How To Survive A Hospitalization
Just two weeks ago, my hospital went live with a full ambulatory electronic medical record. Though the roll out wasn’t without its challenges, the software is simply outstanding. There is almost nothing about a patient’s medical history I can’t now access with a few clicks of a mouse button. Not only do physicians have more technology than ever before with which to diagnose and treat patients, but also, at my hospital at least, we now have access to all the data our technology provides without ever having to leave an exam room. When physicians talk with patients, taking their histories and examining them to figure out what’s wrong, questions immediately begin arising: Could this be heart failure? Could this be emphysema? Could this be interstitial lung disease? Now I can answer these questions potentially within seconds simply by navigating our computer system to see if they’ve had an echocardiogram, a lung function test, or a chest CT.
Not only that, but if those tests haven’t been ordered previously, I can now order them through the computer with the click of a button. No longer must anyone struggle to read my handwriting. No longer are paper requisitions at risk of being lost and tests not scheduled in a timely way. Further, when I order these tests, the computer reminds me of relevant lab results and allergies. Did I forget my patient is allergic to contrast and needs premedication before the CT scan? No problem: the computer flashes a warning to remind me.
Further, I no longer have to keep track of what tests I’ve ordered. When results are ready, the computer sends them to me. I can not only batch review the result of every test I’ve ordered on every patient I see (including looking directly at x-rays on the computer screen), but also respond to each appropriately. I can send Mr. Jones his normal results electronically, I can order an additional test on Mrs. Smith electronically (which my clinic coordinator schedules electronically), and I can prescribe Mr. Black a medication electronically that’s ready at his pharmacy by the time I call him to let him know he needs it. It all sounds a bit like science fiction, but in 2012 it’s become standard operating procedure.
Though the literature shows we are indeed all safer in many ways with the advent of electronic medical records, there exists a dark side many don’t recognize. Especially on the inpatient wards, the implementation of electronic medical records may have led to an unintended consequence that makes hospitalization even more dangerous: it seems to have cut down on the amount of face-to-face communication that occurs between providers.
In his book Imagine, Jonah Lehrer discusses Steve Jobs’ view that innovation comes from interaction. That is, the more that different people talk with one another face to face, the more creative the solutions that will result. Which is why apparently Jobs wanted the buildings that housed his employees to be designed in such a way that forced them to talk with one another on a daily basis. Bathrooms, for example, were only located centrally.
In medicine, too, communication has never been more crucial. With the explosion in our understanding of disease, our ability to diagnose it, and our ability to treat it, no one provider is now likely to have at his fingertips all the knowledge required to provide gold-standard care. Most of us need our colleagues’ help much of the time—especially with patients sick enough to require hospitalization. But never before have we all had to work so hard to be able to get it.
Why? Because the electronic medical record has made it harder for us to run into each other physically. In the past, consultants had to document in a paper chart by each patient’s bedside—the same chart in which the primary service wrote their daily progress notes. It was an enormous hassle tracking that chart down. But in making the effort, we often ran into each other and talked. And when we talked, we asked each other questions. And from the dialogue that ensued, all parties involved obtained greater understanding of the others’ perspective and ideas. And plans were often hatched that wouldn’t have been had we each only read one another’s notes.
This was such a big deal when I used to attend on the inpatient ward that whenever my team would ask a consultant for help with a patient, I would insist my residents not just read the consultant’s note but actually talk to them about their recommendations. Almost every time when such conversations happened, it changed the way we understood the consultant’s note and as a result changed our plan.
Now, however, with the advent of our electronic medical record, consultants can enter their thoughts and recommendations from anywhere in the hospital. And the primary service can read and implement them from anywhere else. Never before have the teams of providers that roam hospital corridors been less likely to run into each other, and therefore less likely to talk about the patients for whom they’re caring together. Unless other attending physicians do what I did—insist their teams make the effort to contact other teams—that communication isn’t going to happen nearly as often as it should.
This is actually alarming. Yes, we’ve cut down on prescribing errors. Yes, we’re far less likely to give a patient a medication to which she’s allergic. But we’re also, I believe, less likely to benefit from the collective knowledge of the entire medical establishment, a benefit that’s never been as imperative to obtain. We may not be as likely to harm patients as we once were, but we may also be less likely to figure out what’s wrong with them if what they have is unusual because we in the medical profession are simply not talking to one another as much as we did.
