EMR: the Premed Threat Dossier

[pkwraith]

EMRs are a topic that premeds should be aware of, but is not often discussed. In short, the practice of medicine as we graduate will be very different than those that are currently

Based on my personal experience in the industry, I'm just going to round out a few points on the impact that we will be seeing.


Why it matters to Premeds. In Residency and Attending, chances are you will be using one. As part of the American Recovery and Reinvestment Act, the HITECH act will be mandating penalties on any hospitals and doctors that are not meaningfully using EMRs, starting in 2015. So, yes, it will be a big part of your professional life. Learn to type (I would be surprised if anyone on SDN can't touch type. But if you are one, address that now).

Does it matter in Applications? Just for applying to med school, EMRs don't really matter. 90% of academics have EMRs already, but you're not going to be doing much with it in M3/M4. You're just going to be reviewing charts (maybe). You obviously can't place orders. I've only worked with one hospital that let med students write notes (the notes just float around by themselves, no one else can see them since they're not considered part of the medical record). However, having an installed EMR is a good sign that your school is technologically-progressive and aware of legal/compliance.

But for Residency applications, you're going to living and breathing EMRs. So, it may be smart to ask questions. Get some idea of what kind of EMR your program is using. What is its scope (notes, orders, results review?), what kind of initial or continuous training, how you can ask for changes in the system, able to remote login or use portable devices, etc.


EMR and lifestyle? Big concern from premeds are on the lifestyle and work-life balance as physicians and residences. EMRs can make you work much, much longer. EMRs have the potential to swing the balance the other way. If you don't take the time and training, you might be working extra hours after shift just getting in your notes. One of the biggest change from EMR is the shift of work towards physicians. Instead of scribbling down orders and tossing them at a nurse or unit clerk, you will have to find your own own orders, figure out the right dosage, etc. Dictation is losing traction in favor of cheaper voice recognition and templates. For a premed, it might be smart to shadow a physician that is currently using an EMR (assuming you have a choice).

On the other hand, EMR has the great potential of giving more flexibility to physicians. I recently worked on a first-generation IPad and IPhone EMR application at a hospital, and I've seen what's in the pipeline. At the current progress, by the time we start as attending, you can do almost everything you need from just an iPhone (or Droid). You can be at your son's baseball game, take a patient call, review the meds/allergies, renew their prescription, dictate a quick note, and be done in five minutes. Situations like that can make being on call a lot less painful.

Are we going to be replaced by computers? Watson will not be replacing us any time soon. I've worked with the Clinical Decision Support in some of the most powerful EMRs, and they are not even close to be handling complex diagnostic/treatments. Can they suggest courses of treatment based on specific combination of symptoms and labs? Of course, and they do that already. But, they certainly cannot handle the nuance of medicine. So do not fear an computer invasion in our lifetime.


;tldr In this thread, we discuss Electronic Medical Records, Clinical Informatics, and the impact on us future physicians.

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[RogueUnicorn]

not gonna lie, this stuff does factor into my thinking re: specialty decisions; it definitely supports going to more procedural fields. regardless of the watson situation, which is a bit scary to think about in and of itself, with EMR, it is becoming very easy to outsource physicians.

 

[Disinence2]

Yes, doctors use medical records. Some of which are electronic.

For people of our generation who are generally rather computer savvy, this saves time and is no big deal.

You will need to learn many different EMR's as you travel to different hospitals, and clinics through med school and residency. You will find that with a few exceptions they are all about the same.

I would argue pre-meds don't really need to be too concerned with them. If your on SDN you have the computer skills to manage them.

 

[Person0715]

I've been shadowing some docs lately who probably did not grow having computers for most of their lives (probably in their late 40's now). I can see the toll it takes when these doctors use electronic medical records. I am by no means saying they are bad docs; they are great doctors who take wonderful care of their patients, but from what I can tell, they don't seem to be the most computer savvy and still peck at the keyboard when typing. So what probably takes a few minutes to write by hand takes three to four times longer when typing on the keyboard.

However, as time goes on, this problem will definitely become more rare.

 

[sk8ngli]

I agree with Person0715. I have been writing my own notes as a case manager and while notes are certainly a pain (I have a couple waiting for me right now!), I adore our EMR system. It's an amazing breakthrough for our patients and truly provides the type of continuity of care that patients (particularly transient populations) could never have had decades ago. Certainly, it's amazing not having to struggle to interpret illegible writing.

That being said, I recognize some of the traps that come with EMRs. Particularly just looking at the most recent 10 visits and no longer really reading a whole cart.

For the doctor that I have been shadowing, I really think the EMR has hindered his performance as an MD. He tailors his visits just to fill in boxes and he. types. so. incredibly. slowly. which puts him seriously behind when trying to keep up with his patient load. Often it will take him 5 minutes just to find his lab orders which can be frustrating for everyone.

For our generation though, the last remaining generation who grew up without a computer but came of age during the computer age, EMR's won't even be a point of discussion. I say the medical industry has only another 10-20years before everyone who doesn't know how to type has retired.

I should hardly call EMRs a threat to any pre-meds who know how to type and use a computer.

 

[boobelle]

EMR isn't so far in the future as you think...in fact, at many locations it's already been in place for a while (e.g. my hospital system switched to EMR over a decade ago). When I was interviewing for residency programs, most were on an EMR and those who weren't were partially in an EMR and would finish converting to full electronic records within a year or two.

90% of academics have EMRs already, but you're not going to be doing much with it in M3/M4. You're just going to be reviewing charts (maybe). You obviously can't place orders.

I wrote electronic notes and orders as a medical student, they just needed to be cosigned by a physician to become "real." Same goes for where I'm currently training as a resident...and students have been able to write/order in the VA system across the entire US for some time now.

If the med school you're considering doesn't let you write orders as an M3/M4 that's a serious (and frankly unusual) deficiency in your education, and you should not attend that school...but I'd be surprised if there are actually schools were you only "chart review" as a clerk or sub-I. At that level you are supposed to be functioning as a doctor with increased supervision (including someone with an MD to confirm your orders and notes).

