-savers and data-entry clerks. Further, the nurses are frequently tasked with entering specific charges for billing as well. It all constitutes an unholy combination for any clinician.
Dear friends, colleagues, Romans, countrymen; dear politicians and administrators, programmers and thought leaders, this is unacceptable. Entirely unacceptable. If the charting system is so poorly designed, and so counter-intuitive to the work we do that it can’t be used real-time, then it should be replaced with something far better. And if it isn’t replaced, then everyone needs a scribe to chart for him or her, or we should allow dictation all around. And if none of that is acceptable, if even those reasonable options are rejected, then every nurse and every physician who stays after shift should be paid their regular hourly rate for time spent charting.
The thing is, these systems are generally not the idea of the clinicians who are saddled with them. They are imposed by corporations and administrators who believe the salesmen and hope to capture more billing and data. They are imposed by the meaningful use regulations of the federal government. But as a rule, when we clinicians say a system is bad, or won’t work for us, we are patted on the head and dismissed.
“It’s fine, it’s an industry standard. You can learn to use it. You don’t want to be a problem doctor do you?”
One of my friends is in a group shopping for new systems. When his partner asked to take the potential EMR for a test drive, the salesman said, “Sure, as soon as you sign the contract.” Pathetic. I call on everyone involved in implementation of EMR to find the simplest, most physician and nurse friendly systems possible. And to do it by asking and involving the end user. By which I mean those who provide patient care, not those who cull through it for billing and documentation. Some people chart more slowly than others. That can be an individual issue.
But when a system consistently causes good, efficient doctors, nurses, NPs and PAs to stay long past their shifts, or come in on days off, or chart from their homes (which should be places of recuperation and rest), then we need to give them something back. Equally toxic, some physicians and nurses can only get out in time by charting in a manner that results in a pages long list of checkboxes, rather than a descriptive, informative story.
America’s emergency departments are overwhelmed with passwords, required fields, clicks and key strokes, at the same time as they are overwhelmed with the sick and dying. They are the last safety net for the uninsured and underinsured. They are the point of rescue for the poor, the brutalized, the traumatized, the addicted, the psychotic. Day in and day out, nurses and physicians in emergency departments, indeed all over the modern hospital, do their best against sometimes overwhelming odds. In the midst of this, poor charting systems constitute a crushing blow.
Pay the staff for their time spent charting, or fix the systems. Or both. But something has to give.