Healthcare // Electronic Health Records
Commentary
6/20/2014
10:48 AM
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EHR Proliferation Hurts Physician Workflow

Doctors are being forced to pull data out of multiple EMRs -- plus use phones and pagers -- to care for patients. This context switching slows down work and frustrates the goal of electronic health data.

Technology Declares War On Cancer
Technology Declares War On Cancer
(Click image for larger view and slideshow.)

This year's medical student graduating class will be the first group of physicians trained without paper-based medical records. These students understand how electronic health information is supposed to be better than paper, but what will they encounter in reality? Most doctors and other healthcare workers already in the trenches are familiar with less-than-positive scenarios.

Let's say a Mr. Jones is admitted to the intensive care unit with a possible cardiac condition. You spend close to one hour reviewing his medical history in the ER. Concerned with his EKG tracing and abnormal electrolytes, you admit him to the cardiac intensive care unit.

Later, the cardiac intensive care unit pages you. The charge nurse in the ICU doesn't know why you were paged and tracks down Mr. Jones's nurse. She received a call from the lab about an elevation in his troponin level and wanted to advise you of his slowly declining blood pressure and increase in heart rate. She also mentioned that his EKG and chest X-ray have been completed and are in the "system." You review the findings to create an assessment and plan.

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Your computer requires you to connect to the VPN client and log into the hospital system. Once a secured connection has been obtained, a gateway into the electronic medical record (EMR) system enables you to access his labs. You see nothing ominous, so you navigate to the nurse flow sheet.

Navigating EMR gulags
You begin dealing with the technical difficulties of the EMR and the disparate pieces of data that summarize Mr. Jones's physiologic state. Closing that EMR, you next connect to the radiology management EMR system to view his chest X-ray. A similarly slow process allows you access to his EKG, stored in yet another cardiology management EMR. After navigating three different EMRs, you make a diagnosis and prescribe a course of antibiotics. You enter the orders into another EMR. Data is stored, transferred and acted upon in disconnected and unrelated systems.

(Image: Ardonik (Flickr))
(Image: Ardonik (Flickr))

In another scenario, a healthcare provider might receive a piece of information, such as a set of vital signs or the result of a lab test. If the information raises a question or requires a decision from a physician, the provider calls the doctor. The contact is often a manual one, using the antiquated paging system or some technological surrogate such as text messaging or a phone call. Regardless of the contact method used, doctors are not always in a position to take a call or page. That person might not even be the doctor for that patient anymore.

The dizzying pace of context switching
Although the specifics vary with disease and patient, this flow of work -- even in today's EMR-centric health systems -- is commonplace. The issue is context switching. In the cases described, the nurse's and physician's workflow is interrupted because they need to switch contexts from current tasks to respond to the new issue.

When the doctor receives the call, message, or page, the first context switch is required. The doctor gets notified on a pager, but has no clue regarding the urgency of the page unless an alphanumeric message comes through. The question being asked often requires tracking down additional EMR-based information in order to make a decision. This leads to another context switch, in which the doctor has either to request additional information from the nurse or log into the EMR to gather recent trends or lab data.

These multiple switches between unconnected EMR systems and personal mobile communications devices disrupt everyone involved. They require us to hold multiple, disconnected pieces of patient information in our minds while proceeding to gather information from the next source. It hurts

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A board-certified anesthesiologist, researcher, medical educator, and entrepreneur with more than 15 years of experience in healthcare, Dr. Voltz has been involved with many facets of medicine. He has performed basic science and clinical research and has experience in the ... View Full Bio
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Gary_EL
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Gary_EL,
User Rank: Ninja
6/22/2014 | 1:41:20 PM
Re: Growing Pains
Yes, I am interested in working on this problem. I'm not sure if it is proper InformationWeek procedure to put my email address in a comment, so I will contact a managing editor on Monday to find out how to contact you.
don voltz
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don voltz,
User Rank: Author
6/22/2014 | 8:14:44 AM
Re: Growing Pains
Hello Gary,

I completely agree these issues will not be solved overnight. I think instead of continually lamenting about the problems, physicians and other providers need to become part of the solution. Granted, this is not for everyone, but those inclined to put in the time and energy to bring solutions to the market or to the IT folks in a non-threatening way just might help our plight. I fully appreciate the limitations of expanding and customizing the complex EMR's that have been deployed. With our input, reflection on our workflows, and communication of our needs (possibly even bringing other solutions to the table), will help move this issue along. I have been involved in this aspect of healthcare while maintaining a full-time clinical position. Although I am frustrated and feel like we have a huge hurdle to climb, it is my hope that we can collaboratively address the clinical needs and help move the initiative in a direction for the betterment of healthcare. If you are interested in working together on solutions please let me know. The more of us tackling the problem the better. 
Gary_EL
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Gary_EL,
User Rank: Ninja
6/21/2014 | 8:43:02 PM
Growing Pains
Unfortunately, the problems that Dr. Voltz brings up are all too common, and not likely to go away soon. Competing systems do not play well with each other, and medical MIS people have a tremendous task on their hands forging an army out of the various militias, to take an analogous example from today's news. Some hospital system have the size and clout to FORCE the providers to build solid hooks into their part's so that their MIS departments can forge them into a solid working machine. Perhaps the federal government can take the embryo standards developed therein and use them as a basis for a national standard.
Alison_Diana
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Alison_Diana,
User Rank: Author
6/20/2014 | 2:34:43 PM
The Default Position
One approach some hospitals are taking is to standardize on one EMR throughout the entire organization, eliminating the best-of-breed approach that allowed different departments -- say, ER, radiology, and cardiology -- to pick their preferred EMR. While this doesn't address all the issues you raise, it does get rid of the multiple electronic records often associated with one patient. However, many physicians I've spoken to don't like this practice since some EMRs are not well-suited to the intriciacies of specific departments, according to them. They're unwilling to cede EMR control to a central body, which makes buy-in more challenging. 
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