Shocking News. Anesthesiologists Lie.

I've mentioned before that anesthesiologists are notorious for not being completely truthful on their anesthesia records. During an operation, the only person continuously keeping track of a patient's vital signs is the anesthesiologist. This has led to anesthesia records that are suspiciously too perfect. How can a patient undergoing open AAA repair have vital signs that barely deviate during the entire case? Yet I've seen records from other anesthesiologists that look exactly like railroad tracks stretching across the state of Kansas.

Now that many anesthesia records have moved into the digital realm, the opportunity to fudge the vital signs are more limited. The computer records every number, good or bad. Yes one can go back and change the measurements to their liking, but the computer documents that a change has occurred, and who changed it. At last, anesthesia records that are true to life.

But apparently not quite. Clever, or deceitful, anesthesiologists have still found ways to lie on their records. A study out of the University of Michigan shows that anesthesiologists are still trying to cover their asses on their records. The authors examined 434,554 records at the university from 2006-2015. Out of that huge database, they found that there were only 238 self reported medication errors. That works out to just 5.5 errors per 10,000 patients. The researchers are incredulous that such a small rate of medication errors really happened. By comparison, a study in the Canadian Journal of Anesthesia in 2012 found a reported medication error rate of one per 203 anesthesia records.

The most common medication error in the Michigan study was poor judgement, such as giving a drug that the patient is allergic to. The second most common error was giving the wrong drug. The errors caused almost ten percent of patients temporary harm, including prolonged intubation, unplanned admission to the hospital, or cancellation of the case.

So is this a problem isolated to the University of Michigan? It's highly likely that many institutions face the same issue. The authors suggest that anesthesiologists should be encouraged to be more forthcoming with their medical errors. An institution that wants more open communication without fear of retribution would greatly aid in identifying costly errors that lead to unnecessary patient suffering. Good luck with that.

The Decline Of Medical Neologism

Medicine has always been good at inventing new terms to describe the human condition. Traditionally the words were based on Greek and Latin roots. That's why we get words like "hypokalemia" that can still stump new medical students, National Spelling Bee contestants, and electronic medical record software engineers alike.

Later on, the French made their contributions to the medical dictionary with lyrical terms all their own. Phrases such as peau d'orange (to describe the orange peel looking skin of advanced breast cancer) and cri-du-chat (the crying cat sound a child makes when he or she suffers from chromosome 5p- syndrome) flummoxed our less savoir faire young doctors. However, they do make the speaker seem more sophisticated and worldly if he can easily slip French words into a medical conversation.

American medicine has been in ascendency for the last couple of centuries. Therefore it is appropriate that American English words (not equivalent to British English) would make its way into a doctor's dialogue. Unfortunately we have not been quite as creative at inventing new elegant sounding phrases like the French.

For instance, we have descriptions like "cobblestone" to characterize the look of the intestinal mucosa of a patient suffering from inflammatory bowel disease. Or we get a contribution from the uniquely American melting pot with a term like "schmutz" to represent nonspecific debris on the body. Descriptively accurate? Yes. But decidedly pedestrian.

All of which leads me to a head turning note I saw on a patient in our hospital computer. It would seem that despite millenia of development of medical terminology, some young doctors feel they have to come up with new words to truly chronicle the plight of their modern patients. Thus the appearance of the phrase "stably-sick".

Now some purists would say that doctors should never refer to patients as stable. Stables are where one beds down horses for the night. But since it has been universally used to refer to patients who are neither deteriorating nor improving, I'm not going to quibble with it. But then this doctor can't quite bring himself to say the patient is stable. The patient is also very ill as illustrated by the need for IV pressors to maintain blood pressure. So is the patient progressing or sinking? Hmm. Let's think about this for a minutes. Since we can't make up our minds, let's just mash two words together and broadcast to every doctor and nurse who reads this note that despite our years of medical training we are too indecisive to truly understand this patient's medical condition.

Maybe medical schools should include a semester of French as part of the curriculum. That way if these new doctors are going to start making up words and putting them into legal documents, they can at least sound educated, not like graduates from the generation that gave us "twerking".