This is the thing that scares me about being hospitalized the most. I always recommend that people bring with them an advocate when they’re hospitalized, a family member or close friend who can help make our system work for the patient when the patient is too sick to make it work for himself. But now I also tell that that person’s top priority should be ensuring that all the members of the patient’s medical team—not just the consultants, the radiologists, and the pathologists, but also members of the primary service itself—talk to one another in person on a daily basis. I now believe that if there’s any one intervention anyone could make in 2012 to increase your chances of not only surviving a hospitalization, but also of being given the right diagnosis and the right treatment, that’s it.
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In my company we have great Unified Communication integration (IM and Phone) for our personal computing system. This means that I can often just IM someone or call them if I don’t understand a request or I want more context. Additionally, there are sites like Quora (www.quora.com) that provide great, high-quality, long-form Q&A that might be good for clinical care as well. If a doctor is looking at an exotic or unfamiliar set of facts, why not post it to an internal community of doctors some of whom may have a specialty in the area to get feedback? It sounds like that additional layer of communication/collaboration technology would help immensely in the areas you describe.
And what do you do when there are mistakes in input?
You are so right on so many levels.
I had an oncologist fresh out of a residency trying to figure out if I had cancer several years ago. After nine months of testing she wanted to have a urology consult. I have my own urologist who reviewed the CT scan. He called his buddy the surgeon to brainstorm. The surgeon called his trusted oncologist (not the one I had been seeing). A day later the oncologist saw me after hours. They all got together and three weeks later they had a dx. Rare form of non-Hodgkin’s. The surgeon removed my 17″ long spleen a few days later. I totally blame the delay because the fresh oncologist didn’t seek out opinions both from other oncologists as well as a general surgeon who was most worried about the massive spleen. Thanks for this post. I enjoy reading your blog
Wow! You have just accurately verbalized my take on this electronic/computerized method of relaying and communicating patient data. I am a RN currently working in an acute care hospital setting that “went LIVE” last October with this computerized bedside charting and have witnessed the physicians’ despair in obtaining the “whole picture” of the patient, as well as the nurses’ inability to follow the plan of care for their patients, or providing relative information to the physicians in a timely manner. We must all advocate for our patients and loved ones if they are hospitalized. Thank you for this post. I am going to print it and share it on my unit. Keep caring for all of us. Your voice is appreciated.
Hmmm, interesting. I’d be the patient, as am not a medical person, and I do like the idea of all my info being in one place and easily accessible. Less need to keep all my own tests, remember what has been done.
Most certainly agree that a friend/advocate is a good idea. When information is being given verbally it’s hard to remember it all and when ill it’s hard to remember to ask all the right questions.
Awesome and very well written, Alex. I couldn’t agree more. How often do we misinterpret an IM or email because we don’t TALK to the person. I’ve gotten into trouble many times because of a misinterpreted text because there was no verbal discussion. Excellent article.
I had a frustrating experience last year at a facility that uses this same kind of electronic records. The big problem was that it took a month to get a diagnosis because none of the doctors knew what the problem was but they never called in other doctors to confer—even when it appeared to be a rheumatological problem, no one ever called in a rheumatologist for help. Finally I made an appt myself with a rheumatologist and he knew within 15 minutes what was wrong with me. It really opened my eyes about how proactive you have to be in solving your own health problems.
You know what I miss about medical records? The docs’ handwriting. As difficult as it might have been to decipher at times, the handwriting was a glimpse into the thoughts of the physician. Whether it was a sprawl or multiple spiked humps, it gave me insight into the haste or thoughtfulness of the writer.
I also miss the serendipity of leafing through a medical record. That might also account for some of the creativity in care as information from separate sections got mashed together in my brain, making me think about other things and possibilities.
EMRs are so sterile, sometimes so limited by the menu options, and so easy to overlook crucial details in the monotony of the computer page.
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I have recently had positive experiences with the medical group I use and the way one clinic knows what the other clinic saw and thought. I also recently read Oliver Sacks “A Leg to Stand on” and there were some interesting emotional/physical thoughts in it that face to face doctors and patients need to think about.
