Any value in favoring PGY training that's entirely paper-based charting?

[WanderingDave]

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I'm interviewing at family medicine programs, and one of them so far has been at a hospital whose charting is still entirely paper based. There are ample computers for retrieving lab values (and probably dictated consults and progress notes), but these computers are from the 80s and have monochrome green screens.

These things don't chafe me in and of themselves. I'm not a luddite, but I'm not much of a gadget guy either, and all the cool toys I get to play with was low on my list for choosing medicine as a career. When the standard of care for any given case can be achieved with simpler, older, lower-tech, or thriftier solutions, I err on the side of going that route. I have a lot of respect for doctors who have the guts to do what I call "McGuyver medicine", for example, working somewhere with scant material resources, but nonetheless cobbling together diagnostic and treatment plans which somehow manage to get the patient healthier.

I'm no conservative, but if there's priceless educational merit in learning something the old-school way, I think it's worth considering. I've never regretted learning to drive using a manual transmission, and feel bad my kids may not have that opportunity.

Can anyone point out any major pluses to cutting my teeth on the whole doctoring thing using paper charts? I can think of two possible ones:
1. Some claim that writing something by hand commits it to memory more solidly than typing it, or even worse, activating it by clicking a series of virtual buttons. I wonder if knowing how to give medical orders would come to me sooner and more solidly if I wrote them out longhand.
2. I might be better prepared for working overseas, or in highly underserved ares of the US.

 

[rvca1981]

Dude, you are not going to have any advantage over me just because you wrote all your notes by hand.

 

[brats800]

Using an EMR makes me:
1) more efficient
2) more legible
3) more desired by a job that uses EMR

 

[MedMan25]

I would have to agree with the above. We all know how to write on paper, not everyone knows how to use emr software. Hospitals are only going in one direction with regards to charting. Training at a hospital that still uses paper charting is only going to put you at a disadvantage in my opinion.

 

[deleted87716]

I would consider being paper-based in this day and age to be a decided negative. I've been out of residency for ten years, and they had an EMR three years before I started. Any residency that's still on paper is way behind the times.

 

[WanderingDave]

Dude, you are not going to have any advantage over me just because you wrote all your notes by hand.

You say it like I'm being ridiculous. I'm getting more and more sure the answer is no, but it's still a legitimate question. I was most interested in the effect on writing orders, and learning how to order and what to order, rather than notes.

If paper documentation is a skill I'll never need or use in practice, and it doesn't teach anything better than the new way, to hell with it.

 

[smq123]

You say it like I'm being ridiculous. I'm getting more and more sure the answer is no, but it's still a legitimate question. I was most interested in the effect on writing orders, and learning how to order and what to order, rather than notes.

If paper documentation is a skill I'll never need or use in practice, and it doesn't teach anything better than the new way, to hell with it.

Hmmm.

I would say that I felt like I learned more about how to write for certain meds when we were on paper, than I would have if I started out on EMR. (We switched over after my intern year). There's something to be said for writing orders and prescriptions from scratch, rather than picking from a drop down menu. It's not a big thing, in my opinion, though.

I think it's kind of a non-issue, really, at least for the inpatient side. Any outpatient clinic should be on EMR, now that they are offering incentives for proven meaningful use.

 

[J-Rad]

I am a peds subspecialist, but I trained in a miltary residency that, at the time, was using paper records for inpatient (orders had to be written in the chart, however, most had to be entered into the military's archaic-but-functional DOS- based computerized order entry and system. Results could also be reviewed in this system). Outpatient went to a horrendous EMR, but it breaks down so often that you still have to use paper charting fairly often (then gets scanned into the EMR).

On the other hand, I trained in a fellowship that started with its own robust home-grown EMR that did a lot, but there was still a need to write some orders at the bedside. One year in the who hospital went through a complete overhaul and a well known commercial EMR that did everything was installed system wide (a discussion of the growing pains associated with this is outside of the scope of this discussion) so I've seen first hand different variations. So here is my take:

There is zero advantage to training in a program without an EMR. With respect to smq, who I think makes a valid point, that one small benefit is so outweighed by the advantages of an EMR so as to be negated.