Our Hospital's First Ebola (Computer) Virus Scare

Our hospital recorded its first ebola scare today. A woman came in for a routine outpatient procedure. She has been coming to us regularly for months so nobody was especially on guard about any potential health hazard with this lady.

When we opened her electronic medical record, a stunning display popped out. Right at the top of the page, in bold red background lettering, the computer had declared she was positive for the ebola virus. A minor panic nearly ensued as everybody started scrambling for protective gear and wondering how we would all get along as roommates for the next 21 days in quarantine.

Then cooler heads prevailed. A quick call to the IT department confirmed that this was an error. In fact, if we had looked up every patient that was in the hospital at the moment, they all had the same ebola warning. The department was inserting new programming into the system for the diagnosis of ebola, which didn't exist before. Somehow it had crossed over into the live system and infected every patient's chart (pun intended).

After that we all gave a big sigh of relief and laughed at the stupidity of IT. Now we can go back to ignoring the big bold warnings about our patients with MRSA, VRE, MDRO, etc...

Hypopotassemia

This is what happens when non-medically trained personnel develop electronic medical records. While scrolling through an infernal list of diagnoses that would properly describe my patient's condition, I came across this terminology that I am not aware of. Hypopotassemia. Hmm.

Obviously somebody was trying to put into word the condition of a low potassium level of the body. But as any first year medical student, or maybe even a premed, can tell you, the proper term for low potassium is hypoKALEMIA. Comes from the latin word for potassium, kalium. That's why on the periodic table the atomic symbol for potassium is K.

This is just a microcosm of the FUBAR that happens when nonphysicians insist on knowing better than doctors how to run our business.

Anesthesiologists Are Not Physicians. My EMR Says So.

The other day I happened to glance at the computer screen of the circulating nurse in the operating room. She was entering information for a case and was on the page that listed the personnel that were in the room. Typically, the EMR asks for the names of the surgeons, the nurses, the surgical tech, etc. I couldn't help but notice that anesthesiologists have their own category.

Hmm. Is the computer implying that anesthesiologists are not physicians? Why do anesthesiologists have a different line at all? The Physician lines make no distinction between attending surgeons, assistant surgeons, or surgical residents. Isn't that just as important to know when it comes to documenting who was working in the OR? Shouldn't there be a separate line for "Attending Surgeon", "Assistant Surgeon", and "Surgical Resident"? If our computer system doesn't really care about categorizing the physicians in the room, then why does it break out anesthesiologists as being separate from other physicians?

Also, why are we placed way down at the bottom of the list? Are we not deserving of a spot higher up on the screen? Instead our names are to be entered after all the nurses and just before the technologists. I say the EMR is dissing the anesthesia profession. I need to talk to our IT guys and give them an earful about the great medical field of anesthesiology. I guess I should just be thankful they used "Anesthesiologist" instead of just "Anesthesia". That would really raise my hackles.

Online Shopping At Work, The Great Benefit Of Having An EMR

When our hospital went to all electronic medical records recently, we had to buy tons of new computers. This ensured that no impatient doctor or nurse ever had to wait for somebody to finish before they can log on and complete their patient charting. We now have multiple computer workstations in every conceivable location short of the bathroom.

But along with this new advance in patient care has come increased temptation. For you see, it is all too simple to start surfing and shopping on our powerful gigabit high speed internet connection. And many staffers do exactly that. You can see it on every ward and in every room. It's easy to find somebody who is logged into their Facebook account updating their status. Or they're shopping for new shoes and bags. Or they're checking out the cheapest tickets to Cancun.

Has all this new technology actually distracted us from our duty to diligently look after our patients?  While the goal of implementing EMR's is to improve patient care and prevent mistakes, I sometimes wonder if  the exact opposite is happening. People seem ever more distracted as they constantly seek out the nearest computer to sate their internet needs which in actuality is insatiable. Whether to check their emails that they last looked up five minutes ago or to find the best deal of the day for a refurbished iPad, non medical use of our computer system is rampant.

The hospital has put in some blocking software to prevent introducing viruses into the system. These mainly affect the foreign country and porn sites, not that I had ever looked of course. But if there were no blocking software I don't think most people would surf there anyway, mainly out of embarrassment of doing so in a public setting. I would think that they could easily block shopping and social media sites. But they don't. Maybe there are just too many for them to try to block in an ever evolving world wide web? Or maybe they are afraid that keeping the staff from misusing the computers will bring down morale? Perhaps they fear that people will just switch to their smart phones instead and start walking into walls since they are staring down at a four inch screen held at chest level.

