A Trip to the ER: EMRs Aren’t Enough

Guest Post: I got the following story that someone wanted to share about the challenges of EMR and workflow in a hospital. I love reading first hand experiences with EMR. Reminds me of a great experience that Neil Versel documented at an urgent care during HIMSS. I look forward to hearing your comments on the story.

Last month, my wife felt some discomfort in her chest. They weren’t pains, nor were they indigestion so much as a gurgling sensation. After two days and no change, she called our family physician. He told her she could come in for a blood enzyme test, but the lab result would take four days. Instead, he said to go to an ER where they could get the result in half an hour.

That evening, a Friday, we went to the nearest ER, at Large, Modern, Suburban DC hospital (LMSDC.) We walked right up to the triage nurse, a woman in her 60s who stood there and took down my wife’s info on paper: Name, Chief Complaint, Age, and Triage Class, a 3. We were handed the paper, the only copy, and sent to the first of what would be three exam rooms.

The room was for EKGs. It was equipped with a machine, bed, etc., and a desktop PC. After a few minutes, a tech came in and ran the test. I asked how the scan got into my wife’s record. She told us it was sent electronically to imaging where it would be reviewed and put in the record, but she didn’t know how it was entered, electronically or scanned in.

We had three more visitors, two nurses and an admissions clerk. Admissions came in with a COW, a computer on wheels. She started asking demographics, insurance, etc., but was called away. The first nurse came in went over why we were there, about meds, etc., took a blood sample and did something on the room PC and left.

The second nurse came in, went over symptoms, meds, etc., again, and scribbled the information on a scrap of paper in her hand. We never saw either nurse again. While waiting for the next step, I saw that the first nurse had logged into the PC, but not logged out.

We were then moved to a small exam area with five beds to wait for an attending and to wait for four hours until time for another blood sample. The area was run by a tech I’ll call Sam. Sam was a remarkable multitasker. Among other things, we saw him:
• Arrange patients and families in the cramped space
• Look for other staff
• Take blood
• Check orders
• Organize a stack of loose forms into their patient clipboards
• Change bed sheets
• Check the EMR for updates
• Check on patient moves

Sam did all this, and from what I could tell, was the only person who was actually followed the different aspects of his cases.

At first, the area was at capacity with crying children, their worried parents and others typical of a Friday night in an ER. While Sam directed traffic, the admissions clerk caught up with us and finished my wife’s record.

Around nine, an attending came in. He stopped midway in review for a half hour cell call and then returned. He recommended that she should go on a heart monitor and stay overnight. After the attending’s visit, we settled down to wait for a room. Sam checked every now and then to see where it stood, but it went nowhere.

About eleven, while making my second run to the ER vending machines, I saw the attending and mentioned that it was getting pretty boring waiting for a room and a monitor. Surprised, he said he’d ordered the monitor and that it should have been put on in the ER. With that, he checked with the charge nurse to get it done. The charge nurse came to see us and had us move to another area with a monitor, which a nurse started. Just after midnight, still waiting for a room, my wife sent me home. She called about one to say she’d been moved to a medical floor and was on a monitor.

I knew that LMSDC adopted an EMR three years ago and, indeed, it was clear that meds, complaints, orders, etc., were being entered into it. However, it was also clear that their system was a receptacle not a workflow tool. Apparently, LMSDC simply overlaid the EMR on its paper system, eliminating some parts, but keeping others. These other elements persist in their own parallel world. For someone such as Sam, who tries to keep his patients current it means more work not less. This explains why he had to deal with the EMR and constantly sort and organize paper forms into their proper patient clipboards.

Even that is not LMSDC’s major ER workflow problem. The heart monitor problem shows there is no shared task list. That is, once the attending entered the order, and I believe he did, the order is in the EMR. However, who is to carry it out and when should become a task that all others can see. Thus, the conversations among the attending, the charge nurse, Sam, my wife and me should have been unnecessary.

A couple of gratuitous points. LMSDC’s system is heavy on desktop machines. It cries for laptops or pads. Nurses, techs, attendings spend their time flying from one desktop to another, logging in and, sometimes, out. It’s a machine centric rather than a user centric system. Users never have their own workspace. They are always in hit and run mode. Even if they have a good system workflow and a good shared task list, they spend enormous time and energy logging in and out of room machines. It’s no wonder things get lost in the cracks.

LMSDC’s system runs both patients and staff ragged in another way. We moved three times, no record I expect. Nurses came and went. The attending should have been on skates. The only one with a dedicated space was Sam which explains why he could get so much done without exhaustion. How much easier their difficult lives and their patient’s lives would be if the patients came to the staff rather than endure the ER’s fast action minuet.

What’s so amazing is that despite their poor IT support and their constant motion, the staff was invariably professional, focused and friendly.

Best of all, after a night in the ER and a morning on a medical floor, my wife was discharged. She’s fine.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

8 Comments

  • Glad to hear the patient in this story is fine. Nothing like going to the ER on a Friday night with heart pain!

    I am a salesperson for Microsoft. I focus specifically on our CRM solution for Healthcare.

    This story interests me greatly. EMR’s are not a tool for care coordination as this story so wonderfully illustrates. EMR’s hold critical information to enable care coordination but they have no workflow capabilities etc. This is where CRM completes the solution.

    Here’s a 5-minute demo providing a highlight of CRM in a “Patient Relationship Management” context.

    http://www.microsoft.com/dynamics/crm/demos/healthcare/MSDynamicsCRM_Healthcare_PRM_Silverlight_WEB_072008/default.html

  • Sadly, the story is about as typical as it gets. I too am glad that the author’s wife is well, but it seems that is the case despite the system rather than because of it.

