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ER Goddess

ER Goddess

Why EMRs Don't Work for EPs

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000650968.84260.39

    I doubt anyone fully grasped how dangerous the click of a mouse could be back in 2009 when President Obama signed the HITECH Act requiring physicians to abandon paper charts and begin using electronic medical records. The past decade has introduced a whole new world of medical errors by putting EMRs in the hands of fallible humans. Even when computers function flawlessly, the humans using them certainly do not.

    Even the brightest physician's working memory can only process a finite amount of new information at a time. Physicians are less efficient at task-switching and less likely to complete tasks when their working memory gets overburdened with competing stimuli. (Ann Emerg Med. 2016;68[2]:189; When we are interrupted, our performance suffers. Before EMRs, when we were still using timesheets, physicians were interrupted an average of 31 times in 180 minutes. (Acad Emerg Med. 2000;7[11]:1239; Now we are interrupted even more by incessant requests to enter orders.

    With paper charts, we still had the page we were working on in front of us when we got interrupted. Now, requests for orders force us to toggle away from that task. Evidence has shown that when tasks are similar, as when we're toggling between two patient screens, we're less likely to return to the primary task because our mind has just completed a similar task and incorrectly assumes the first task is done. (Ann Emerg Med. 2016;68[2]:189; Even if we do toggle back to our original screen, we're more prone to error because of the increased cognitive load of data entry. Judges don't do court stenography during a trial, and CEOs don't take minutes while running a board meeting. (KHN. March 18, 2019; Alas, doctors do not enjoy the same privilege of cognitive offloading.

    Errant Clicks

    Making us click a mouse for every test or treatment not only heaps more cognitive burden onto our shoulders, but also makes it frighteningly easy to make a wrong click. Sometimes we mistakenly click the right order on the wrong patient. Maybe we thought we closed a chart, but lag kept the old one open; maybe someone took a patient off the tracker and it jumped; maybe as we switch between charts, we're so focused on our medical decisions that we don't realize whose chart we're in. Any of these mix-ups could result in something as egregious as a patient with ankle trauma getting the chest CT meant for the patient with dyspnea. Sometimes we're in the correct chart, but we unknowingly click the wrong order.

    Speed and accuracy are inversely related, so sometimes we click one up or one down from the item we wanted as we hastily place orders to meet time metrics. We may also confuse items that are visually alike—NS 20cc/kg for NS with 20 KCI, tbs for tsp, Flonase for Flomax, VEC for VANC. I had a colleague who wanted a soft-tissue CT of the neck but accidentally ordered a CTA because it was named “CT Neck-Angio” and she didn't see the angio part.

    Sometimes we miss a click altogether and accidentally order nothing. It took me several shifts with Epic to remember that “Accept” does not equal “Sign” for discharge prescriptions. I'd print my discharge and look for the prescriptions only to realize I hadn't made that second necessary click. If we get interrupted before clicking “Sign” or we close without saving, despite our thought and work, our patients get exactly what we ordered—nothing.

    Computer-Mandated Delays

    Computers force ED staff to do their jobs linearly rather than simultaneously, and they magnify human inefficiency by allowing an incomplete task by one person to block time-sensitive care by others. It can be downright scary when we are unable to order meds or tests on critical patients because they have not yet been registered in the computer system. Even when they are in the system, we're unable to enter certain orders until data have been entered in specific fields, like weight for pediatric patients. Then, we often have to wait for orders to be verified by a pharmacist, who is not even in the ED and has no idea how critical the patient is or how time-sensitive the order is.

    Patients can't get printed discharge instructions at the end of their ED stay until they are registered. On nightshifts when there is just one registration clerk and I'm rapidly moving through a high volume of low-acuity patients, patients often sit for an hour after I've discharged them. This type of computer-mandated delay didn't exist 10 years ago.

    Even more frustrating than waiting for others to do their jobs is when we can't do our own job in a timely way. Sometimes I can tell a nurse in two seconds exactly what medicine to give, but it takes 10 minutes to figure wout how to order it in the computer. This will invariably happen to the sickest patients because they require drips, which are the hardest to order.

    No matter how clinically efficient you are, you won't be able to do anything fast if you don't know the idiosyncrasies of your particular EMR. You'll spend precious time discussing the specifics of your order with a nurse, canceling your order, then redoing it, like the time I ordered tetanus as tetanus and was asked to change it because tetanus in my particular system is supposed to be ordered as Boostrix (who knew?), or when I selected a lidocaine concentration that wasn't in my Pyxis. Once I ordered an ultrasound in ultrasound instead of in the ED, so the ED ultrasound tech didn't see my order until I redid it with the correct location tag. These kinds of piddly little details delay patient care.

    It's downright scary how computers can magnify human error and inefficiency. A physician clicking the wrong box can escalate to a deadly error, and one person getting held up or missing a click can end in nerve-wracking delays in care by the rest of the team. Armed with a mouse and a keyboard, we're set up for more spectacular mistakes and delays than we ever were with pen and paper. As we move forward in the era of EMRs, we must be wary of just how dangerous it can be for patients at this vulnerable intersection of technology and human fallibility.

    Next month: The fallibility of EMRs themselves.

    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 at

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