Problems with VA’s EMR

A tip of the Dr. RW hat goes to Retired Doc (glad he’s back from his blogging hiatus, by the way) for reporting this story:

The top Republican on the House Veterans Affairs Committee
demanded Wednesday that the VA explain how it allowed software glitches to put the medical care of patients at its health centers nationwide at risk.

Reading between the lines of this report it appears there were two issues, one of which, patient data showing up under the wrong name, was indeed a glitch. The other issue, inappropriate medication stop times, may be more complex and illustrative of a more pervasive problem in how we use EMRs.

Disclaimer: I have never used the VA EMR but I have received electronically generated records from the VA and talked to some users. The print outs have a lot of electronic clutter. Frustrated users describe multiple mouse clicks for simple tasks. I can easily imagine the resulting user fatigue making it difficult to follow order trails. A more general problem with hospital EMRs that feature CPOE is that secretaries and nurses are disengaged from their traditional roles in order processing. Consequently an important safety net is removed. That’s a problem with the culture around implementation of the EMR rather than the EMR itself.

Specifying the duration of medications by directly entering start and stop dates is counterintuitive to how we did it in the paper days not to mention distracting to the traditional clinical train of thought. In the paper environment I could order a tapering course of steroids by writing “Solumedrol 80mg IV Q 6 hours x 4 doses then 40mg IV Q 6 hours x 4 doses then 20mg IV Q 6 hours x 4 doses then D/C.” Although it was clear to me and others exactly what I wanted clinically the order processing was, for me, a black box---not what I was trained to do. The secretary and nurses, knowing my clinical intent, took care of all the entry and processing stuff, and all the checking and double checking to make sure it happened as intended. Not fail safe, but worked well. All those layers of safety are gone in the electronic environment, where entry and processing are in the doctor’s lap. So I can imagine a gazillion ways infusion times got messed up in the VA system by virtue of design, not necessarily a glitch.