EMR and lifestyle? Big concern from premeds are on the lifestyle and work-life balance as physicians and residences. EMRs can make you work much, much longer.

If you can type, EMRs actually speed up work. And if you are a 20-something premed who can't type, you have bigger problems than an EMR. (And for older docs who can't type, it's possible to integrate a dictation system with the EMR.) For myself, typing a note is significantly faster than handwriting. Also, with paper notes and orders you have to physically be on the patient's floor...whereas orders and notes on an EMR can be done long-distance (hell, I could write them from home if I wanted to). So I'm not running 20 minutes from one end of the hospital to the other every time I want to replete somone's K, or any other hundreds of orders I write a day.

In short, EMR is a reality and while it has it's pros and cons, the pros vastly out-balance the cons. The physicians who have trouble with the conversion are often a) those in single-practice who have difficulty bearing the expense of starting up an EMR and/or b) older physicians who have been using paper records for decades. For those of us who have grown up with computers, the EMR is logical.

You're forgetting many of the pluses...the ability to quickly access old notes, labs, and imaging from any time a patient has ever come into contact with the medical system, and so there's MUCH less reinventing of the wheel when a patient is readmitted (and, more likely than not, can't remember what meds they're taking or comprehensively recall their major medical problems or history). Electronic orders reduces medical error by populating common dosages and being able to crosscheck for interactions and allergies (this can go overboard, but much better than paper orders)...our EMR order system communicates with the machines used to dispense meds to nurses, so there's an additional check there. Having an electronic system also significantly speeds up the time from writing an order to having a med administered or a test run. Also, while it's cliche, it's ridiculous how horrific people's handwriting is....being able to actually read and understand notes and orders is invaluable.

 

[TooMuchResearch]

Yes, doctors use medical records. Some of which are electronic.

For people of our generation who are generally rather computer savvy, this saves time and is no big deal.

You will need to learn many different EMR's as you travel to different hospitals, and clinics through med school and residency. You will find that with a few exceptions they are all about the same.

I would argue pre-meds don't really need to be too concerned with them. If your on SDN you have the computer skills to manage them.

👍

 

[pkwraith]

EMR isn't so far in the future as you think...in fact, at many locations it's already been in place for a while (e.g. my hospital system switched to EMR over a decade ago). When I was interviewing for residency programs, most were on an EMR and those who weren't were partially in an EMR and would finish converting to full electronic records within a year or two.



I wrote electronic notes and orders as a medical student, they just needed to be cosigned by a physician to become "real." Same goes for where I'm currently training as a resident...and students have been able to write/order in the VA system across the entire US for some time now.

If the med school you're considering doesn't let you write orders as an M3/M4 that's a serious (and frankly unusual) deficiency in your education, and you should not attend that school...but I'd be surprised if there are actually schools were you only "chart review" as a clerk or sub-I. At that level you are supposed to be functioning as a doctor with increased supervision (including someone with an MD to confirm your orders and notes).



If you can type, EMRs actually speed up work. And if you are a 20-something premed who can't type, you have bigger problems than an EMR. (And for older docs who can't type, it's possible to integrate a dictation system with the EMR.) For myself, typing a note is significantly faster than handwriting. Also, with paper notes and orders you have to physically be on the patient's floor...whereas orders and notes on an EMR can be done long-distance (hell, I could write them from home if I wanted to). So I'm not running 20 minutes from one end of the hospital to the other every time I want to replete somone's K, or any other hundreds of orders I write a day.

In short, EMR is a reality and while it has it's pros and cons, the pros vastly out-balance the cons. The physicians who have trouble with the conversion are often a) those in single-practice who have difficulty bearing the expense of starting up an EMR and/or b) older physicians who have been using paper records for decades. For those of us who have grown up with computers, the EMR is logical.

You're forgetting many of the pluses...the ability to quickly access old notes, labs, and imaging from any time a patient has ever come into contact with the medical system, and so there's MUCH less reinventing of the wheel when a patient is readmitted (and, more likely than not, can't remember what meds they're taking or comprehensively recall their major medical problems or history). Electronic orders reduces medical error by populating common dosages and being able to crosscheck for interactions and allergies (this can go overboard, but much better than paper orders)...our EMR order system communicates with the machines used to dispense meds to nurses, so there's an additional check there. Having an electronic system also significantly speeds up the time from writing an order to having a med administered or a test run. Also, while it's cliche, it's ridiculous how horrific people's handwriting is....being able to actually read and understand notes and orders is invaluable.

I'm not forgetting the pluses. I simply didn't want to make a block of text longer than it is, and seem like a shill for the EMR industry 🙂
I think we can all agree with the pros. So, I'm glad that you listed out most of them so I didn't have to. I don't think they're a threat--I just like the title Threat Dossier.

As for Premed not needing to care about EMRs. It's going to be a big part of life as we know it. They should do definitely do some research on what's out there and what's coming up, because it will inevitably be necessary for them to do their job.

Few things that are barely implemented right now, but will be in full swing when we graduate, that I haven't mentioned.

1. Much easier information exchange between hospital systems. Instead of dealing with faxing and forms after forms, it's just a matter of a few seconds to be able to access the patient's record from a hospital across the country.

2. Interactive touch screen monitors in ICU, anaesthesia, and ORs. No more fudging around with keyboards. Just hop around to different vitals, zoom out, zoom, drag things around in on an Iphone.

3. Much more patient control. Patient portals are becoming increasingly important, allowing them to request Rx, make appointments, and even do electronic consults. Personal Health Records are going to be a bigger penetration. Handle it wrong as a physician, and you're dealing with tons of extra work answering emails. Handle it right, and you have a more happy, healthier patient base and saved time.

4. Google-style searching of patient charts.

 

[SissyAlice]

This is actually pretty cool, one of my volunteer positions involves rolling EMRs out in a hospital... Never knew how revolutionary it was, since they seem to be the next logical step in medical records. Something I can possibly talk about in my PS or in interviews! The system we're using is probably a little more involved on the patient side than most.