Paper records have many disadvantages (probably more than I can think of), here are a few:

-At the mercy of handwriting-yeah, how many people have legible handwriting in medicine and how many are willing to improve their chicken scratch?

-They get lost (how many times does a chart get lost on someone's desk or at a nurses station).

-Even if they are where they are supposed to be-usually medical records when not in use-they are not available quickly especially at those hours when emergencies in which having a chart might be helpful tend to occur.

-As for prescriptions, which are again at the mercy of handwriting, handwritten prescriptions encourage our silly medical abbreviations, which really aren't a good thing for patients or record keeping in general.

-Are only available to those that are in proximity to where the paper records can be reviewed. Want to review a clinic patient's chart before your clinic the next day? You have to be in the hospital. Don't a fair amount of FM residencies have home call during which you might get questions from outpatients? How easy is it to review pertinent charted history from home with a paper based system? Of course everyone can give you a detailed and accurate medical history for themselves and their families, right?😉

-Did I mention the handwriting thing? Many paper charts are not only dangerous for illegibility but often inconvenient for the resident. How much do enjoy calling the butthole consultant who doesn't really like to talk to you and expects you to read his recs in the chart to get clarification on his recs because he can't write for shiz? Yeah, that happened to me a few times with our senior, high ranking peds cardiologist.

-Like I said I'm sure there are more.

Now about EMRs. The problem with them is that there are many different ones out there and they all have different capabilities. They all are at the mercy of computers. They can have major issues with implementation if you are unlucky to be around at that time. CPOE isn't always a panacea-you still have to check things carefully. I'm sure many EMRs don't have a clean and easy way of RXing different doses per day (e.g. coumadin). Some of the problems of paper charts have been replaced by EMR-specific problems, the worst of which is the un-reading, un-thinking, copy-paste forward problem. And there are other things (and I had many specific gripes about the EMR in my fellowship). But let's take a look at the things I really liked about having the EMR:

1. All in house records were available to me immediately no matter what time of day. Since we also had access via Citrix, I could be home and able to look at records. Kind of nice when I was getting called by an ED two hours out about a patient of ours with complex congenital heart disease. Probably pretty nice for the FM resident carrying the Mommy pager (or whatever you call it). By the spring of my third year, I could also get access to everything on my smart phone via the Citrix app and they were working on getting the EMR specific app available to use (the Citrix app makes for kind of clunky access).

2. While CPOE has its inherent difficulties, it is still much better than paper RXs. It can reduce errors if used correctly and discourages over-abbreviation. Our EMR could also electronically prescribe to almost every pharmacy in the state and a remarkable number across the country (for non-narcotics).

3. Copy-past functions can be very convenient if used correctly and safely. In our EMR you could also create "smart phrases" which allowed for entry of large bllocks of text with a quick prompt for frequently used phrases.

4. Our EMR also allowed for the use of voice to dictation software. Great for non-typists like myself.

5. A good EMR has a lot of room for modular additions of capabilities. By the end of my fellowship, patients were able to access their own charts and electronically send requests for refills or messages to their physicians. I was also able to look at cath cineangiograms via the EMR (i.e. could look at them at home) something that wasn't available at earlier. Since I could get telemetry at home as well (outside the EMR), the only thing I couldn't look at home was echoes. One nice thing was there was an agreement with some outside hospitals that we could access their online PACS system to read their peds echo for them-from home.

6. You may have figured this out, but since our EMR did everything for the hospital (orders, charting, entry and look up of bedside data) and since I could use the EMR at home, I could do all of that at 0300 when I called from the family at home.

So I shared some things I liked above that don't seem directly related to the EMR (the telemetry, the echo thing). But let me ask you: what is your impression of a (teaching) hospital system that has instituted an EMR and other things to both benefit patients and clinicians vs. a system that wants to stick with what is becoming increasingly archaic and comparatively less safe, less efficient, and less convenient. I think this should factor into your decision algorithm.

 

[WanderingDave]

J-Rad, thanks for a most thorough reply.

It seems the cons far outweigh the pros for learning on paper. There's really no arguing with spending less time and effort writing and reading charts, so long as the new way isn't more error prone. That's time that could be spent at bedside or reading.