    Despite the hype, there is no doubt that EMRs are not intended to assist in patient care. Their primary purpose is to assist in the documentation of patient care, and the “assistance” is directed not towards the efficiency and effectiveness of those who provide the care, but for the E and E of those who monitor and pay for the provision of that care.

    LMSDC probably reports glowing improvements in their care and attribute those improvements directly to the EMR (when it is advantageous for them to do so!) In fact, there is a real question as to whether the inefficiency imposed by the use of the EMR is offset by the increased collections the hospital receives due to its use. There is little question as to whether the actual health care provided is improved – a number of recent studies have demonstrated that it is not or is, at best, only slightly improved; certainly not by enough to justify the added costs.

    It is ironic that the documentation demanded by the government and insurers is both the reason EMRs have received so much emphasis as well as the reason they have generally been such relative failures. The current goal of most EMRs, by necessity, is to turn a paragraphical narrative of medical decision making and treatment into an auditable “pick list” of reimburseable diagnoses.

    It’s hard to foresee a set of circumstances and technologies which will achieve that goal without causing terrible redundancy and inefficiency; so far, it seems my view is consistent with the reality of the EMR industry.

    Regarding the comment about customers – yes, patients are customers. Problem is, most of them don’t realize that the system views them as such. Health care payment systems have no illusions about the ethics of patient care – they are all about the money. It will be an interesting day when the patients realize that.

  • A Davis,
    I agree with much of what you said. Most EMR systems weren’t even designed to improve patient care. They were documentation engines and reimbursement engines. That needs to change.

    However, your comments about recent studies seem to come from someone who has just read the headlines and not the actual studies. Here’s one post I did about a study which describes how a headline doesn’t describe well what the study actually found: https://www.healthcareittoday.com/2011/01/25/study-ignores-other-benefits-of-electronic-health-records/

  • John,
    At the risk of appearing argumentative, I respectfully disagree. I did read the studies. Where we differ appears to be on what one defines as “health care.”

    As you noted, we agree that current EMRs are designed for documentation rather than patient care. Accepting that does not preclude the notion that there are other benefits to using an EMR, and I have alluded to them in other comments in other venues. Those benefits, however, do not include improved health care, when health care is defined as the provision of knowledge, judgment, testing and treatments related to eliminating or limiting the effects of a pathological process or event.

    As a business tool, EMRs do have utility, and the link you provided helps demonstrate that. If the onerous federal and insurer documentation requirements could be eliminated, they clearly would have great utility. But, as your link also suggests, the business environment of health care is not the same as the provision of medical care, and the claims that EMR usage equates to better medical care are simply not well supported.

  • A Davis,
    I don’t mind argumentative as long as we avoid personal. Plus, I’m perfectly fine to agree to disagree with people who have different opinions. Some of my favorite people are ones with whom I disagree on many topics.

    Although, I think you’re right that we mostly agree with each other and it was more a matter of defining health care. I was defining more of the business of health care and your definition is a bit different: “provision of knowledge, judgment, testing and treatments related to eliminating or limiting the effects of a pathological process or event.”

    I will say that I’ve seen the inklings of where EMR could actually improve health care the way you define it as well. Although, I’d definitely agree that we’re not there yet and still have quite a ways to go before it will happen. However, getting the data electronic is one of the first keys to unleashing the power of the data so that it can improve health care in the ways you mention.

  • John,
    We definitely agree on a lot, but I’m not quite ready to call it a love fest.

    It seems to me that there are 2 big, fundamental problems with EMRs which overshadow all others. One is the use of medical staff as data entry clerks, and the other is the demand that the medical decision making process be reduced to a set of billing codes.

    The data entry issue is essentially technological. Voice and handwriting recognition will eventually allow the needed ease of data entry which is currently lacking, and there is ongoing progress there.

    The “thinking to billing” conversion is more problematic. Apart from the obvious loss of information (as opposed to data) in the process, the transition of goals from providing care to paying for it is profoundly oppositional to the foundational tenets of medicine which put the care of the patient above all other concerns.

    The business of medicine cannot be ignored, but nor can it be allowed to become the looming shadow in the exam room which the EMR is potentially (and, in some cases, actually) causing it to be. Business should be a back office function, but it is a goal of payers (govt and private) to put it front and center between the patient and the care provider. Allowing third party payers to do that is ultimately destructive to medicine and to medical care.

    The only sound approach to addressing the business of medicine is to cause the patients to have some economic “skin in the game”, so that they will make, individually, the rationing decisions that their personal situation dictates. That sounds harsh, but it is much less harsh to require a person to make hard decisions than to have those decisions thrust upon him or her based on the economic priorities of big business or big government.

    If business is _not_ the goal, then EMRs in the exam room have a bright future. If business remains the goal, then EMRs will simply become a rationing tool used to limit costs for the third party payers.

  • Dang, I’ll have to keep working on the love fest.

    The data entry/interface portion of an EMR must be improved. It’s absolutely the pain point of EMR software. I’m not quite as convinced that voice and handwriting recognition will be the solution. Although, I’m not sure what will be the solution.

    I can’t help but wonder if a new model of care really is the solution. As you say, the patients need to have more skin in the game so that doctors will provide better care instead of maximizing reimbursement models which don’t have the patient’s best interest in mind.

    Of course, this new model of healthcare will require good data from an EMR. Unfortunately, most EMR software today is a big billing engine as opposed to a patient care engine.

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