As an advocate for one of these programs, I do really see the crazy awesome benefits it can have... But putting these programs together is extremely difficult, especially with an older audience (90% of who I work with: doctors & patients) 😕 The hospital I am working with is team based though, so the additional workload probably evens out.

Something I'm concerned about is the fact that errors can be more easily overlooked on computers because people tend to just skip over things and not read them thoroughly on computers(although some will have error check-ers).

 

[pkwraith]

This is actually pretty cool, one of my volunteer positions involves rolling EMRs out in a hospital... Never knew how revolutionary it was, since they seem to be the next logical step in medical records. Something I can possibly talk about in my PS or in interviews! The system we're using is probably a little more involved on the patient side than most.

As a volunteer experience, that is definatly very useful. Not only can you get almost full access to most departments, but you get tons of clinicians interaction.

Something I'm concerned about is the fact that errors can be more easily overlooked on computers because people tend to just skip over things and not read them thoroughly on computers(although some will have error check-ers).

Yes, alarm fatigue is definitly a major problem. And one of the sources is that EMRs are typically designed and implemented by non-MD trained professionals (like me), and a lot of the extra rules is also mandated by hospital management. So, physicians get tired out by extraneous warnings, and few of them eventually can get in trouble (since every action they do is tracked and audited).

However, many issues can be addressed if physicians/med students are more proactively involved in the process. At every hospital, there is a change submission process (some easily accessible than others). As med students and as physicians, if something is not working well, they should submit the issue. I know it's "not our job", but it's certainly better in the long run.

A question to any current medical students reading this: is EMR training involved in your education and in what way? Do they just give you a login and let you at it?

Simply because adding an EMR changed the patient-physician dynamics in many ways. One example: I've seen many clinicians (physicians, nurse, et all) now pay more attention to the computer than the patient in the room, losing eye contact and patient rapport. Many of them are not even aware they're doing it. In the future, it may be quite important to work in a computer while teaching students how to interview and interact with patients.

 

[damndinosaur]

this is a great thread, and i think very important.

i got a job not too long ago with an EHR company (EHR = EMR), and i can tell you first hand that there are some serious advantages and also disadvantages to the EHR system. most of these have already been mentioned above, but one thing that hasn't been touched on is that EHR technology, and most of the companies that make and implement the software themselves are fairly new, and kind of learning as they go (lol i work for one, and let me tell you, EHR is by no means perfect yet)

another thing to consider is that because of the new Healthcare bill and the incentives given to doctors to implement EHR quickly (up to $44,000 given in installments to those who implement by the end of this year), many doctors decided to go with an EHR company that wasn't very user-friendly and didn't provide all the functionality they needed. this has caused a lot of doctors to be dissatisfied with EHR on the whole, even though they chose to go with a system that was probably not the best (in order to receive the incentive payments). because of this, a lot of doctors are contemplating switching to a different service. older doctors especially are hesitant about this whole EHR thing, but younger docs are of course tech savvy enough that it isn't a problem

there's also a big business side to the whole EHR thing. the system is not cheap to install or maintain (monthly and yearly costs), and it also forces doctors to be much more accountable for the information they put in, because that info is readily available to insurance companies and also the patients (this is the goal in the future). many EHR companies that are smaller are also prime targets for acquisitions by larger healthcare corporations, and if this happens, we could be looking at a fairly standardized medical recording system in the future, for better or worse

it's important for all of us interested in medicine to educate ourselves more about this

 

[Captain Fantastic]

EMRs are here and will only get more ubiquitous thanks to Medicare's "Meaningful Use" requirements, but really it's not like any pre-med should be picking a medical school based on the EMR vendor.

 

[NightGod]

Also, while it's cliche, it's ridiculous how horrific people's handwriting is....being able to actually read and understand notes and orders is invaluable.

This is HUGE for me. I have absolutely horrific handwriting (partly due to the fact that I skipped half of my second grade year, so I didn't have formal teaching in cursive writing for about half of the alphabet lol) and SO much slower than my typing is. I can type 60+ WPM literally with two broken hands (well, broken left thumb and right wrist) and I write at maybe half of that, so I'm ecstatic that EMR is going to be the reality when I get to that point in my career.

 

[ywlke]

Simply because adding an EMR changed the patient-physician dynamics in many ways. One example: I've seen many clinicians (physicians, nurse, et all) now pay more attention to the computer than the patient in the room, losing eye contact and patient rapport. Many of them are not even aware they're doing it. In the future, it may be quite important to work in a computer while teaching students how to interview and interact with patients.

This. Yes. I've been on the patient end of this happening.

 

[ywlke]

many EHR companies that are smaller are also prime targets for acquisitions by larger healthcare corporations, and if this happens, we could be looking at a fairly standardized medical recording system in the future, for better or worse

it's important for all of us interested in medicine to educate ourselves more about this

"Standardized" could be either good or bad...the big thing I think should be done is to use industry-standard technologies (e.g. SSL, SQL databases, LDAP) in an interoperable way. That way, it shouldn't matter ultimately what company you get your EMR software from, any EMR interface should be able to read any other EMR backend database to an extent. Unfortunately, I think a lot of decision makers on the customer side (i.e. doctors, hospital management, etc.) don't always consider these, and on the vendor side, being interoperable is either seen negatively (makes it easy for the customer to switch platforms) or is an afterthought (how long were we stuck with websites that worked in Internet Explorer but not Firefox? same idea).

 

[theWUbear]

In short, the practice of medicine as we graduate will be very different than those that are currently (due to EMRs)

Wait am I still in 2011 or did this thread transport me back to 1995

 

[Nooblet]

90% of academics have EMRs already, but you're not going to be doing much with it in M3/M4. You're just going to be reviewing charts (maybe). You obviously can't place orders. I've only worked with one hospital that let med students write notes (the notes just float around by themselves, no one else can see them since they're not considered part of the medical record).

what are you talking about? at my school med students fully use the EMR. we write notes every single day that are visible to everyone. every single school i know of is like this as well. at my school, at the tail end of our 3rd years they let us start putting in orders, and its almost expected during 4th year, of course the orders are looked over and signed by the resident or attending. paper charts largely do not exist anymore

 

[theWUbear]

90% of academics have EMRs already, but you're not going to be doing much with it in M3/M4. You're just going to be reviewing charts (maybe). You obviously can't place orders. I've only worked with one hospital that let med students write notes (the notes just float around by themselves, no one else can see them since they're not considered part of the medical record).