I really like the idea of better accountability through EMRs, too. If everyone can read clearly what everyone else ordered, right after they've ordered it, no matter who they are or where they are, that provides more opportunities for feedback and comparison of workup strategies.

I must say, I wouldn't miss vying with other (snarly and underpaid) employees for high-attention patients' charts. And I'm not looking forward to getting woken up by some other care provider who couldn't find, couldn't read, or couldn't be stiffed to schlep over to the hospital floor and look at my orders.

 

[FutureInternist]

I think Medicare/Medicaid is mandating that all hospitals have complete EMR by end of 2012. Our out-patient clinics were converted & now they are working on Physician Order Entry etc. Soon, we will be typing our daily notes.

 

[MeowMix]

Efficient EMR > paper > crap EMR is my preference

A bad EMR is worse than a paper chart. Functionally inaccessible from home, frequent crashes, poor design requiring extra hours to chart...all of these negate the value of the EMR and waste your precious time. Our program moved to a clinic emr during my third year and it is a total POS. I dread the day they take that system into the hospital for CPOE.

I moved to a program with a superb EMR, and every day I give thanks for its existence.

 

[cabinbuilder]

Efficient EMR > paper > crap EMR is my preference

A bad EMR is worse than a paper chart. Functionally inaccessible from home, frequent crashes, poor design requiring extra hours to chart...all of these negate the value of the EMR and waste your precious time. Our program moved to a clinic emr during my third year and it is a total POS. I dread the day they take that system into the hospital for CPOE.

I moved to a program with a superb EMR, and every day I give thanks for its existence.

I completely agree. I just quit a job because of their EMR. I was only able to see 14 patients a day because they required me to do my own chart typing and I was typing approx 5 hours a day working a 12 hour day just to keep up with the charting. The most hideous experience ever and I will NEVER ever work a job where I have to be the typist. I don't mind EMR for the reference value but dictation will always be superior in my personal work flow. Like the OP, I actually prefer paper charts for the easy of information access. I find have to go through screen after screen of things in EMR just makes my head spin and takes away from my time spent with the patient. Of course I'm not as savvy with computers and my younger counterparts and that had a lot to do with my personal preference.

 

[brats800]

Of course I'm not as savvy with computers and my younger counterparts and that had a lot to do with my personal preference.

I think this is a key point. I feel very comfortable around computers and type pretty fast. I usually have less than 5 minutes of work to finish each note when I walk out of the room after a 10-15 minute clinic visit. If a patient shows up late or fails an appointment, I get caught up and finish everything on time. We have residents who are slower with the EMR and it, of course, takes longer to finish their charts after clinic.

 

[cabinbuilder]

I think this is a key point. I feel very comfortable around computers and type pretty fast. I usually have less than 5 minutes of work to finish each note when I walk out of the room after a 10-15 minute clinic visit. If a patient shows up late or fails an appointment, I get caught up and finish everything on time. We have residents who are slower with the EMR and it, of course, takes longer to finish their charts after clinic.

Trust me, I type very fast too. But the EMR I was using you still had to free type the HPI and the Assessment and Plan. Plus go through about 30 screens for the ROS and PE, not to mention different screens for all the preventative care, IZ's, and Diabetic flow sheet. It was taking me 5 hours to do 15 charts. Not worth the time or effort when I can dictate the same in 1 hour.

 

[deleted87716]

It was taking me 5 hours to do 15 charts. Not worth the time or effort when I can dictate the same in 1 hour.

So you're doing all of your notes at the end of the day...? Yuck.

I chart as I go. I did it on paper, and I do it on EMR. When my patient is walking towards the door, I'm finishing up their note. At the end of the day, my notes are done. Wouldn't have it any other way.

 

[cabinbuilder]

So you're doing all of your notes at the end of the day...? Yuck.

I chart as I go. I did it on paper, and I do it on EMR. When my patient is walking towards the door, I'm finishing up their note. At the end of the day, my notes are done. Wouldn't have it any other way.