I am glad the hospitals can do this as I, like everyone, have heard of deaths because a doctor did not know what another one knew. But I am thinking of this when you have different hospital groups with each having its own computer links but not to a separate group across the state or country.
As the son and “advocate” of elderly parents who spend too much time in the local hospital, I’ll certainly agree with your post. But I’ll add another problem with EMR that its many passionate proponents seem to overlook (probably because they haven’t been hospitalized lately).
Remember when the “experts” used to insist that computers will take over the drudgework and free us up to do wonderful creative things? In practice, computers created more drudgework than ever, requiring us to spend ever more time doing it at the computer. That’s exactly what I’ve observed at the hospital. The EMR system requires nurses to spend more time charting than they did in the Dark Ages of paper records. To ensure “quality,” each record needs complete data, entered in the correct format. And that doesn’t include all the time they spend logging on or off the system, including having to log back in if they’ve made the mistake of going too long without typing.
The EMR system’s insatiable hunger for complete, correctly-formatted data means that nurses spend most of their time sitting at computers, endlessly charting charting charting. When they do take time away from charting at their station, or charting in the hall, to visit patients’ rooms, they invariably wheel in a portable computer. They spend a few seconds gathering all the mandatory data, and then spend the rest of the time they’re in the room typing it into the computer. If the patient has a concern, it has to wait until all the data is entered and verified.
If the patient presses the call button, she faces an interminable wait. The nurse who is supposed to notice and respond is, of course, too busy serving the EMR system. If I go to find the nurse, she is of course typing away on a computer. And her scowl instantly conveys her resentment at presuming to interrupt her most important duty. She’ll send a nurse’s aide to tend to the patient, since an RN’s time is far too valuable to waste on something other than charting.
I’m sure EMR systems greatly benefit administrators, accountants, insurance companies, auditors, lawyers, and all the other parasitic interests that our broken health care system primarily serves. But their benefit to patients is far less clear. What is apparent is that they have accelerated the dehumanization of patients and lowered the quality of care. They’ve reduced the patient to an inconvenient piece of meat who happens to accompany the data in the chart, and who has an annoying tendency to interfere with the staff’s primary job of keeping the system supplied with data.
I should also mention that my mother had the bad timing of needing care while the hospital staff was completely preoccupied with getting their new EMR system up and running in time for a mandated deadline. The care she got was clearly substandard. As a result, she was back in the ICU the day after her discharge with three life-threatening infections plus a bedsore. Her doctors give her almost no hope of survival, but survive she did. But the sepsis and pressors put her already marginal kidneys over the edge. So she now requires dialysis, which led to further hospitalizations first from infected catheters and then from a fistula that too often gets clogged.
Although this was almost certainly the result of negligence, caused by the push from management to get EMR up and running on time, my mother refuses to take any action or even let the hospital executives know what happened. She knows she will need their services and doesn’t want to “make enemies.” She perhaps has a point. But more than the ordeals she suffered, I’m angry that the executives surely got their bonuses for implementing EMR on time, but remain blissfully oblivious to the sacrifice patients made for that achievement. I’m sure my mother wasn’t the only one.
I’m sorry for the length of this comment. But EMR is a hot button for me, because of what I’ve seen too many times.
My retina specialty group recently installed an EMR system and, so far, the results are awful for both the group and its patients. Everyone who data enters in that system—physicians, technicians, aides—spend so much more time doing that than they used to with handwritten notes. The system is slower than the old, handwritten system; screen changes are slower; sometimes the system slows down for no known reasons. And the screens are visible to patients and, as a patient and a person who has long worked with data entry screens, I can say that these screens have got to be hellish to work with: lots and lots of info on each screen and all presented in a very small font. My doc is very frustrated with this system as it creates such delays that patients experience long waits to be seen and docs and staff have shorter lunch (and other) breaks and longer days because the system cannot handle the daily patient loads. Awful!