Yeah I think OP doesn't know what he's talking about. OP: I'm a premed and I write notes related to my clinical research after doing lung function tests on patients. Umad? Uknowwhatyou'retalkingabout?

 

[theWUbear]

On the other hand, EMR has the great potential of giving more flexibility to physicians. I recently worked on a first-generation IPad and IPhone EMR application at a hospital, and I've seen what's in the pipeline. At the current progress, by the time we start as attending, you can do almost everything you need from just an iPhone (or Droid).

As long as your device can run a citrix client you can access Centricity/Logician, Epic Hyperspace, and a host of other EMR's wherever you are. Again, this thread belongs in 1995 not 2011. It's not 'in the pipleine', it was available in 2006 as you say it may be in the future.


Sorry to keep harping on this thread, but it seems like the epitome of a premed knowing little about what he/she is saying

 

[ywlke]

As long as your device can run a citrix client you can access Centricity/Logician, Epic Hyperspace, and a host of other EMR's wherever you are. Again, this thread belongs in 1995 not 2011. It's not 'in the pipleine', it was available in 2006 as you say it may be in the future.

Citrix won't give you a mobile-friendly app though, although yes, you would get access to it. However, last time I checked, iPhone apps for medical records are being worked on today, 2011-2012. By the time we are attendings, it'll be on to whatever the next great thing is...

 

[pkwraith]

As long as your device can run a citrix client you can access Centricity/Logician, Epic Hyperspace, and a host of other EMR's wherever you are. Again, this thread belongs in 1995 not 2011. It's not 'in the pipleine', it was available in 2006 as you say it may be in the future.


Sorry to keep harping on this thread, but it seems like the epitome of a premed knowing little about what he/she is saying

Citrix is not a solution. It's one of the biggest obstacles in EMR implementation right now, not only because of pricey license costs for each concurrent user sign-on, but also limited upward scope(KP ran into a lot of issues with this), contributes to most of the latency, adds another layer of unnecessary infrastructure. That's why many EMR vendors are moving towards Web-based clients now.

And the most important part: Usability and functionality (something that doctors should actually care about). Having natively-supported applications in the respective device is 100x better, in both user interface, integration and access. You can have crappy poor-resolutioned access with limited controls using a citrix login, or something that is actually designed to work naturally with your device. You can feel free to use a cobbled-together option while everyone is moving ahead of you.

But then again, if you had an idea of what you were talking about, you would've known that.

what are you talking about? at my school med students fully use the EMR. we write notes every single day that are visible to everyone. every single school i know of is like this as well. at my school, at the tail end of our 3rd years they let us start putting in orders, and its almost expected during 4th year, of course the orders are looked over and signed by the resident or attending. paper charts largely do not exist anymore

That's very good to hear. The last time I was working on setting up med students in an ED, the Attendings pushed back (long story) and nothing changed. I really do look forward to getting a lot of values out of EMRs as a MS. However, my point was that Medical Students simply don't use the EMR enough to use EMR as a critera selection. If you do think that their scope is enough for EMRs to come up in your school selection, I will defer to you.

But, can you answer the previous question I posed?
Is EMR training (stand alone training, integration into classes) involved in your education and in what way? Do they just give you a login and you just figure it out?

 

[pkwraith]

Wait am I still in 2011 or did this thread transport me back to 1995

I wasn't aware that there was a federal mandate in 1995 that required national implementation of the system. Apparently, you thought hospitals in general are risky high tech adopters, when they are generally very risk-conscious entities. Apparently, EMR is now finished, and there's going to be no changes and improvements whatsoever, and we've reached the peak of progress. We can only discuss things when they first appear on the market, and never again.

But, continue with your quippy one-liners as you are definitely adding value to this thread. Or you can actually detail experiences you had with EMR and your own thoughts.

 

[eablackwell]

When I toured a hospital at my school's second look, one of the docs showed us the handheld devices they use. You just scan the wristband and the medical records pop on screen, then you have the ability to add to it write Rx, etc right there. It was amazing!

 

[BeachBlondie]

Medical technology is certainly nothing to be feared. If anything, it should be celebrated! It makes obtaining records faster(for the most part), more organized, and remotely accessible. Talk to some of the hospitals in Europe who are still doing paper, and they will tell you that they are IMPLORING their management to switch over.

Medical technology on a broader scope is awesome. One of the studies I am managing is tracking the performance of robotics-integrated total joint replacement. As a whole, surgeons' placement of the ortho components is a HUGE determining factor in the rate of failure of implants (i.e. dislocations, etc.). Our multi-center studies show that surgeons are pretty much all over the map for placement--50% in the optimal range, 50% out. With robotics, we can ensure proper placement AND CONSISTENCY. We're doing things with robotics--like pre-operative planning--that was never attainable manually.

Killer stuff.

 

[pkwraith]

Medical technology is certainly nothing to be feared. If anything, it should be celebrated! It makes obtaining records faster(for the most part), more organized, and remotely accessible. Talk to some of the hospitals in Europe who are still doing paper, and they will tell you that they are IMPLORING their management to switch over.

You don't need to go as far as Europe. There's a ton of hospitals in the US scrambling right now. At this point, we're probably at the Laggard stage of implementations in the US, with still a significant amount of hospitals/clinics on paper. And the many are some combinations of EMR and paper. I think the only truly paperless hospitals (from a year back or two) was Northshore and a few Kaiser sites. The next couple of years are definatly going to be crunch time due to HITECH.