Whatever the case our EMR is here to stay. And the shopping spree will not be denied.

EMR Is Destroying The Nursing Profession

We've all seen this before. You're walking through the wards of the hospital. All around are the beeps of IV pump alarms blaring from the rooms. The call light has been activated from a room where a patient wants some medical attention. Yet all you see are the nurses sitting at their stations, noses pressed up close to the computer screen or down at their keyboards, busily charting their patients for the electronic medical record system.

It has become all too common to see this as nurses are so busy documenting their patients on the computer that they have little time for actual patient care, or even recognition. When we implemented our new EMR a few months ago, it brought a dramatic slowdown in admission of patients into our outpatient surgery center. The electronic implementation of the preop admitting note is so onerous that the nursing manager told the nurses to cut corners, not all of it beneficial to the patient.

The EMR was forcing the nurses to ask their patients many nonessential questions that delayed admissions but had no practical implications for the patient' hospital stay. Questions that had to be answered on the computerized records include: Do you always wear your seatbelt when riding in a car? What religion are you? Do you use contraception when you have sex?

Because all these mundane questions were delaying the start of cases, the nursing manager decreed that some questions don't need to be asked. You know, such trivial stuff like what kind of meds the patient is taking. Some patients were taking fistfuls of medicines every day. All these drugs had to be entered into the EMR individually, along with the dose, the frequency of intake, and the last time the drug was taken. This could easily eat up fifteen to twenty minutes of preop time. Therefore the manager said that was not important for nurses to know. That information was for doctors to get from the patient and should not take up any nursing time.

Another time saver that was cooked up was the disregard for a patient's lab work. The preop nurse was not to waste any effort looking up a patient's labs. That information too was not worthy of a nurse's time. Laboratory work was the responsibility of the surgeon and anesthesiologist to look up and analyze before surgery, not the nurse.

As you can imagine, many of the nurses were appalled by the new rules. They had just been demoted to being computer entry clerks. The job of the preop nurses was no longer to evaluate the patient for appropriateness for surgery. Instead they're supposed to find out if the patient had gone to the bathroom that morning and enter it into the computer. Everything else squandered too much time to be bothered with.

How sad for our nurses and the nursing profession.

Worst History And Physical Ever, Thanks To EMR

Click to enlarge

I was looking for my preop patient's history and physical written by a consultant in our new fangled EMR system the other day. Scrolling down hundreds of notes from physicians, residents, fellows, nurses, physical therapists, social workers, etc. I finally located what I wanted. At least I think it's the preop clearance note that I wanted.

Reading through this note felt like the worst case of cutting and pasting I have ever come across. It appears to have come straight from the hospital billing office. The only thing the note was missing were the ICD-9 codes after each unspecified diagnosis. How can a physician produce a history for a patient and label virtually every diagnosis "unspecified"? It makes you wonder if the patient actually has the disease or whether the consultant was too lazy to write more specifically in his note. In other words, this H+P was total garbage. Thanks to our new EMR, this kind of shenanigan is all too common.

Yes we can read doctors' notes more easily now. Unfortunately, what's typed in makes even less sense than before.

EMR Starts. Hilarity Ensues

Writing orders on paper charts used to be so simple, if labor intensive. First you have to hunt down your patient's chart. It could be located anywhere: in the patient's room, at the nurses' station next to the room, at the nurses' station at the other end of the ward, in the nurses' break room where a consultant took it while getting his coffee and didn't bother to bring it back. Once you find it, you write your order and put the chart into the orders rack where the secretary will take it down and inform the nurse about the order. Most medical charts also have little color coded flags you pull out depending on the type of order: green for a routine order, red for stat order, yellow for discharge orders, etc. It was tiresome, but effective.

With the advent of electronic medical records, the days of searching for a patient's chart are over. The chart is nothing more than a plastic binder with next to nothing inside. All information are conveniently found within the nearest workstation. What can possibly go wrong?

