When do we get EMR 2.0?

In a recent New York Times opinion piece, nurse educator Theresa Brown and internist Steven Berman suggest that physicians and nurses join forces to oppose their common pain point - the electronic health record.

Some respondents to this article, which appeared on New Year's Eve, were skeptical that "one thing" - the EMR - could possibly cause so much disruption and stress.  Presumably these commenters never worked in healthcare.  As odd and simplistic as it may seem to an outsider, yes, the electronic charting systems in most hospitals frustrate clinicians, and contribute materially to workplace stress, anxiety, depression and burnout.  The consequences are borne not only by themselves - though this would be reason enough for action.  They affect their families, the hospital organizations for which they work and, most importantly, the patients who rely on us.

No one disagrees about certain advantages of an EMR over paper.  Sitting in my living room, where I am now writing on an early Saturday morning, I can review the chart of any patient that requires my attention.  This "portability" also makes it possible for the doctor and nurse to be charting at the same time,  putting an end to what was a persistent question in the world of paper records: "damn it, who has the chart?" And, of course, legibility is no longer an issue.  In this regard, a whole category of medical error relating to misunderstood doctors' orders has been eliminated.  No longer is there a need to worry that similar looking hand-written abbreviations (dubbed "dangerous" by The Joint Commission) will be misinterpreted.

Additionally, the new systems presumably improve safety by allowing for "alerts" that prompt us when we enter a medication to which the patient may be allergic, or at the wrong dose, or that might interact with another.  These have been somewhat helpful, though false alarms plague the process.

But separate from the inefficiencies pointed out by the authors - or maybe interacting with them - are at least two other problems with current EMRs.  The first is the "cut and paste" issue.  In an effort to claw back a little time (so as to be able to spend at least a few moments with the actual patient), physicians will liberally move text from one note to another.   The problem is that this can create inadvertent errors in sequencing - as when yesterday's "yesterday" is no longer yesterday when written in today's note.  Or when it is noted, accidentally, for four days in a row that "the patient is going to cardiac cath today."  This particular problem creates a chart that is untrustworthy - an issue for patient care to be sure, and also for risk management and regulatory compliance.

There is an even larger issue with the structure of most EMRs.  To the non-physician, the only way I can think to describe it is as a Picasso effect.  You know those paintings where the lady has two eyes on the same side of her face, or a nose coming out of her shoe?  In yesteryear there was a section of the physician's note where he set down his diagnostic impression, usually in the form of two or three sentences that summarized the salient symptoms, physical findings and study results in a way which made the case for one or several alternate diagnoses.  This was the distillation of his medical detective work, and his thought process was laid out for his colleagues to appreciate.  To extend the metaphor, this was the coherent picture of the patient's situation.

This has vanished.  In its place is a set of fields for "problems" attached to ICD.10 codes.  It is the clinician's job to atomize his actual "impression" so as to fit this format, which more often than not obscures the diagnostic thought process.  More fundamentally, it may interfere with diagnostic reasoning itself.  Diagnostic error is hard to measure, but it is hard to image that this is not increased by a system of record keeping that discourages narrative.  Author Joan Didion famously said, "I write entirely to find out what I'm thinking."

Perhaps I am being too optimistic, but I do believe that the current problems will be solved. The question is when. The VA system's EMR is reportedly much better liked by its users than any others, and it's an old system by IT standards.  We have to insist on better.  Our patients deserve no less, and our profession, our wellness and our very lives hang in the balance. 

Ref:
1.  T Brown and S Bergman, "Doctors, nurses and the paperwork crisis that could unit them," NY Times, December 31, 2019
2.  J Weiss and P Levy, "Copy, paste and cloned notes in electronic health records," Chest 2014, 145(3): 632