Medical technology on a broader scope is awesome. One of the studies I am managing is tracking the performance of robotics-integrated total joint replacement. As a whole, surgeons' placement of the ortho components is a HUGE determining factor in the rate of failure of implants (i.e. dislocations, etc.). Our multi-center studies show that surgeons are pretty much all over the map for placement--50% in the optimal range, 50% out. With robotics, we can ensure proper placement AND CONSISTENCY. We're doing things with robotics--like pre-operative planning--that was never attainable manually.

I definitely agree. Medical technology can really help with consistency, and standard of care. Just taking the EMR example again, large organizations can push automatic suggestions and best practices to thousands of physicians at a time. When they see a patient with X,Y,Z they can give standard treatments. They don't have to constantly stay up with hundreds of papers of research. And better yet, they can now track results vs treatment (evidence-based medicine!) in their database. I do acknowledge that there will be a balancing act between consistency and individual intuitions.

 

[BeachBlondie]

I think that medicine has come to a very interesting point. And, we're the generation that will be there to experience the changes as we enter into a new era. A lot of the surgeons here (and I work at a big research medical center) were reticent to have robots in the OR, guarding their craft like so many physiological carpenters; proud to work with their hands and their tools. But, the younger docs are all for it....they've embraced this new cyborg dynamic: surgeon-robot. The battle between generations is incredibly fascinating.

 

[BoxAtDaRedLight]

I think EMR is great because of the reduction of medical error but overall it's taking time away from physician's treating the patient seeing as how now the physician has to sit down and document everything they did during their visit. I can see how many will cut their visits short to be able to see the same amount of patients as before and still be able to type their notes. This is how it works with the personnel in my department. They are pushed to see 18-20 patients for their therapy treatments in an 8 hour shift and still do all their notes which are nearly 16 pages of information they need to fill each. So what they do is find any reason to cancel the session on a patient to be able to fit in what they can consider "adequate" treatment on another. I also think it will take away the jobs of unit secretaries who would normally input all the orders made by the physicians in the charts. So as far as a hospital is concerned it seems like it hurts as much as it helps. I know the facility I work for is only switching to EMR because of the money the government is offering to facilities whom switch over.

As far as the office my little sister works at it's created more work for her because she has to input all the information into the system's storage through scanning etc. So I guess it's relative to where you work. She's not complaining because summer hours are niice 😀

I personally liked charts, they are at your fingertips and information is there. If handwriting was a little better across the board it would make things so much easier🙄

 

[music2doc]

OP, why the fuss? If you've worked in a hospital setting as a tech, you've probably been using EMRs since day one. (Our local hospitals, at least, have been using EMR systems for years.) They're really pretty easy to use and the good ones have plenty of shortcuts. My main concern is what happens when it all goes down. What happens when I have several traumas come into the ED together and another dept has somehow managed to lock us out of those accounts? Sounds simple, right? Just go to paper...but in our ED (and others like it) you cannot perform labs, imaging, or even EKGs (or write any orders whatsoever) without access to a pt's account. In other words, when this has happened, we've ended up stalled in the ED doing our best to save the pt w/o being able to get the proper diagnostics or write the necessary orders (nursing or medical) for the pt. Yes, there are downtime protocols in place to work around all of this but they tend to be cumbersome and still waste precious minutes. As for finding records, however, that's facilitated quite nicely by the EMR, as are things like dosage requirements (and I wouldn't want my nurse "interpreting" my scribbles on a pad anyway -- that's one major way medical errors are made).

 

[BeachBlondie]

I personally liked charts, they are at your fingertips and information is there. If handwriting was a little better across the board it would make things so much easier🙄

At some institutions where the EMRs may not be the most accessible or organized, I could see the time commitment becoming a problem. But, personally, I access patient records every day electronically and I could not FATHOM having to keep hard copies for everything. It would be an absolute nightmare. Especially because the total joint arthroplasty patients' average age is above 60--meaning they have A LOT of history to cover.

I also think that the paper trail would be different per medical focus. If you're a GP, I feel as if you'd need to write more extensively as you're the one establishing a lot of the foundation of information on a given patient. Our surgeries? Get in, record the necessary operative information/radiographs, make notes on how the surgery progressed, and you're out.

 

[BoxAtDaRedLight]

My facility used to have both the EMR and charts. But they changed the old EMR system. It used to be that nurses, case managers, and other ancillary staff would type their notes into the computer. Doctors would dictate and someone would put their dictation into the system. Then as they wrote orders the unit secretaries would process these orders and send the orders to each department. Now they changed it where they are doing away with all the charts and the physicians must put in their own orders, their progress notes are in one section. Honestly I see some really vague notes with terrible punctuation and grammar, especially many of the older foreign doctors.

"ches pain, compln of LLE pain as well. order US R/O DVT"
"CBC in AM, xfusion for HGB under 8"

I don't know I am just much more thorough in my notes..

 

[pkwraith]

OP, why the fuss? If you've worked in a hospital setting as a tech, you've probably been using EMRs since day one. (Our local hospitals, at least, have been using EMR systems for years.) They're really pretty easy to use and the good ones have plenty of shortcuts. My main concern is what happens when it all goes down. What happens when I have several traumas come into the ED together and another dept has somehow managed to lock us out of those accounts? Sounds simple, right? Just go to paper...but in our ED (and others like it) you cannot perform labs, imaging, or even EKGs (or write any orders whatsoever) without access to a pt's account. In other words, when this has happened, we've ended up stalled in the ED doing our best to save the pt w/o being able to get the proper diagnostics or write the necessary orders (nursing or medical) for the pt. Yes, there are downtime protocols in place to work around all of this but they tend to be cumbersome and still waste precious minutes. As for finding records, however, that's facilitated quite nicely by the EMR, as are things like dosage requirements (and I wouldn't want my nurse "interpreting" my scribbles on a pad anyway -- that's one major way medical errors are made).

My fuss is just information dessimination and discussion. I think for many premeds, they just think Electronic Medical Record, is just paper chart that is on a computer. It will be a big part of our lives as a physician, and is worth discussing as any other major aspects of future lives.