As it turns out, many doctors are still stuck on the old ways of doing things. We recently got a memo from the hospital's chief of staff admonishing physicians for improperly entering orders into the computers and communicating it to the nurses. It seems that some doctors were writing computer orders without letting anybody know about them. It was up to the nurse to serendipitously discover the orders hours later, orders that can be time sensitive or vital to the patient's health. Some of the examples he cited include:

"Hold heparin until after cardiac biopsy"

“Call the Code Blue team to assess the patient.”

“The patient may take her own sugar packets from Starbucks, if she falls into a coma from hypoglycemia”

“Please ask family for doses of diovan, cardizem and amiodarone, then start immediately”  

These were actual orders entered into the computer by doctors and not verbally relayed to the nurse. Obviously no names have been attached to them to protect the innocent, or the ignorant. You can imagine the outrage of the dumbfounded nurse who stumbles across such orders hours after it was placed by the physician. 

So the hammer has come down on the doctors at the hospital. If an order is important, it is imperative for the physician to find the nurse and let her know about it. Otherwise the nurse cannot be held responsible for delay in patient care. Are we having fun with EMR's yet? 

Thinning The Herd

You could call it Darwinism by EMR. In my ongoing reports on our hospital's conversion to all electronic medical records, I've mentioned some of the difficulties of adjusting to this 21st century reality. There has been much frustration and hair pulling by all as the seemingly mundane tasks of writing notes and orders on a paper chart are transformed into time-consuming chore that a few months out still require handholding by a team of software support people who roam our hallways.

Now comes word from our Chief of Staff that several doctors have had enough of this. In a recent email, he noted that a couple of dozen doctors have resigned or downgraded their status with the hospital. The ones who remain have either chosen to do consulting work only, thereby eliminating the hassle of entering computerized orders, or retired to "Emeritus" status, which pretty much is the same as resigning while still maintaining a link to the medical center (free parking in the doctor's parking lot and free breakfast with free newspapers in the lounge).

Most of the physicians who resigned were ones who were close to retiring anyways. They had few patients in the hospital and didn't have very active practices. The EMR was just the final straw for these guys, most of whom went to medical school in the 1960's and 1970's. Many didn't know how to type, much less use a computer mouse. It must have been infinitely aggravating for them to try to enter an order for "Accucheck" to measure a patient's glucose level and have the computer reject the order because it could not identify it. The doctor would have to know that the order is actually listed under "Glucometer". Grrr. It's a wonder more doctors haven't resigned by now because of this craziness.

How are the older anesthesiologists holding up in our group? I've mentioned in the past about how rusty some of my colleagues are in performing some basic anesthesia skills. But so far they are all using the EMR quite well. Maybe it's because we have so many support people hovering around the preop and postop areas to assist them. Perhaps it's because anesthesiologists have very simple documentation requirements. Most of our paperwork is easily converted to templates that are quickly filled out with a few clicks of the mouse. So our department has been spared the angst suffered by our internist and surgical colleagues during these trying times. We'll have to see what happens when our operating rooms finally converts to electronic anesthesia records, which is promised in a couple of years. The thinning of the herd will continue unabated.

Missing My Anesthesia Cheat Sheet

We are a few months into our new electronic medical records and I have to say I have grown to like it very much. It does make work a lot easier for me. Everything is just a few clicks away, if you know where to look. Preop orders? One click to pull up the prefilled order form and one click to sign it. Done. History and physical? One click to get the template. One click to fill in past medical history. One click for past surgical history. Click, click, click. Sign. Done. It really is a time saver, at least for anesthesiologists.

However one I thing I do miss is having the actual paper H+P in front of me during a case. As a byproduct of all the convenience of clicking in a patient's history, I tend to forget details about the patient. I'm the kind of person who remembers things better if I write it down first. Now I don't ever actually write anything down and it gets kind of tough to recall what I just pasted into my electronic assessment.

For instance, the surgeon may ask what antibiotics the patient is receiving. Nowadays I really don't have a clue. I have to log into the computer, open the patient's file, and look for the patient's medications list. What allergies does the patient have and what are the reactions. Again, log in, look up the patient, and check the allergies list. How tall is the patient? Same routine. Same delay. Same tedium.

