Monday, September 19, 2011

When the Electronic Medical Record Died

It's never supposed to happen of course. But it happened today: the computer froze and could not be resurrected - a brief interlude to the daily clinic routine.

The reactions are predictable:

"Damn it. What the hell's wrong?... Let's try to re-boot.... (a long pause) ... A switch turned off, then on... Come on, baby!!!!!... Shoot, still nothing!"

Clicks upon clicks, then an embarrassed look on your face. "Sorry, Ms. Jones. Usually this system works great..." !@#$^%&$)#! "Seriously, um, .... just a moment." The doctors walked out of the exam room.

"Hey, you guys having the same problem I'm having?"

"Yeah, our terminal's not responding either. I think we've got a Code Green."

(Editor's note: I know what you're thinking... don't go there...)

"How about a piece of paper? Oh, and a pen? Anybody got a pen? Damn, where are the pharmaceutical reps when you need them?" The office manager sprung to action: "I'll get out the Code Green box!" You figure there's a plan, but seriously, this is it? Some archaic progress notes appear, the medical assistant found a pen, then some interesting order forms that you've never seen before appear. "Dang, I have to fill those out?" You think, "How will the lab and xray get these?" "Do we call the orders in? Maybe someone walks them down. Hey, maybe the patient can help out!" After all, the only way out is through this mess. But it didn't stop there:

"What about that prescription - anybody got a prescription pad?"

"No, got rid of those a long time ago. We're electronic now, remember? Can't use them any more."

"No? Shoot, what do we do?"

"Try calling it in," someone shouts from down the hall.

"Why didn't I think of that? Good thing I have my handy, dandy cell phone!" Google is consulted, the number for the patient's preferred pharmacy appears, the call is made and order placed on the recorder. The patient is impressed: "Thanks, doc! That was nice of you to call it in for me." We shook hands. Mission accomplished.

Sorry, no 'After Visit Summary" was given to the patient, no medication list was printed. No copy of the note was sent back to the referring, no orders to verify, no orders pending, no quality assurance pay-for-performance measures were completed, no billing codes entered and as a result, no bill instantly submitted. Surely our quality measures took a hit.

Instead there was just a handshake, a look in the eye, and an "Appreciate your patience" message tacitly transmitted. In return: "No problem, doctor, I appreciate your help with this."

Suddenly it dawned on me: "Damn, it's like the good old days!"

Oh sure, it took a little longer and I'm sure my notes were illegible to anyone but the most seasoned of veteran nurses. Whether I get paid for these visits remains to be seen, too. But this once, for a tiny moment of time, I experienced a blast from the past that proved, beyond a shadow of a doubt, that the computers are about the computers, rules, protocols and billing while health care was still about the doctor and the patient.

Like turning off the TV and computer at home, it was a brief but beautiful respite from the daily monotony of a thousand keyboard clicks. Sure, the transition from electronic medical record to a paper-based one was abrupt and challenging. But I found patients responded to our efforts with much more appreciation, not just an aire of expectation. And despite the challenges of the day, it was good to know that I can still be a doctor that thinks out of the box and not just a clerical secretary.



Tim Hulsey, MD said...

And what about when you can't re-boot? When the grid is down for an extended period? When the grid is hacked? During a disaster? Tornado? Hurricane? Earthquake? Flood? Blizzard? Terrorist attack? Alien invasion? When there might be injured people? Even if you've got your iPad, better, as Wes says, to keep a pen and a piece of paper in your pocket (although the Paper Work Reduction Act will assure that there is plenty of PAPER around).
I hate to sound like a broken record, but, even though I love technology for many things, EMRs are a BAD IDEA!

DrWes said...


Given the inevitable march toward government-paid health care and the ridiculous documentation, recording mandates, and prescribing practices that such a system requires, I can only suggest that EMR's will soon be the ONLY way a doctor stands a chance of maintaining the slightest bit of sanity in the years ahead.

Your points about distaster preparedness are critical, however, since today's medical students and residents have never had to prepare for life without an electronic record and, to date, I have never seen a single contigency plan made to do so.

Yes, sir, there's serious "flail potential" if that occurs.

Keith said...

Bet it feels good not to be a data entry clerk for a brief time! I get the impression you are not exactly enjoying the wonderful digital world that is going to save us tons of money and make our health care system ever more efficient. the question remains, efficient for who?

Keith said...


I would also say in response to your comment to Dr. Hulsy, it maight actually be more cost efficient to forgo all the hoops that one needs to jump through to obtain the 1 and 2% bonuses (or penalties down the road), and not spend all the dough and time on these monstrosities. Recent studies have shown little improvement in quality (weren't we told this would cut down on errors?!) and do not cut costs (weren't we told we would save buckets of money?!) with neither seemingly being true, at least to date.

I might just take my 5% Medicare hit and do without my shiney new EMR and stop becoming a participtaing MD in Medicare to make up the difference.

Tim Hulsey, MD said...

Wes said, "... EMR's will soon be the ONLY way a doctor stands a chance of maintaining the slightest bit of sanity in the years ahead."
If doctors could design what they need for an electronic medical record, I might agree with you. It seems the one you use is not making anything any easier for you. When does the sanity part kick in?
Wes said, "... today's medical students and residents have never had to prepare for life without an electronic record..."
Or take a math class without a calculator! Better to interact with patients than the computer and learn how to work more than a 40 hour week. I make a really good curmudgeon!
Why would we change to a system that has so much fail potential? As many disasters as we've seen just recently, where EMRs would be, not only worthless, but detrimental for replacing the hard record, how do we justify this in relation to good patient care?
The government, which could give a rat's a_s about patient care, is the only benefactor.
Keith said, "... I might just take my 5% Medicare hit and do without..."
Let's see- 5% x $0.00= $0.00 lost. Sounds good to me.
Admit it Wes, you dislike EMRs as much as I do. Everything is inevitable if you don't fight it!

InformaticsMD said...

Oddly enough, my mother would not have been maimed and then died if the ED in the hospital where she went for her care were still using paper.

Unless the clinicans were using disappearing ink...

How do I know this?

I once worked in that ED, pre-EHR.

-- SS