I'm glad you have had great experiences, and I agree that downtime is something that is a major hassle. You have disruption of continuity of care and just a lot of stress and having staff memorize additional protocols. It's not an isolated problem either. Many EMRs have downtimes for maintenance and upgrades. Popular news items of recently are tornadoes and thunderstorms that take out power generators on hospitals.

However, I wouldn't be surprised if in a decade, we can keep them up 99.9% of the time. There's a lot of movements towards Web Clients, backup computers/generators, multiple servers. Overall, this deficiency should gradually improve over time.

My facility used to have both the EMR and charts. But they changed the old EMR system. It used to be that nurses, case managers, and other ancillary staff would type their notes into the computer. Doctors would dictate and someone would put their dictation into the system. Then as they wrote orders the unit secretaries would process these orders and send the orders to each department. Now they changed it where they are doing away with all the charts and the physicians must put in their own orders, their progress notes are in one section. Honestly I see some really vague notes with terrible punctuation and grammar, especially many of the older foreign doctors.

"ches pain, compln of LLE pain as well. order US R/O DVT"
"CBC in AM, xfusion for HGB under 8"

I don't know I am just much more thorough in my notes..

Notes is the one of the biggest area of difficulty for EMRs. In this area, I think that technology is still kind of playing catchup to what we need it to be. You have the current options right now:

Free text: Illegible abbreviations and words as you mentioned. Poor typers and computer illiterate physicians spending painful hours typing. Extremely difficult to be used for reports and almost useless for data analysis.

Dictation: Great for physician. Anyone can do it--just pick up a phone and start talking. But, it's the most expensive option, so hospitals don't like paying for it, when they see the other options. Cost concerns are going to be putting major pressure on this.

Voice Recognition: Pretty decent for physician. Some problems if you get crowded into a busy office with three other physicians, talking at the same time. Requires some training and practice. You have to pay some software costs, so it's not cheap either. But, it does have some cool factor. At some facilities, the physicians are almost hands-free. They can jump around a patient's chart, write notes, review meds just with voice commands in Dragon. Pretty sweet.

Templates: point and click on buttons, which generate text. By far the fastest, especially when you can save/edit old notes and settings. But, you run into issues with robotic notes that often have too much information. I've heard of a couple notes program out there that remember what you type and how you type it, and craft a more customizable note. But, I haven't actually seen it in action, and they're not mainstream (yet).

And another problem is EMRs making it too easy to dump tons of information on your note. Yes, it is awesome to pull in all the Labs, Med Rec, History into your note automatically. But, a lot of notes end up suffering from too much irrelevant information, whether because of billing or covering your but (which I guess it inescapable).

 

[NightGod]

And better yet, they can now track results vs treatment (evidence-based medicine!) in their database. I do acknowledge that there will be a balancing act between consistency and individual intuitions.

Scientific American has an article on exactly this topic this month. Very interesting stuff. At this point, it seems that large part of the struggle is going to be getting the public to accept the results of CER. A large portion of the technical issues are solved and a good chunk of the necessary technology is in place, but people still balk at cost vs effectiveness analysis because it is so easy to spin into 'care rationing' and 'death panels'.

 

[BoxAtDaRedLight]

Scientific American has an article on exactly this topic this month. Very interesting stuff. At this point, it seems that large part of the struggle is going to be getting the public to accept the results of CER. A large portion of the technical issues are solved and a good chunk of the necessary technology is in place, but people still balk at cost vs effectiveness analysis because it is so easy to spin into 'care rationing' and 'death panels'.

Yeah I think this was the one I read.

 

[BoxAtDaRedLight]

My fuss is just information dessimination and discussion. I think for many premeds, they just think Electronic Medical Record, is just paper chart that is on a computer. It will be a big part of our lives as a physician, and is worth discussing as any other major aspects of future lives.

I'm glad you have had great experiences, and I agree that downtime is something that is a major hassle. You have disruption of continuity of care and just a lot of stress and having staff memorize additional protocols. It's not an isolated problem either. Many EMRs have downtimes for maintenance and upgrades. Popular news items of recently are tornadoes and thunderstorms that take out power generators on hospitals.

However, I wouldn't be surprised if in a decade, we can keep them up 99.9% of the time. There's a lot of movements towards Web Clients, backup computers/generators, multiple servers. Overall, this deficiency should gradually improve over time.




Notes is the one of the biggest area of difficulty for EMRs. In this area, I think that technology is still kind of playing catchup to what we need it to be. You have the current options right now:

Free text: Illegible abbreviations and words as you mentioned. Poor typers and computer illiterate physicians spending painful hours typing. Extremely difficult to be used for reports and almost useless for data analysis.

Dictation: Great for physician. Anyone can do it--just pick up a phone and start talking. But, it's the most expensive option, so hospitals don't like paying for it, when they see the other options. Cost concerns are going to be putting major pressure on this.

Voice Recognition: Pretty decent for physician. Some problems if you get crowded into a busy office with three other physicians, talking at the same time. Requires some training and practice. You have to pay some software costs, so it's not cheap either. But, it does have some cool factor. At some facilities, the physicians are almost hands-free. They can jump around a patient's chart, write notes, review meds just with voice commands in Dragon. Pretty sweet.

Templates: point and click on buttons, which generate text. By far the fastest, especially when you can save/edit old notes and settings. But, you run into issues with robotic notes that often have too much information. I've heard of a couple notes program out there that remember what you type and how you type it, and craft a more customizable note. But, I haven't actually seen it in action, and they're not mainstream (yet).

And another problem is EMRs making it too easy to dump tons of information on your note. Yes, it is awesome to pull in all the Labs, Med Rec, History into your note automatically. But, a lot of notes end up suffering from too much irrelevant information, whether because of billing or covering your but (which I guess it inescapable).

