Thursday, June 11, 2009

The problem with EMRs

Despite public clamor for widespread adoption since publication of the IOM’s To Err is Human, a decade later we still lack hard clinical data to show that EMRs enhance patient safety. If anything they may be adverse to the cause of patient safety. Why? Multiple reasons are considered in a recent editorial in the Archives of Internal Medicine. In particular the authors list nine pertaining to CPOE:

(1) additional work for clinicians; (2) unfavorable workflow changes; (3) never-ending demands for system changes; (4) problems relating to persistence of paper records; (5) changes in communication practices with false assumptions; (6) negative emotions generated from changing established practices; (7) generation of new types of errors ("e-iatrogenesis"12); (8) loss of ordering autonomy to accommodate CPOE goals and system limitations; and (9) overdependence on the new technology.13

For the most part these are problems in the institutional culture built around the EMR rather than any limitations of the EMR itself. Additional work for clinicians is created by taking nurses and secretaries out of the loop of many aspects of order processing in which clinicians have no prior training or experience. The theory is that removing a layer of human involvement removes one more opportunity for error, making the ordering more direct and clean. That theory, by the way, has no evidence to support it, and it’s equally plausible that this actually removes a layer of safety. In other words maybe we would be better off to take the P out of CPOE! In many ways order processing is baggage which distracts doctors from real clinical issues.

Item 5 is “changes in communication with false assumptions.” You bet. One such false assumption is that after conversion to a paperless system nurses will remain as engaged as they were in the paper days. Not that they don’t want to stay engaged (and the exceptional ones will), but the EMR burdens them with so much onerous and meaningless “documentation” that their time for honest to goodness patient care is limited.

Item 8 speaks of “loss of ordering autonomy to accommodate CPOE goals and system limitations.” Yeah. Remember how nice and easy it was to write your favorite 3 day steroid taper in paper orders? Or “hold coumadin any time INR is greater than 3?”

Electronic notes open up a whole different set of problems:

For example, rigid structures or templates impede readability, and the patient's story may become a patchwork of cut and pasted excerpts.19 Cut, pasted, and propagated
preliminary test reports or inaccurate historical content can easily lead to incorrect decisions downstream. Independent histories and examination findings may never be recorded or may be missed as when a single physician's history is copied again and again. Overly long notes, facilitated by "copying forward" with new daily increments, contribute to an inability to quickly page through the medical chart for critical information…. It becomes clear quickly why a loss of confidence in the accuracy of the medical chart might emerge.

I’ll take the old handwritten barely legible one liner any day.

The mandate for universal adoption of EMRs over the next several years is ill conceived and premature.


Anonymous said...

EMR when properly implemented can have a lot of advantages too. Unfortunately most current EMR's are poorly designed and don't bring the advantages they could. For example I am still waiting for the day I can order lab tests and x-rays with one or two clicks. Also complicated medication schemes can also be made as easy as a few mouseclicks...

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EMR Medical said...

Electronic medical record (EMR) is like piloting an airplane; it is an incredibly efficient piece of technology, but without expertise and practice using it, it won't do what one wants. And although EMRs can solve workflow problems.