During the paper and pen analog era of physician records, all that would be in front of me on my handwritten H+P. That information would  be no more than a few seconds away from me, a quick glance at my quickly scribbled note. Now that is obsolete, never to return again. I can't help feel that some intimacy is lost between a patient and his physician when the doctor can't even remember his height and weight. But at least we are getting more efficient at dehumanizing our patients.

Medicine Without Charts

Our hospital has been using electronic medical records for over a month now and in general most people have adapted well to it. Still it is shocking to open a patient's plastic binder and find almost nothing is inside that can be considered a chart. Sure all the progress notes now are legible since everything has to be typed in. There is less chance of an order mix up because there are all sorts of electronic nanny barriers that prevent you from giving something like penicillin if the patient gets anaphylactic reactions to penicillin.

But that doesn't mean all is hunky dory. Maybe it is just our particular system, but I find it harder to find the information I want these days. Before, I could scan through a chart to find the note I'm looking for. I can skip through the pages of social worker and nutritionist notes to find the ones written by the cardiologist or the nephrologist, since those are labeled at the top of their notes "Cardiology" or "Renal". Now when I click on the Notes section in the EMR, I get pages of notes that have been written into the computer by everybody who has been taking care of the patient, including nurses, respiratory therapy, and other ancillary services. While I can focus down to just physician notes, they are not labeled by the type of physician, just their names. Therefore, unless I know the specialties of all the doctors in the hospital, it is very hard to find the pulmonologist's note or the ID doctor's note. All I have a bunch of doctors' names.

That's what I miss since moving to an EMR, the ability to quickly scan through a chart to find the information I need. Most doctors know that daily progress notes in general don't have much new information so they can be quickly skipped to the ones that truly hold new relevant details. With the new system, it is impossible to do this. I have to click on every single progress note and hope something important is written on it. In fact I've missed important information on a patient because in preop I don't have the time to open every progress note on a patient that may have been in the hospital a month or longer. The surgical procedure note that details the patient's recent abdominal surgery may be three pages down on the list of physician notes. The cardiologist's interpretation of a patient's echocardiogram may be lost in the vast trove of information that doesn't distinguish between what's important and what's filler.

We're all still learning the system so I'm hopeful that these frustrations will eventually be ironed out. The amount of customization available to a doctor is mind boggling so there must be a way to get to the things I need without so much fuss. At least I'm keeping my fingers crossed and hoping for the best. In the meantime I still have to do the maddening pattern of clicking open each freaking progress note one by one and hope there is more information there than the patient's morning vital signs.

The Invasion

D-Day for our hospital's implementation of our new EMR system finally arrived. Over the weekend, multiple frantic emails were sent out to everybody to remain calm and orderly. The hospital promised that there would be plenty of support for anybody who needed help. The program went live over a weekend to introduce the staff slowly to the computers. They even offered free food the entire weekend. Damn, why can't I ever be on call when there is free food?

When I arrived on Monday morning, I was overwhelmed by literally an army of support staff roaming every hallway, nursing station, and anywhere there is a computer. The multitude of assistants seemed to outnumber hospital staff two to one. I heard the hospital spent millions of dollars getting this system running and I can see where a lot of the money went. We even hired anesthesiologists from other hospitals who have already transitioned to this EMR program to come help us specifically on anesthesia related matters. What a sweet job that must be.

The problem that many of us feared would happen, that there would not be enough computers to go around, was resolved by the appearance of multiple portable workstations. In the electronic era, when the nurse, the surgeon, and the anesthesiologist all need a computer, usually at the same time, one computer per patient is not going to be enough. Now there are computers everywhere. EMR's must have been conceived by a conspiracy of Dell Computers, the federal government, and hand surgeons specializing in carpal tunnel syndrome.

The months of planning actually paid off pretty well for anesthesiologists. With the help of a couple of volunteer anesthesiologists, the IT guys developed templates that made entering the patient's histories quite painless. Just click, click, click, and you're done. I can definitely get used to this.