The doctors have one where it is free-notes/ templates. Still, it takes them a long time and they seem pretty pissed off. Thankfully if you aren't a physician you can switch back to the old module and type away easing the process imo.. But that's only if you're not a physician 🙂

 

[Nooblet]

That's very good to hear. The last time I was working on setting up med students in an ED, the Attendings pushed back (long story) and nothing changed. I really do look forward to getting a lot of values out of EMRs as a MS. However, my point was that Medical Students simply don't use the EMR enough to use EMR as a critera selection. If you do think that their scope is enough for EMRs to come up in your school selection, I will defer to you.

But, can you answer the previous question I posed?
Is EMR training (stand alone training, integration into classes) involved in your education and in what way? Do they just give you a login and you just figure it out?

I dont quite understand what you mean about using the EMR as criteria selection? I am 100% certain that any respectable school uses EMR and that medical students have the ability (and requirement) to write notes and input orders. I know many many medical students in a variety of schools across the nation and this is definitely the case. If a school did NOT have EMR or did and didnt let students use it, that would be a terrible school to learn at in my opinion. In fact I dont even understand how that is possible if students were not allowed to use it. A M3/M4's job is to basically act like a doctor - its practice. We see patients on our own, write notes, come up with assessments/plans, and present them to the attending to cosign. Shadowing is for premeds.

With the pros and cons discussion, you wont find a single young doc who doesnt agree that the pros are >>>>>>>>>>>>>>>> cons. Yes, notes can be overly long and have too much superfluous info pulled into them, but thats usually when you start out at the beginning of M3. Over the M3 year you learn whats relevant, whats more important, and notes become shorter, more concise. In fact at the end of the year, most attendings will tell you to cut the crap.

To answer your question, there is EPIC training several times throughout M1, M2, M3 year, but these are largely viewed as an annoyance. If you have the computer savvy of a normal 20 something year old person in this day and age, most things on the EMR are very intuitive. Those that are not are learned easily on the job. There were several times during M2 where they would assign us some fake patients and we would fully work them up and input orders in EPIC which probably provided the best training, but seriously this could have been learned in 2 minutes instead of some long exercise.

In terms of training on patient interaction with regards to the EMR, this is largely a moot point in any ward month as you will not be using the computer in the patients rooms on daily rounding, but will come up in clinic occasionally. My family practice rotation provided some "training" on how to keep it personal while still being effective on the EMR. Really its more about personality than it is about training. If you are a person who is aware and sensitive to patient interaction, you will do better in this area regardless if you have a paper or computer chart. Anyway I'd be happy to clarify if i was unclear

 

[ywlke]

Citrix is not a solution. It's one of the biggest obstacles in EMR implementation right now, not only because of pricey license costs for each concurrent user sign-on, but also limited upward scope(KP ran into a lot of issues with this), contributes to most of the latency, adds another layer of unnecessary infrastructure. That's why many EMR vendors are moving towards Web-based clients now.

Sounds like a poorly implemented Citrix...when done properly I'm fairly certain it would work fine. Unfortunately there's far fewer IT folksen out there that are thoroughly familiar with thin client/virtual desktop technologies as compared to traditional Windows workstations which often leads to an adequate technology being blamed for poor implementation decisions. Also...as far as product licensing goes...you would be lucky if concurrent user licensing is an option. Most go by per-device or per-named-user licensing, either of which will almost always be more than the number of concurrent users. The point of Citrix or other virtual desktop solutions is to centralize the software in the datacenter so you don't have point-of-access data security issues, among other advantages.

As far as web-based clients go, I'd want to see EMR workstations prohibited from accessing the general internet...I've seen "clinical workstations" (admittedly in a lounge area as opposed to critical care) infected with malware/adware before and that's not something I would want to be risked in a patient care environment. And browsers are easier targets for infection than proprietary software, so this is a bigger issue for web-based EMRs than non-web-based EMRs.

 

[ywlke]

However, I wouldn't be surprised if in a decade, we can keep them up 99.9% of the time. There's a lot of movements towards Web Clients, backup computers/generators, multiple servers. Overall, this deficiency should gradually improve over time.

Maybe this is just me, but I feel like downtime issues mostly result from cost-conscious deployments because, for the most part, the technology for 5 9's and higher availability already existed yesterday, it's just that it's not cheap to do. And EMR vendors also have to design with that in mind, so yeah, hopefully they'll have moved past the EMR basics in a decade and have figured out what they need to do to make it more reliable and usable.

 

[pkwraith]

Sounds like a poorly implemented Citrix...when done properly I'm fairly certain it would work fine. Unfortunately there's far fewer IT folksen out there that are thoroughly familiar with thin client/virtual desktop technologies as compared to traditional Windows workstations which often leads to an adequate technology being blamed for poor implementation decisions. Also...as far as product licensing goes...you would be lucky if concurrent user licensing is an option. Most go by per-device or per-named-user licensing, either of which will almost always be more than the number of concurrent users. The point of Citrix or other virtual desktop solutions is to centralize the software in the datacenter so you don't have point-of-access data security issues, among other advantages.

As far as web-based clients go, I'd want to see EMR workstations prohibited from accessing the general internet...I've seen "clinical workstations" (admittedly in a lounge area as opposed to critical care) infected with malware/adware before and that's not something I would want to be risked in a patient care environment. And browsers are easier targets for infection than proprietary software, so this is a bigger issue for web-based EMRs than non-web-based EMRs.

The hospital web server still sits behind their firewall. Malware/adware isn't going to be any more a problem than it already is. Citrix is a necessary evil right now, simply because there are little other choices.

But, everyone recognizes that it's stagnant technology. Take, Epic, one of the largest EMR vendors. They're moving from to a web based client, away from Visual Basic. That's the future. Faster, cheaper, more accessible.

I dont quite understand what you mean about using the EMR as criteria selection? I am 100% certain that any respectable school uses EMR and that medical students have the ability (and requirement) to write notes and input orders. I know many many medical students in a variety of schools across the nation and this is definitely the case. If a school did NOT have EMR or did and didnt let students use it, that would be a terrible school to learn at in my opinion. In fact I dont even understand how that is possible if students were not allowed to use it. A M3/M4's job is to basically act like a doctor - its practice. We see patients on our own, write notes, come up with assessments/plans, and present them to the attending to cosign. Shadowing is for premeds.