I’m an old timer. Several thoughts. I’ve used both the Misys and Epic systems. Epic is so complex and advanced, even an eight year old would have a problem maximizing its potential. Even seeing 10 elderly patients with multiple co-morbidities a day, especially if several are new patients, is nearly impossible because it takes at least an hour to see each patient [if one is a hands on doc]. Were I rich, I would hire a scribe like some of my colleagues. Second, I now do much of the the work of the nurse, the secretarial staff, the transcriptionists, and the billers. EHRs have put many people out of work. Third, with the billion + dollar systems there is no privacy since it linked, not only to many hospitals but even to various governmental agencies. Fourth, in the future, perhaps within fifty to one hundred years, we will see near Star Trek advancements. A technician will be able to pass a probe over the patient and the computer will spit out a plan and prescriptions. With the advancements of robotics, even many surgeons will become obsolete. A computer specialist will take over the role of physician. Fifth, with the use of so-called “smart phrases”, one, if they were so inclined, could cut corners to the detriment of the patient and an accurate report. It is said that unless a Family Practitioner, for example, sees thirty patients a day, he or she will fail to make money. It will be nearly impossible to see thirty patients a day, without cutting corners [fudging]. Sixth, with AVS [a paper report of the doctor’s visit to the patient], paper and therefore trees are not spared, despite the rhetoric. In fact, every order and referral to hospitals and facilities that does not use the same system are still printed and faxed. Before, a phone call may have sufficed. Seventh, even the finest systems go down. Without a paper record, at those times, one is at a loss. Eighth, a limit of these systems is the programming ability and meticulousness of the staff. One can not always count on the nurse, the front desk people, etc., to adequately review or make the necessary visit to visit changes that reflects the actual state of the patient. Unless the physician carefully reviews the meds, history, etc. many errors will be introduced.
I’m not sure many of my patients want their employers or the government to know that they are taking Percocets for a chronic painful condition nor psychoactives for a well controlled bipolar or schizophrenic disorder. By standardizing patient care too, it is supposed to diminish lawsuits but it seems to me, in the hands of a good lawyer, there will be more data in which to hang a well meaning doctor.
Now the good points. No more ink stains on my shirt and, and, and???? OK, the facilitation of the transfer of patient records.
Thank you so much for this fabulous post, Alex. There’s so darned much food for thought here…and not just about USA medical care and medical professionals. Electronic Professional Texting (EPT) has become a widespread practice, even among the critically illiterate. I’m thinking that, perhaps, a huge deficit in patient care is not instigated only by omissive face-to-face interaction amongst professional care-givers, but also via the basic English writing skills that those EPT users lack. As an English writing skills workshop presenter myself (for adult professionals in my area), I engage with many professionals (with USA college degrees–yep, even those with MBAs and Ph.D.s) who often cannot write—CLEARLY—even simple instructions or notes to/for their colleagues or staff members. It’s frightening. For us all. Thanks again for your usual, astute observations here. I love reading your work! ~Roxana
Thank you so much for these thoughts! I wish this was printed in a major news outlet (NY Times comes to mind) As other responses have pointed out, EMR seems to have turned nurses (I am an ICU nurse for 25 years) into data entry techs. We now spend much of our time entering information into pre-programmed boxes….and yet when one reads this information, you still have no idea what a patient actually “looks” like. The art of medicine lies in the subtle changes, and clues that a patient gives off. These never can appear in a box of an EMR, which usually gives the health care provider a choice of answers….and no way to chart something that does not fit in. Like many nurses, I have given up trying to indicate what I actually see, and just click on the box in order to get back to the real work of caring for a human being. This, combined with not being part of the discussion between physicians as to the plan of care (or as you point out the lack of such discussion) short changes the patients. It would seem a combination of electronic chart and hand written chart, or at least free texting, would be a better solution.
Another small point. One can lose the tenor of an exchange if it is not face-to-face, and that often is an important aspect of the communication.
This seems like a culture problem as much as a physical problem. Western medicine is battlefield medicine; you see as much when you walk into a hospital and see the word “Triage”—which is ridiculous for civilian medicine. They’re not going to just let you die because they’re busy; indeed, hospitals engage in the opposite of “Triage,” instead concentrating exclusively on urgent patients first, then less-urgent ones.
But this fetishism of military medicine extends to doctor training. Doctors are hazed into viewing themselves as all alone, with no support system to fall back on. This makes sense in the context of a shipment of wounded pouring into a medical camp. Whatever you do, that’s what you did. But it’s completely insane in the context of civilian medicine.
So, first change the doctor culture of abusing their students. Then teach the students that doing good medicine, instead of mindlessly aping previous approaches, involves collaboration.