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ER Goddess

ER Goddess

Physicians Must Demand Accountability from EMRs

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000655008.23298.28
    Figure. EMR
    Figure. EMR
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    The gap between expectation and reality is where frustration lives. This is where doctors and nurses find themselves when it comes to electronic medical records. We had great hopes for EMRs in 2009 when Obama signed the HITECH act requiring all physicians to abandon paper charts. Ten years later, a vast chasm runs between those expectations and the actuality of being handcuffed to cumbersome and error-prone EMRs. Physicians are exasperated, and the $13-billion-a-year industry that sells EMR technology profits at our patients' expense.

    We hoped for systems that would make medical practice easier and more efficient, but we've been forced to adopt technology designed more for billing than for supporting nurses and doctors. We hoped for a universally accessible information network that would allow patient records to be accessed by any doctor or hospital in the country. Instead, we have countless different proprietary EMR systems that don't talk to one another, so 36 billion tax dollars later, we are still transferring data via fax and CDs.

    Our nation has spent the past 10 years trying to transition our medical records from horses to automobiles, but we're still using early technology without seat belts or air bags, and it will be deadly if we're not careful. (Kaiser Health News. March 18, 2019; http://bit.ly/2CJHK84.)

    Last month I wrote about how human fallibility can lead to problems when we grab the mouse and get in the EMR driver seat. (EMN. 2020;42[1]:9; http://bit.ly/2udRNkD.) If we want to keep patients safe as we drive their care using fledgling EMRs, we must recognize that we humans are not solely responsible for these errors. The EMR technology itself is just as culpable because of its inherent fallibility in two serious technology shortcomings that endanger patients—data omission and information overload.

    Data Omission

    All too often, valuable information we enter into EMRs is simply lost in cyberspace because of an internal software glitch or communication failure between systems. Thanks to escript transmission errors, I've had patients show up to pharmacies without a prescription. Fortunately, there is usually real human contact between patients and pharmacists, who call on their behalf. But what happens when a lab test or radiology order fails to transmit, no one on the receiving end is looking for the order, and we have no idea that our order never went through?

    Several lawsuits have been filed over exactly that issue. The order for the head CT that would have identified Vermont lawyer Annette Monachelli's bleeding aneurysm was simply never transmitted after her primary care physician ordered it through the clinic's software system, eClinicalWorks. She died two months later from that undiagnosed aneurysm, leading to a first-of-its-kind case against eClinicalWorks, which ended in the largest financial recovery in Vermont. (Kaiser Health News. March 18, 2019; http://bit.ly/2CJHK84.)

    Likewise, the order for herpes simplex testing on Fabian Ronisky's CSF was never transmitted to the lab, delaying the diagnosis of herpes encephalitis and administration of acyclovir. The order appeared on Epic's screen, but its software didn't interface with the lab's software. Epic claimed the doctor didn't click the right button to send the order and that the hospital, not Epic, had configured the interface with the lab. They then quietly paid to settle the suit. (Kaiser Health News. March 18, 2019; http://bit.ly/2CJHK84.)

    Even when temperamental computers are working without glitches and not losing the information we give them, the EMR designs fail to give us crucial information. Certain information fields, for example, are not accessible to all staff, so physicians' free text comments may be missing from the screen when the nurse views the order. In one instance, a physician typed instructions in the free text field with an amlodipine order, not knowing the field was only for use by pharmacy. The stipulation that the drug be held for when a patient's blood pressure was below a threshold was omitted on the nurse's end, and the patient received the drug while hypotensive. (Health Data Management. http://bit.ly/35hfaXe.)

    The system I use omits the detail of whether a drug is in our ED. I don't know that I've delayed patient care by selecting a medicine we don't have until a nurse says we don't have it or that it's coming from the pharmacy.

    In some systems, even what one would think would be one of the most basic functions of EMRs and certainly one of the most important advantages—drug allergy alerts—are omitted in some circumstances, such as when medications are listed as part of order sets. Information omission in this scenario can be deadly.

    Overload Dangers

    Information overload can be as dangerous as information omission. Alarm fatigue is particularly problematic. False alarms account for between 85 and 99 percent of ED alerts. It's easy to overlook the real medication alerts because we have to click through so many “fake” ones about minor drug interactions and insignificant cross-sensitivities.

    Cluttered visual displays with hidden bottom lines also put patients at risk. It's difficult to find the important information when we are visually assaulted with a screen of inessential data displayed in confusing ways. In some systems, EPs see a dropdown menu listing 86 options just to order Tylenol. Our cognitive load should be medical decision-making, not dropdown menus in a tiny font. We make mistakes when we divert our mental energy away from doctoring to focus on reading through dosages and forms. Physicians unintentionally select the suppository rather than tablet form in roughly one of 1000 orders. (Health Affairs. November 2018; http://bit.ly/2QDOV85.)

    Order sets can pose problems too. There are order sets for blood transfusion, antivenin, pediatric fever, stroke, myocardial infarction, sepsis, and everything else under the sun. These sets are complex to look at, and they set us up for ordering unnecessary imaging and labs when we don't have the time to cull carefully through every item.

    EMRs can overload our prescriptions with auto-populated administration schedules, which may save time but can set us up to err. I recently had a pharmacist ask if I meant to prescribe only one ondansetron. I didn't. When I convert a medication given in the ED to an outpatient prescription, the EMR automatically transfers the quantity given in the ED to the prescription. If I forget to change it, the patient is prescribed only one dose. I never had that problem when I wrote out my prescriptions.

    Who is held accountable when EMR technology hinders good patient care? There are gag orders to protect EMRs, but no protection for nurses and physicians when we fall victim to the dangers of the systems. EMR companies will point the finger at us, making the case for user error over shortcomings in their technology. If we are going to be held responsible, we must not allow ourselves to be set up for failure by accepting technology that falls short. We must hold the makers of the technology accountable and demand a product that is more clinician-friendly than coder-friendly. It's time to take a hard look at how to improve EMR technology to maximize patient care success.

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    Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.

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