Home Blog Goodbye hand cramps, hello carpal tunnel

Goodbye hand cramps, hello carpal tunnel

March 2008

Love them or hate them, electronic medical records are now a reality. The state of Massachusetts is considering a law mandating that all hospitals in the state have an EMR by 2015.

And the influential Leapfrog Group has emphatically endorsed EMRs, particularly the use of computerized physician order entry. Enough of the validations!

As a techophile, I always have looked forward to working with an EMR. After being told that an EMR was coming “next year” for about five years, I finally got to experience one last year.

Since then, I am hooked, and I’m not going back to paper charts–done with those, finito! I can still feel the frustration of desperately looking for a chart on days that I was running behind. By my calculation, I might have spent between 5% and 10% percent of my time on certain days hunting charts down!

Then there were all those times that pages in a chart went missing. Or the time I used to spend trying to figure out what a colleague or consultant had written in a chart, and the phone calls that began with, “Doctor, I was not sure what exactly you wrote…”

Plus, I was one of those that never could get away from writing detailed notes. Finishing a week of hospitalist work, my entire right upper extremity would ache for a few days, recovering from writing miles and miles of progress notes. Goodbye hand cramps!

And hello carpal tunnel!! It is now a pleasure to read notes, access a chart from outside the hospital and not ever have to go to the medical records department to complete a chart again. But is an EMR the Promised Land? Certainly not.

I have now seen two major EMR systems be rolled out, and I’m convinced there’s no escaping the quirky side of EMR implementation, regardless of the system that your hospital chooses. I have seen physician reactions run the gamut from outright joy to unbridled hostility and disdain. I’ve even seen one specialist let loose with a tirade of colorful language while trying to operate an EMR, directing his anger at the nursing staff and finally stomping off the ward!

There’s no doubt that implementing an EMR, if not done thoughtfully, can be very disruptive. Just think of the highly publicized implementation failure (and medical staff revolt) at Cedars-Sinai Medical Center in Los Angeles, which scrapped a $34 million EMR system. At the other end of the spectrum, the VA has successfully implemented a custom EMR.

Putting in orders on an EMR certainly takes longer compared to handwriting them. Some physicians just copy and paste their previous progress notes, at times fairly mindlessly. Others generate ultra-lengthy notes by incorporating everything–detailed lab results, X-ray reports–just because they can. And then there is the dreaded system downtime; in a completely digital environment, a total downtime can raise adrenaline and cortisol levels by a factor of 10!

I almost forgot to mention the multiple alerts that one gets while putting in orders. And guess what? With alerts firing off so frequently, it does not take long for “alert fatigue” to set in–a condition where the user blithely ignores the well intentioned alerts, some times perilously.

As EMRs become more prevalent and as competing information systems market themselves aggressively, interoperability will become a big problem, not only between competing inpatient EMRs but between inpatient and outpatient systems. It seems ironic that with extensive digitization, we will still have to print out a chart on old-fashioned paper and send it via fax or mail–so pages can then be scanned in once they are received.

In 2004, the federal government created the office of the national coordinator of health information technologies to address the issue of interoperability and to establish a national health information network. Those are good intentions, but not much progress yet.

This segues into another vexing problem: how to incorporate older chart records into the digital environment. Scanning millions of pages into an EMR sounds like a daunting and expensive task that I suspect most hospitals won’t be keen to undertake.

Another Achilles heel of EMRs: privacy. It is not uncommon for providers to log on to a chart and then not log off, leaving the chart open on the screen; this is particularly egregious with CPOE. According to the LA Times, an average of 150 providers have access to portions of a patient’s chart during a hospitalization.

Where do hospitalists fit into the EMR picture? There is no doubt that they are front and center! As hospitals convert to EMRs, hospitalists will be their natural partners in this process, generating acceptance within the medical staff, and shouldering planning and implementation responsibilities.

I predict that hospitalists’ work RVUs will go up with EMR implementation, as those few remaining outpatient doctors stop coming to the hospital after being given an ultimatum to spend between three and five hours in EMR tutorials and as specialists lean more on us, especially when CPOE is rolled out. With hospitalists sure to become one of EMRs’ main end users, the day is not far off when a hospitalist will don the mantle of chief technology or information officer of a major health care system.

So, here are my questions:

When an EMR is rolled out, how much of a slowdown does it cause? How should a hospitalist team be staffed during an implementation to offset that slowdown? And how long does it take a group of doctors to become adept with a system and recoup their original speed?

I have heard figures anywhere from 20% to 30% as far as a slowdown in efficiency for at least a few months; after that the pace picks up. But I have to admit this is water cooler talk, and I have not seen any studies showing legitimate data.

And as I think more about it, here’s another big question: Will EMRs actually lead to increased efficiency, besides improved patient safety? Can I as a hospitalist perform my rounding work faster without sacrificing face-to-face time with my patient?