It just wasn't feasible, I was chronically shortstaffed and was doing my own calls to patients and dealing with tons of labs, etc that were coming through all day. I was yelled at for the staff having overtime so was stuck doing the secretarial work, etc. to get the staff out on time. That meant that all of my charting had to wait until the end. It was a really bad situation and no way to ever catch up. My nurse was chronically on the verge of tears just trying to keep the flow going. It didn't work for any of us. Glad to be out of there. Plus I was taking over an existing practice and was trying to learn every patient and clean up past mismanagement. So that meant everyone had at least 10 diagnosis to go over. I just can't be thorough and do all the charting before the patient left.

 

[ghost dog]

So you're doing all of your notes at the end of the day...? Yuck.

I chart as I go. I did it on paper, and I do it on EMR. When my patient is walking towards the door, I'm finishing up their note. At the end of the day, my notes are done. Wouldn't have it any other way.

If I can avoid it, I will never use an EMR based practice. I am currently in solo practice, and thus I am the only one who has to read my handwriting (although it is quite legible - if I do say so myself).

My nightmare experience with EMR: as a resident ( 10 yrs ago) doing a rural elective , I had the unpleasant experience of using a disastrous EMR system. Print up a pt's script: it would print up the wrong one, not once but 3 times. Rinse and repeat all day long.

Also: running through pages and pages of "user friendly" sheets in order to find what I was looking for. What a nightmare.

I swore to myself: never again.

The only way I will use EMR, is if I'm forced to.

 

[brats800]

EMR has gotten much better in the last 10 years, especially for "computer literate" docs...

 

[RLMitchell1]

"If I can avoid it, I will never use an EMR based practice. I am currently in solo practice, and thus I am the only one who has to read my handwriting (although it is quite legible - if I do say so myself). "

I think this attitude is a disservice to patients. What if they move? Want to take their business elsewhere? Develop a disease state that requires transfer of a significant part of their medical records? You are basically holding all of their patient data hostage by refusing to keep it in a remotely exportable format. I'm all for docs having the right to their own notes etc, but a large portion of the rest of that data, including care plan details like what medications have been tried and haven't worked, lab results, etc are integral to quality future care. Unless you are importing data into some kind of registry system you also aren't doing population-based outreach, which is going to become the standard of care in primary care.

I look forward to the day when PHRs and patient portals are the norm and we no longer think we own a patient's health history. Its like a bank owning my financial history. Imagine trying to buy a house if your entire financial record was housed in some folder in illegible handwriting.

 

[J-Rad]

I agree that a bad EMR can bring incredible pain, but a good one really does make one not want to go back to the (not so) "good ol' days". This is still said as I currently wait for one of the worst EMRs to actually start working for the second day in a row and after complaining a whole bunch about the pains gone through to transition to the system in fellowship.

 

[ghost dog]

"If I can avoid it, I will never use an EMR based practice. I am currently in solo practice, and thus I am the only one who has to read my handwriting (although it is quite legible - if I do say so myself). "

I think this attitude is a disservice to patients. What if they move? Want to take their business elsewhere? Develop a disease state that requires transfer of a significant part of their medical records? You are basically holding all of their patient data hostage by refusing to keep it in a remotely exportable format. I'm all for docs having the right to their own notes etc, but a large portion of the rest of that data, including care plan details like what medications have been tried and haven't worked, lab results, etc are integral to quality future care. Unless you are importing data into some kind of registry system you also aren't doing population-based outreach, which is going to become the standard of care in primary care.

I look forward to the day when PHRs and patient portals are the norm and we no longer think we own a patient's health history. Its like a bank owning my financial history. Imagine trying to buy a house if your entire financial record was housed in some folder in illegible handwriting.

Written like a person with absolutely no real world experience.

Just because your notes are electronic does not mean they are somehow automatically awesome.

I have absolutely no intention of going EMR - zilch , nada, zip. My notes are very comprehensive, and quite legible. I don't think another MD would have problems reading them, and in no way is an office remaining paper based taking a patient's medical history "hostage". This is ridiculous.

 

[DocYuki]

I just believe that access is key in a good EMR. Let's say you're taking call from home. To be able to check up on a patient's chart, look at the notes from their hospital stay, and send in a new Rx from your computer is amazing. The ability to get different doctors sharing health information on the same system dramatically improves accessibility and gets everyone on the same page, which is undoubtedly better for the patient in my opinion.

