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Emergentology

Emergentology

The EMR Dilemma

Hidden in Plain Sight

Walker, Graham MD

doi: 10.1097/01.EEM.0000655004.29136.91
    Figure. EMR
    Figure. EMR
    Figure
    Figure

    If you're like me, you work with an Epic EMR. (Cerner, Meditech, AllScripts users: worry not, this is relevant to you too!)

    You've probably heard of Storyboard, a new user interface coming to the Epic EMR. Essentially all of the “relevant” info that users need about a patient is available to them on the left side of the screen: a photo of the patient, his demographics, some other background information, and, new to the sidebar, information customized to the particular user's “role.” An emergency nurse, for example, might see different information from the emergency physician, who might see different information from the interventional cardiologist, and so on. These are set up by Epic, with some customizability by the hospital, but I don't think customizability by the end user (at least not yet).

    Yay. I think. It's an acknowledgement that health care has a lot (a lot a lot) of different roles, and those roles really affect our goals for the patient (and therefore what should be displayed front and center in the EMR). I care about things (disposition, disposition, disposition) that the internist doesn't really think about, and vice versa. I want to see a trend of vital signs during the visit or if the Zofran has been given. The internist might want to see blood pressure readings over the past year or preventive care the patient needs.

    This role-based design is probably pretty similar to how we all end up using the EMR differently, even if it is designed as one size fits all. The anticoagulation pharmacist certainly reviews a patient with a totally different mindset from mine. He probably rarely reads discharge summaries, and never really cares what yesterday's urine culture is growing. Maybe he has filters set up to hide the neurology notes or a report that auto-trends the INR.

    This customization coming from Storyboard is a welcome change, but the information I want is a lot more nuanced, and that actually can be frustratingly difficult to find.

    Hiding Information

    There are things we always care about because they can and do always change what we do about a patient on a blood thinner, who has active cancer, or is pregnant. Then there's the stuff that matters depending on chief complaint. If you cut your hand, I don't really care if you have high blood pressure, glaucoma, or asthma or if you had hernia surgery last week. But if you're here for abdominal pain or chest pain, I probably care whether you were recently hospitalized or had surgery or a recent ED visit.

    Clinical informaticists often talk about the critical importance of the EMR not hiding information from users, like if the patient just saw his cardiologist for worsening angina and had a positive stress test; that information should be listed in the chart in case the patient forgets or can't tell you.

    Sadly, just as your smartphone's photo app holds photos you'll never look at again and you never clear it out, the EMR seems to have an insatiable appetite for documenting everything. Every. Little. Thing. Our medico-legal system and the if-you-didn't-document-it-didn't-happen culture encourages this, no doubt, but so does the EMR itself: Don't hide anything from users ever. Show. Them. Everything. It's like a digital hoarder's dream.

    When I'm trying to quickly figure out why an unconscious man has a GI bleed, whether he ever had an upper or lower endoscopy, if he's on blood thinners, if he ever was admitted for GI bleeding, if there is a note from gastroenterology or any recent primary care visits for dark stools, fatigue, or anemia, or to trend his hemoglobin, I open the chart and am given every little detail that I simply don't and will never need.

    Front and center, defaulted to reverse chronological order, I'm given the fact that the nutrition team called him three weeks ago, and he didn't answer. And then a cryptic note that he was scheduled for an endoscopy two months ago, but it was cancelled. And then three more phone-tag notes and then seven emails to and from his primary care physician about a skin tag and his anxiety. Then there are another two visits from psychiatry. And five notes seemingly to get an outpatient chest x-ray. Finally, I see his discharge summary from last year showing his admission for GI bleeding due to severe diverticulosis.

    Finding Information

    There are obviously other ways to look for information in the chart, and lots of ways that Epic and other EMR vendors have tried to address this issue, by adding a search bar (Epic's is often inaccurate or too broad), looking at the problem list or past medical history (sometimes these are out of date, inaccurate, or blank for patients visiting from out of town), and adding filters for discharge summaries, specialty, and procedure notes.

    This is not a dig at Epic or any health system or hospital. But it is, I hope, some acknowledgement that we've reached a turning point in digital medicine (or jumped the shark). If we show the user everything, we often hide the critical information buried in a sea of documentation garbage. It's like when the White House or local state government releases 12,000 pages of documents on a topic. They're betting that the one smoking gun email on page 9152 will be missed.

    I am looking forward to this user role-based design project Epic seems to be encouraging, but I think it won't go far enough. Give me a filter for notes and information that an EP would care about based on a particular clinical scenario, and I'll be able to do my job doctoring instead of clicking, skimming, and scrolling.

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    Dr. Walkeris an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns athttp://bit.ly/EMN-Emergentology.

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