Any new technology necessarily has a phase in which unnoticed bugs as well as unforeseen challenges crop up. In its early stages, the snail’s pace of a dial-up connection often made using the Internet onerous: before completing an email, one was often interrupted by pop-ups, viruses, cryptic 404 error messages, and a cacophony of sounds from the modem as the line repeatedly disconnected. Yet, as technology matures, the ability to send an email anywhere in the world now rests in our pockets. EMR has often been decried as time-consuming, disorganized, and plagued with errors; these problems are temporary and addressable. Moreover, EMR offers some unique and compelling benefits that are sure to make paper records obsolete.
The most common complaint about EMR is that it is hard to get the patient’s full story. An EMR will only accept what input it is given; it cannot generate its own data. For those pining for the “good old days,” there are blank notes into which one can free-text grammatically correct notes to their heart’s desire. There is also endless customizability in creating template H&Ps for different chief complaints. For example, in my CHF-exacerbation template, rather than a generic HPI I can write:
HPI: *** is a *** year old *** with a PMHx of CHF (last echo: ***, EF: ***%), ***….
This, and numerous other subtle modifications enable me to not only remember to ask the patient important questions (a la Atul Gawande’s checklists), but also remember to weave critical details into the story at precise locations, to shape the narrative unfolding in my reader’s mind.
As far as locating data entered by others, EMR clearly outshines paper charts as well. Sitting at my computer in the county hospital, I can limit the notes I view to the subtypes “H&P,” “Discharge Summaries,” and “Progress Notes.” From my chair, I can view all relevant notes and labs not only from prior admissions, but from the AIDS clinic she visits near her house, the Ophthalmology clinic she visited last year, and the biopsies that were sent out when endometrial cancer was suspected last month. Any, all, or none of these data may be relevant to this particular admission, but having it instantly at my fingertips is a luxury that paper simply cannot reproduce.
Finally, EMR is dramatically more accessible than paper charts. The initial barrier of poor handwriting is immediately discarded. The second barrier of traipsing up n flights of stairs to the patient’s floor, finding the chart, and wresting it away from the poor medical student who is trying to decipher the last consultant’s handwriting is also (thankfully) gone. While I am in an elevator on the way to noon conference, I am able to enter in an order that I forgot during morning rounds from my iPad. And as long as we’re trying to minimize handoffs, what about the handoffs that occur during order entry on paper?
Overcoming these fairly mundane inconveniences is not the only benefit of a full EMR. There are many unique benefits that have already revolutionized patient care. The cardiologist on home call can log in with his laptop and view the telemetry output of his entire ward; the medical team can instantly flip through each X-ray, CT, or MRI done in the past several years to compare a questionable lung spot to a CXR done at a previous admission; the hapless intern can have time to choke down some cereal while scanning his patient’s morning labs, even though he slept 15 minutes late this morning. EMR will continue to transform the way we practice medicine for the better, and the wisest approach to realize that it is just a tool that will reflect what we put in.
Garbage in, garbage out. Clinicians would do well to really learn the ins and outs of the technology so that they can best tweak it to their practice’s needs.
Deepak Ramesh is a medical student.