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Unhappy Camper (Vol. 1, Issue 11)

Dr. Howard Schulman’s article in the ProJo last month (see http://www.projo.com/opinion/contributors/content/CT_schulman21_09-21-10... ) pointed out many serious flaws with EMR technology, and a particular one that I’d like to expound on here.  He writes, “I am concerned about a new class of medical error directly related to EMR use. Frequently, instead of writing out medications, medications are ordered by drop-down menu. I know of at least two serious adverse outcomes, including one death, caused by a physician inadvertently ordering the wrong medication from a drop-down menu.”

I, too, have experienced this drop down menu error on several occasions, luckily with no adverse consequences so far.  Local pharmacists seem to be adept at catching the errors and calling me, but one should not assume that will always be the case.  Drop down menus (sometimes called picklists) may have a lot of choices in the list, resulting in lists that are quite lengthy.  In most EMR applications I have seen, the physician selects the appropriate choice with the pen-stylus, highlighting the choice, which is then inserted into the appropriate prescription field. I have witnessed occasions where I have definitely selected the correct choice, but in pulling the pen away from the screen the menu choice slips down to the next menu selection.  Usually the menu choices are listed alphabetically, so that a selection of “qd” can easily slip/scroll to a “qid” resulting in a four-fold dosing error. So, even when you made the correct choice, your EMR may not reward you by capturing the correct information.  This is both a frustrating and dangerous scenario.

We have made adjustments to our use of medication picklists by placing our most commonly used meds into templates or order sets. You should also be able to customize the meds listed by alphabetically adjusting the most common meds used in your practice, such as by adding a leading space to the drug name.  We’ve also taken the precaution of deleting entirely from our e-formulary some rather nasty meds we’d never be using.  A good example is amoxapine, a tricyclic antidepressant, which shows up on the list right ahead of the very-often prescribed amoxicillin. The only problem with doing this is if a specialist does prescribe such a med, you’d like to able to present it on the patient’s med list to ensure medication compatibility checks, even if you’d never prescribe it yourself.

The pen selection problem is not confined to eRx but can also befuddle any picklist within your EMR system, for instance the selection of incoming faxes.  Try this yourself next time you receive a list of incoming raw faxes into your Fax InBox.  Wave the pen over the list and you can see that the fax list order magically dances in front of your eyes.  Faxes you were in the process of assigning to one patient may be the fax on a different patient, or instead be the latest offer for Florida vacation homes. And the fax you thought you are deleting may be one that you haven’t yet read and it might have been important, so choose carefully.

We have 4 Fujitsu Lifebook tablets and one IBM ThinkPad tablet in our office and both types are subject to these errors. Calibration of the pens are essential but do not necessarily correct for the unintended scrolling within a picklist. One has to adjust the sensitivity for double clicking instructions in Pen and Touch>Pen Options>Double-tap>Settings>Spatial Tolerance.  Adjusting to a smaller spatial tolerance setting may help some, but cannot correct for single-tap (selection) errors.  So I think many of my fellow physicians will continue to be challenged by this serious type of error for a long time.

Pen sensitivity can be also complicated by battery life of the pens themselves.  I’ve had pen-styluses wear out in less than a year, causing both very long screen refresh times and very frustrated physicians.  You can’t replace the batteries is these things, so at $50 per pen it’s not an insignificant charge to the budget.

An additional error type related to input seems to occur when typing freehand into a data field.  In this case, while the physician is typing along, the hand brushes across the touchpad at the front of the computer, “causing the text insertion bar to move about and start inserting the new text in an entirely different place”.  This results in something like “causing theinserting the text in insertion bar anplace entirely different” gobbledygook.  It happens without the physician’s knowledge unless you are directly monitoring as you type. Most hunt and peck typists like myself do not find this amusing. But we may have solved this problem, at least, by downloading a rather neat Google App called TouchFreeze available at: http://code.google.com/p/touchfreeze/   This free app claims to disable the touchpad only when the keyboard is actually being used.  It’s not guaranteed, but it seems to be working well on Windows 7 for us over the past two weeks. Or perhaps it’s just wishful thinking and we have actually adjusted our habits to avoid coming near the touchpad.

Capitalization errors are less serious but lead to an unprofessional appearance in the EMR.  Cramped keyboards make this a much more common error in laptops and tablets than with the desktops we were all using in previous days.  One can fix this by setting up a ToggleKeys beep alert that sounds whenever you accidentally hit the CapsLock key.  From the Control Panel>Accessibility Options>Keyboard>Toggle Keys.

It’s too bad we didn’t discover all these input error types until three years into the process of using EMR.  Who knows how many errors like these we have made in the past and will be liable for far into the future.