With the pros and cons discussion, you wont find a single young doc who doesnt agree that the pros are >>>>>>>>>>>>>>>> cons. Yes, notes can be overly long and have too much superfluous info pulled into them, but thats usually when you start out at the beginning of M3. Over the M3 year you learn whats relevant, whats more important, and notes become shorter, more concise. In fact at the end of the year, most attendings will tell you to cut the crap.

To answer your question, there is EPIC training several times throughout M1, M2, M3 year, but these are largely viewed as an annoyance. If you have the computer savvy of a normal 20 something year old person in this day and age, most things on the EMR are very intuitive. Those that are not are learned easily on the job. There were several times during M2 where they would assign us some fake patients and we would fully work them up and input orders in EPIC which probably provided the best training, but seriously this could have been learned in 2 minutes instead of some long exercise.

In terms of training on patient interaction with regards to the EMR, this is largely a moot point in any ward month as you will not be using the computer in the patients rooms on daily rounding, but will come up in clinic occasionally. My family practice rotation provided some "training" on how to keep it personal while still being effective on the EMR. Really its more about personality than it is about training. If you are a person who is aware and sensitive to patient interaction, you will do better in this area regardless if you have a paper or computer chart. Anyway I'd be happy to clarify if i was unclear

Sounds good. Do you have access to Playground environments just to play around?

If you don't mind, I'd like to put some of this information in the OP to make it more comprehensive, since one area that I don't have a lot of experience with.l

 

[ywlke]

The hospital web server still sits behind their firewall. Malware/adware isn't going to be any more a problem than it already is. Citrix is a necessary evil right now, simply because there are little other choices.

But, everyone recognizes that it's stagnant technology. Take, Epic, one of the largest EMR vendors. They're moving from to a web based client, away from Visual Basic. That's the future. Faster, cheaper, more accessible.

I was going more for malware/adware infecting browsers on point-of-care computers. If the EMR software is web-based, then that malware can easily intercept EMR data from an infected browser.

I'm not saying web based is necessarily bad, but there are extra precautions to be taken. I'm not sure why Citrix and Visual Basic are being equated here though...they are completely unrelated technologies and can be used alone or in concert...just as Citrix could just as easily be used with a web-based EMR.

 

[jmath27]

If the EMR software is web-based, then that malware can easily intercept EMR data from an infected browser.

Couldn't you possibly work around this by running the EMR software via a virtual machine? The office I shadowed during spring break utilized hp core2duo laptops to access virtual machines (where the EMR clients were located) from their centralized server (not sure if it was a linux or server2008 box). I mean wouldn't this make malware interception a lot more difficult?

 

[ywlke]

Couldn't you possibly work around this by running the EMR software via a virtual machine? The office I shadowed during spring break utilized hp core2duo laptops to access virtual machines (where the EMR clients were located) from their centralized server (not sure if it was a linux or server2008 box). I mean wouldn't this make malware interception a lot more difficult?

Well that's sort of what I was saying. Citrix is one particular virtual desktop product. It can be used to access a virtual environment (VM or otherwise) located on a server. If I understood pkwraith correctly, he was saying the virtual layer has been causing problems where he has had to interact with it and that it is getting dumped in favor of direct web-based EMR.

 

[NightGod]

Well that's sort of what I was saying. Citrix is one particular virtual desktop product. It can be used to access a virtual environment (VM or otherwise) located on a server. If I understood pkwraith correctly, he was saying the virtual layer has been causing problems where he has had to interact with it and that it is getting dumped in favor of direct web-based EMR.

I think the issue is more with interfacing with the EMR from a remote site. Local machines would almost certainly be tied directly to the server so a Citrix solution would just be silly. The advantage of going web based is that it will work on any device you can run a browser on, the disadvantage, as pointed out here, is security. Definitely something that will need to be decided in the long run.

 

[music2doc]

I think the issue is more with interfacing with the EMR from a remote site. Local machines would almost certainly be tied directly to the server so a Citrix solution would just be silly. The advantage of going web based is that it will work on any device you can run a browser on, the disadvantage, as pointed out here, is security. Definitely something that will need to be decided in the long run.

I would assume so... At the hospitals I've worked at, the only ones accessing the EMR application via Citrix are docs or scribes working from home or an off-site clinic. The clinical staff all access the systems directly, although to access images, Scribes have to login via Citrix (something to do w/ the funky setup we have). Clinical staff, however, have the actual EMR application installed on the desktop and simply click the icon to open it. The software resides entirely on the client-side, so there generally aren't latency issues.

As for downtime, I don't mind the scheduled maintenance downtimes. We can plan for those and have things ready. The problem is when the downtime catches us off-guard and results in critical pts' care being delayed due to an unforeseen need to go into downtown protocols. This is especially problematic when it prevents a pt from being registered into the ED, since that puts everything on-hold for the given pt until our ED Registration Dept is able to get the clinical staff a downtime override pt ID. That can take a couple minutes from the time that downtime status has been identified, which may itself take several minutes to identify (i.e., after Registration exhausts its other work-arounds, since they don't want to prevent access to the pts' Hx).

 

[damndinosaur]

"Standardized" could be either good or bad...the big thing I think should be done is to use industry-standard technologies (e.g. SSL, SQL databases, LDAP) in an interoperable way. That way, it shouldn't matter ultimately what company you get your EMR software from, any EMR interface should be able to read any other EMR backend database to an extent. Unfortunately, I think a lot of decision makers on the customer side (i.e. doctors, hospital management, etc.) don't always consider these, and on the vendor side, being interoperable is either seen negatively (makes it easy for the customer to switch platforms) or is an afterthought (how long were we stuck with websites that worked in Internet Explorer but not Firefox? same idea).

that's a really good point, never thought of that. if all the software could sync up seamlessly, then the major differences in the systems would basically be in the layout and personal preference for one company over another