 

[RLMitchell1]

Written like a person with absolutely no real world experience.

"Just because your notes are electronic does not mean they are somehow automatically awesome. "

I didn't suggest that in the slightest. Saying that your paper notes are better than the worst case use of EMRs is a ridiculous argument, and you entirely ignore my argument about the importance of data in primary care outreach and population level healthare. Only slightly less ridiculous is your assertion that I have no real world experience, intuition, or knowledge base to bring to this discussion just because I am a medical student. I look forward to putting people like you out of business.

 

[ghost dog]

Written like a person with absolutely no real world experience.

"Just because your notes are electronic does not mean they are somehow automatically awesome. "

I didn't suggest that in the slightest. Saying that your paper notes are better than the worst case use of EMRs is a ridiculous argument, and you entirely ignore my argument about the importance of data in primary care outreach and population level healthare. Only slightly less ridiculous is your assertion that I have no real world experience, intuition, or knowledge base to bring to this discussion just because I am a medical student. I look forward to putting people like you out of business.

"Putting me out of business?" That's hilarious; fighting for patients must be an American issue.

In Canada, there is a significant shortage of family docs. Ain't gonna happen.

 

[rachmoninov3]

When EMRs go bad...really bad. It is far more efficient for me to write a double-sided progress note on an inpatient than use our emr for charting. Oh the charting is quicker, but doesn't have a way to put in medications, previous lab values, and when it's printed out to the patient's paper chart the emr note ends up being like 6 single sided pages with less information.
At the U as a med student I was doing all my notes on the emr. This one just sucks. However, if you asked me a year ago about the U's EMR I would have told you it sucked too. I just think that even the gen-x/gen-y docs think that EMRs are tedious and designed by people who have never practiced medicine! Or maybe we just love to hate on EMRs

 

[ghost dog]

When EMRs go bad...really bad. It is far more efficient for me to write a double-sided progress note on an inpatient than use our emr for charting. Oh the charting is quicker, but doesn't have a way to put in medications, previous lab values, and when it's printed out to the patient's paper chart the emr note ends up being like 6 single sided pages with less information.
At the U as a med student I was doing all my notes on the emr. This one just sucks. However, if you asked me a year ago about the U's EMR I would have told you it sucked too. I just think that even the gen-x/gen-y docs think that EMRs are tedious and designed by people who have never practiced medicine! Or maybe we just love to hate on EMRs

You said it. I heard a rumour that some areas in the US are forcing EMR based charting; is this accurate ?

 

[deleted87716]

You said it. I heard a rumour that some areas in the US are forcing EMR based charting; is this accurate ?

https://www.cms.gov/ehrincentiveprograms/

 

[ghost dog]

https://www.cms.gov/ehrincentiveprograms/

At a quick glance, these appear to be cash incentives. However, you still have to pony up the dough dough for the EMR , which ain't cheap. Plus the learning curve, plus the pain in the ass factor, should your EMR crash.

 

[deleted87716]

At a quick glance, these appear to be cash incentives. However, you still have to pony up the dough dough for the EMR , which ain't cheap. Plus the learning curve, plus the pain in the ass factor, should your EMR crash.

If you read down the page a bit, you'd have seen the part about the penalties.

Important! For 2015 and later, Medicare eligible professionals, eligible hospitals, and CAHs that do not successfully demonstrate meaningful use will have a payment adjustment in their Medicare reimbursement.

As for the cost, there is at least one free EMR available: http://www.practicefusion.com/

Medicine should've been computerized years ago. Docs are running out of excuses, frankly.

 

[rachmoninov3]

If you read down the page a bit, you'd have seen the part about the penalties.



As for the cost, there is at least one free EMR available: http://www.practicefusion.com/

Medicine should've been computerized years ago. Docs are running out of excuses, frankly.

I have a good excuse: Right now we're still waiting for the free market of EMR coders/manufacturers to give us a good product. The time will come when people may choose to work at hospital x because they have awesomechart rather than hospital y that uses mediturd. Sadly though, it's not hear yet. The free market is not exactly doing what it should because you have huge corporations (banner, centura, christus, kaiserperm,) who invest lots of money in a corporation wide system that is difficult to change if it sucks.