Messageboard

Unhappy Camper (Vol. 1, Issue 14)

My subject today is a continuation, of sorts, from a previous column (See Template for Disaster: http://www.docehrtalk.org/messageboard/2010/08/13/unhappy-camper-vol-1-i... ).  In my experience the majority of EMR documentation errors occur within the first six months of adoption of the EMR system.

EMR systems can be very capable software programs that are able to capture, in some form at least, much of the medical encounter.  But because of these capabilities they are also overwhelmingly complex. The implementation of EMR in a medical office requires systematic workflow changes that are disorienting in the first place. Compounding these changes are the very real economic pressures created by the heavy investment in technology that require that the practice still produce income by seeing patients, even if practicing in an office full of upheaval. That is a very dangerous situation.

Let’s compare this medical world to the aviation world. You may be familiar with surgeons adopting some of the ‘cockpit-resource management’ policies that developed in response to safety concerns when flying complex aircraft. I happen to be an airplane pilot myself, though I don’t fly as much anymore.  In flying, weather conditions are probably the number one threat to a pilot’s success in getting from point A to point B.  In good weather everything is usually great and everyone has a good time—mission accomplished.  When bad weather threatens, the fun disappears.  Unless the pilot is specially trained for flying in adverse conditions (called IFR) it is extremely dangerous to fly into the clouds.  Without a visual reference to the ground, spatial disorientation can become quickly overwhelming to the hapless pilot.  Inner ear motion sensors give out false signals of motion and balance. You may be turning left when you’re really turning right. But pilots are under extraordinary pressure from themselves and their passengers to complete the flight, even when weather conditions dictate they not attempt flying when the visibility is questionable. Witness JFK, Jr’s unfortunate plunge into the ocean off of Martha’s Vineyard a few years back. Yes, pilots have instruments that, with proper training of the pilot, should be able to allow successful completion of the flight.  Of course, unless the combination of the aircraft systems, the air traffic control system, and the pilot’s skills are all top-notch, it’s very easy for something to go wrong. Most veteran pilots know personally of one or two fellow pilots who never made it back.  I do.

Physicians thrown into the clouds (or rather, under the bus) of a complex EMR system are in a similar situation. Physicians will always attempt to be in control of their medical world, but in dealing with an EMR with which they are unfamiliar they will quickly become disoriented.  They may not be able to access or save vital patient data in the correct manner or in the correct place. We are, admittedly, a haughty bunch and once board-certified, feel we should be able to handle most any crisis that comes our way.  And now, as disparate as it is, computer skills such as used in an EMR will soon be a requirement for maintenance of medical board certifications. It seems we are ALL expected to be able to do this, at all costs.

A lengthy EMR training program can certainly help, but the reality is that the physician will quickly forget much of what was learned in that very expensive course.  It takes practice and experience, in spades, to become oriented enough so that important mistakes do not happen. And, unfortunately, it is during this long time of familiarization with the EMR that these mistakes in EMR documentation are most likely to occur.  They may be a mix of medical errors (such as failure to track an abnormal lab result because you didn’t look in all the right places) and of documentation errors (such as documenting on a template that no murmurs were heard on a patient that had an aortic valve replaced), but either can kill you in court. You might not have crashed and burned literally, but when you land the malpractice lawyers will still be there, waiting to pick at your bones.

Having been an Air Force flight surgeon in an earlier life I can attest that pilots are never let loose in actual aircraft without tons of both initial and refresher simulator training, not only on normal procedures but on what to do when things go wrong, like an engine on fire. EHR sandbox training can help gain passing familiarity with the EHR system you’ll be using but unfortunately does little to prepare the hapless physician for what can and will go wrong with documentation, (see http://www.docehrtalk.org/messageboard/2010/10/08/emr-data-entry-mistake... ).  Such training needs to cover not only the EHR system itself, but also the associated but separate software such as MS Word, and all of the hardware, network, and security operational issues involved.