Training Day

Screen Shot 2015-04-06 at 7.20.19 PMDr. Samuels’ day-long training experience is unfortunate, but it’s only the opening chords of a much longer symphony of time commitments required by electronic medical records (EHRs).  Many studies document the extra time that EHRs impose on doctors and patients. Research in U.S. hospitals and medical offices suggest that these systems can add a half-hour or much more time to a day. A study by McDonald et al (2013 JAMA Internal Medicine) found EHRs added 48 minutes/day to ambulatory physicians, and Hill et al found that in a large  community hospital emergency room 43% of all physician time was spent entering data into the EHR. This almost doubled the time spent caring for patients, and tripled the time needed to interpret tests and records. (Annals of Emergency Medicine, 2014).

Some of that extra time is spent with clunky interfaces and  hide-n-go seeking for information that should be immediately available, such as arbitrary or unexpected  presentations of data, e.g., having to find a patient’s history by clicking on her current room number, or lab reports that may be arranged by chronology, by reverse chronology, by the lab company, by the organ system, by who ordered them, or by some informal heading, such as “blood work” or “tests” or “labs.”  Then there’s the constant box clicking (or what clinicians call “clickarrhea”).  EHRs also send thousands of usually irrelevant alerts that desensitize doctors to legitimate clinical recommendations.

Equally important, we must ask how this extra time and frustration affects medical errors and clinician dissatisfaction.  While EHRs offer myriad advantages and will contribute to improved patient care in the future, we should learn from the disadvantages to make the technology even better and less burdensome. Enthusiasts in the industry and in government focus almost entirely on the benefits and downplay the problems—a foolish strategy for patients, clinicians and the industry itself.  (Do we only learn from our successes?)  We have spent trillions of dollars on these systems that are generally non-interoperable and don’t even have one standard data structure.

Ross Koppel is a sociologist at the University of Pennsylvania. Stephen Soumerai is a professor at Harvard Medical School. 

6 replies »

  1. The systems so described are not fit for purpose. The adverse events, errors, and near misses go unreported.

    This week, the doctor had CPOEed and order for BID potassium with a perameter to hold it if the serum k+ was > 4.6 mg%. the order on my palate was obfuscated by innumerable lines of instructions such that I missed the perameter and gave the potassium supplement when the serum potassium was 4.7, and the next day, 4.9.

    The doctor missed it because the MAR is terribly inaccessible and user unfriendly when accessed.

    The next day, the serum potassium level was at life threatening levels and I was beating on myself.

    Yet, I have no one to report this to, because, no one really cares.

  2. Something to keep in mind when it comes to training people on new EHRs is policy and procedure and how those can affect future training days so that everyone is being trained properly, whether they went through orientation with a certified instructor when the system got put in place, or just a coworker at some point in the future.

  3. I think civisisus defendeth the indefensiblith too much.

    I invite him to have dinner at a restaurant where the food is bad and the service is terrible and console himself with how good the food will be in the future!

  4. The professors protesteth altogether too much, particularly since they proceed from the misapprehension that how data input is done now (their complaints seem to dwell exclusively on data input, as if that is all that HIT systems are, or are capable of) is how data input shall ever after be accomplished.

    Perhaps once it becomes obvious even to physicians that data must be acquired from a variety of points (not merely from the point of pens they hold in their own hands), their reflexive distaste for any data not ‘coded’ with their bare hands will begin to moderate.