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ER GODDESS: Anyone Have a Sledgehammer?

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000484526.25678.e3
ER GODDESS

Dr. Simonsis a full-time night emergency physician at Henrico Doctors' Hospital in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns athttp://emn.online/ERGoddessEMN.

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I have a fantasy. It involves my computer in the ED and a sledgehammer. The computer ends up on the floor smashed to pieces, and everyone ends up taking verbal orders the rest of the shift.

You may be wondering what the computer ever did to me and how I could harbor such hostility for technology that is supposed to make health care better. If you are, you clearly haven't experienced computerized physician order entry (CPOE). Yes, readily transferable and accessible information at our fingertips sounds great in theory. Computers make EPs omnipotent in patients' eyes, as shown by the expectation that two seconds after they roll into the ED we know the entirety of their medical history and medication list because it's in the computer. The reality is it's not that easy, and there are still many kinks with electronic medical records (EMRs).

My top three frustrations with EMRs, in no particular order:

1. Physicians should be physicians, not data entry clerks.

If I were asked 20 years ago what skill would be most important for my medical career, I never would have answered “typing.” Now I often feel that I went through med school and residency essentially to be the highest paid clerk I know, sitting at a computer entering ECG and saline lock orders.

I've practiced long enough to remember how it used to be with paper charts. I used to be able to simply tell the nurse or clerk to order what the patient needed. Now, the nurses are telling me I have to enter orders for things that everyone knows the patient needs. I've had respiratory scold me for not putting in an order for BiPAP on a patient in respiratory distress. A particular favorite is when I order a troponin point-of-care and then point-of-care testing goes down and suddenly it's my clerical emergency to change the order from point-of-care to lab. Somehow I've turned into everyone's secretary.

I miss the days of verbal orders. “Morphine STAT!” conveys a lot more concern and urgency when a patient is writhing in pain than “click, click, click” on a keyboard. With the goal of 100 percent CPOE, verbal ordering is dying, and I'm not sure who benefits. Patients? I doubt it. Would you want your physician sitting and mindlessly clicking in computer orders instead of thoughtfully reading your chart, conferring with consultants, and using her education to make medical decisions? Achieving 100 percent CPOE is basically synonymous with interrupting physicians 100 percent of the time to enter Foley orders and change troponin from point-of-care to lab.

2. If we're expected to be clerks, we at least need a customized operating system.

Hospitals want it all. They expect close to 100 percent CPOE while keeping down wait times and length of stays, yet hand us an EMR that handicaps our efficiency. Why in 2016 are we using the Atari of electronic systems? To see every patient using an archaic EMR when I'm solo on a busy night leaves me with hours of unfinished charting to do in my time off or in want of a scribe to keep up with data entry. The fact that physicians did not require scribes before EMRs speaks volumes.

We lose as much valuable time clicking through cumbersome EMR interfaces as we do trying to troubleshoot computer issues. Nothing brings the entire ED to a halt like the physician's computer being disagreeable. It's difficult to do patient care when you're on the phone with the help desk. I've been found on my hands and knees under my desk trying to figure out why my computer won't connect to the server. It's also not unusual to spend 10 or 15 minutes dealing with an ornery printer. And then there is the special treat of system downtime. Who schedules downtime on a Monday night, the busiest night in the ED?

It's frustrating that we are doing printer repair and clerical duties instead of the medical decision-making for which we are trained. There should be a month of med school devoted to printer/computer pathophysiology.

3. Computers should not come between patients and their emergent medical care.

A patient with acute onset CVA symptoms rolls in via EMS. What's the first thing you do? These days it's not A, not B, not C, but K — the keyboard. “I need an order before she can go to CT” is not something that should ever be said about someone with an acute neurological deficit. Getting the patients into the computer has become more important than taking vital signs because, sadly, little to no care can happen anymore without a physician or nurse clicking through screen after screen of an EMR. Often this applies even to acutely ill patients. As much as it makes for a nice chart and prolific billing, EMR screens won't stop a patient's seizure, but giving benzodiazepines will. It is greatly frustrating for physicians to know that patients won't get necessary care until they are registered in the computer and all of the orders have been appropriately entered.

Computer first, care second might be acceptable in an office setting where people are stable, but it most certainly is not OK in the ED when life-saving interventions are time-sensitive.

What about emergent verbal orders? They don't consistently work. Nurses on many occasions haven't been able to override emergent medication. I recently couldn't get verbally ordered heparin for an unstable STEMI patient. Apparently, I'm supposed to stop intubating, lining, and resuscitating and run to a computer.

I will never get used to running from the bedside of a crashing patient to the computer to enter orders. It's wrong that docs have to walk away from sick, coding patients and find a keyboard to make those lifesaving clicks. Emergent care shouldn't be subjected to computer paralysis. It's time to improve our EMRs and how we use them so they consistently improve care instead of impeding it.

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