The only glitch occurred when I tried to enter my preop orders for my first patient. I clicked on my orders and thought I was finished. However the nurse said I had not yet signed my orders. Sigh. So I go back in and again signed my orders. The nurse still says my orders were not signed. After having prided myself on not needing any assistance yet, I finally succumbed to reality, swallowed my pride, and had one of the assistants come over to see what's wrong. We go through the process all over again. This time when I clicked to sign, the assistant saw the problem right away. I didn't actually sign it. I had clicked "sign and hold" instead of the "sign" button right next to it. And that is not to be confused with the "pend" button that I can also use on orders. I clicked "signed" and finally the nurse got my orders. We are only 30 minutes late for our first case. Not great but not as bad as people feared. At least I'm not the last one into the operating room which I consider a win for me.

The day started roughly like that for everybody. But it slowly smoothed out and by the afternoon the operating rooms were functioning pretty well, albeit slow. For anesthesiologists it's easy. We only have two sets of orders to write: preop and postop. Those orders were usually standardized anyway, even before the EMR. Therefore it was easy for IT to basically copy our previous orders from paper into the computer and all we have to do is electronically sign them. For the other hospital staff though, it could be quite a nightmare. Their postop orders could be quite challenging, especially since you can't just freehand write "Labs in AM, CBC, BMP, PT/PTT." Now there are cascading menus for ordering lab work, X-ray images, PRN meds, etc. There are submenus for stat, urgent, during the day, next day, every day, etc. Some orders require justification, like for chest films. Don't worry. There are cascading menus for that too. You can't just write the reason you're ordering something. It has to be one of the choices on the menu. It takes awhile to wade through all these choices. They're there. You just have to look for them.

Despite how painful the transition has been, and they forewarned us that the first six months of an EMR startup is usually very chaotic, we have muddled through quite well. The anesthesiology department has been commended for how smoothly our staff has adapted to the computers. We are not usually the ones holding up a case because of EMR issues. There is no turning back. This is the future of medicine. As we get further into our implementation, the bugs will eventually be worked out, or we will change how we work to fit the computer. I tend to think that it is the latter that will happen.

The Agony Of EMR Instruction Class

Before our hospital converted to electronic medical records, we were told we had to take a class on using the new system. And not just any class. We were stunned to find out we would have to take an entire day off on a weekend to attend. The whole thing was expected to take EIGHT hours. What the... How can a computer software take eight hours to learn, many people demanded. The glib answer that was told to us was that this is not like playing Angry Birds. This is a professional level program that requires hours of training and weeks to familiarize. It is the equivalent of learning something as complex as AutoCAD or Photoshop Pro. These programs are not designed for school children, or adults with the mindset of school children. There is even a test at the end of the class that we must pass before we can be considered successfully trained. And besides, we were told, the IT guys have already streamlined the process down to eight hours. Most other hospitals who have used this program typically required sixteen or more hours of training before certifying someone to use it. We were getting off lucky. So there.

With much grumbling, we scheduled the day we wanted to come in and waste a glorious weekend day. Thankfully our department had set up training days that were designed just for the anesthesia portion of the program. That way we didn't have to sit there and listen to how a hematologist can order a bone marrow biopsy on the system. We were also warned not to come in late. After they close the door, no one is allowed to enter. No one is also allowed to leave early either as the exam would not be handed out until the very end. But at least they will provide food and refreshments. Alas mood enhancing alcoholic beverages would not be one of them.

The morning of the lecture, we filed into the conference room which now looked like Mission Control at NASA. Rows of computers were sitting everywhere facing a lectern. We were instructed to write on a piece of paper how we would like to be addressed and hang it on the back of the monitor so the instructor can see it. Most people wrote their first names. Several wisenheimers wrote "Doctor".

The lecture started exactly on time. The instructor was very friendly and decently knowledgeable. But if somebody knows more than you about something they would seem knowledgeable whether they are smart or not. Shortly it became obvious why eight hours of instructions are necessary to use the EMR. The choices were bewildering. There were buttons and highlights all over the screen. The button labels and icons were not that helpful. Just finding your own patients took multiple mouse clicks to get there. The lecturer moved with the speed of somebody who has given the same talk dozens of time. Soon people were asking him to slow down and repeat himself. It was tremendously difficult to watch his actions on his big projector screen while attempting to do the same ten seconds later on our own computers.

The frustrations mounted quickly. After awhile, instead of asking how an action is performed in the software, my colleagues started asking why it was done that way. Why can't we order something one way instead of the other way? Who decided that the default selection should be A instead of B? Questions were asked of one of the anesthesiologists who sat on a committee that helped decide how the anesthesia portion of the system would work. It started to get ugly. The lecturer tried to answer their questions as best he could, but they were not satisfied.

My eyes started glazing over. Why are my colleagues throwing accusations at this poor instructor? Don't they understand he is only here to instruct us? He is not the one who designed the software and really has no say in how it works. He's only here to help us with the program that we have. I can't believe how absurd these people are. During a particularly long stretch of arguments, I sat back and pulled out my phone and started playing games. There really was no point in following the conversation since it was obvious that nobody in the room can change how the program functions. I'm just resentful that people are dragging this out and wasting a beautiful day fruitlessly bickering about this instead of quickly finishing it so we can all go outside and enjoy the rest of the weekend.

The hours ticked by. Soon enough lunch break arrived. Some people wanted to skip the 45 minute lunch and continue into the afternoon portion of the class. The instructor wisely said everybody take lunch. I think we all needed it. The afternoon session was more of a lab, applying the information we gained from the morning and solving a series of scenarios that were given us. It still took a lot of help from the assistants that were roaming the room to get people to understand it in even a rudimentary fashion. The exam itself was not bad. It was an open book test and we could freely ask anybody in the room to help. I couldn't wait to get out of there. I whizzed through the exam, got my passing grade, and headed out into the fading sunlight. Yes it was easy enough to use the EMR in a classroom setting with people at your beck and call to assist you. How will this work when the time comes? And will I remember any of these instructions when the system goes live in a few weeks. The countdown's on. 

In Pursuit Of EMR Nirvana

Our hospital is undergoing an epic conversion to electronic medical records. The process has been taking place for years. The federal government has mandated that all patient records be recorded electronically by the year 2014. They even have an incentive program available to bribe doctors and hospitals into adopting the new systems. If the carrot doesn't work, by 2015 the government will start wielding its big stick and penalize facilities for not using EMR's. How's that for a refutation of "live free or die"?

Naturally there has been great anxiety about the process. We have all heard the tales of how other hospitals' adoptions of EMR's have fared. Worker productivity falls 50% as everybody tries to get up to speed on the new system. Doctors and nurses quit out of frustration as they try to reconcile with their new electronic overlord. Our hospital administration has held rallies to allay the fears of going all electronic. Balloons and T-shirts have been handed out as goodwill gestures. Much cake has been sliced and ice cream scooped to encourage people to look kindly at the approaching demise of the paper chart.

For weeks every time we logged into the hospital computer, a countdown clock was displayed prominently telling us how soon we were switching to EMR's. This had the perverse sensation of facing a coming apocalypse. As the time ticked down, our emails became more frequent and urgent. Everybody MUST take EMR classes to ensure that we knew how to work the software. Failure to register at one of the classes could lead to disciplinary actions. Doctors were asked to not admit as many patients for the first few weeks while everybody fumbles with the computers. The operating rooms were expected to slow down as turnover time between cases was expected to double.

The future is now. The clock of the apocalypse recently counted down to zero and we turned on the EMR switch. We have now gone about 90% electronic, with a few minor details that still remain on physical paper. It has been an enlightening past few weeks. I'll be writing a series of reports to let the curious know how it went. We've all heard the wonderful tales of how EMR's will save American health care. Now you can follow along and read the reality of taking away centuries old medical tradition and in one stroke going all digital.

Don't call your patient a C.O.W.

In our rush towards electronic medical record keeping, perhaps we haven't fully examined all the possible consequences. At our surgery center the patient's history is entered in preop holding on a computer workstation that is placed on a rolling cart. When the patient is taken to the operating room, this Computer On Wheels follows the patient in, thereby ensuring continuity of the patient's records.

One day as a rather portly patient was brought into the operating room, the circulating nurse yelled, "Bring in the C.O.W.!" I guess the patient took offense to that remark. She remembered enough about that incident to write an angry letter to the hospital administrator complaining about the staff's lack of courtesy calling her a cow. Now we never mention the word cow in the O.R.