A Day In The Life Of A (Reluctant But Coerced) EHR-Using Physician – And Her Patients

A reader, a physician who wishes to be unnamed due to fear of retaliation, writes the following:

Dear Dr. Silverstein,

As you write, there is not a transaction of medical care that does not go through EHR systems.

However, these poorly usable EHR systems stifle creative and
artistic thought required to link risk, benefit, and probability of
diagnosis with risks and benefits of testing and therapeutics.

Assuring safety and efficacy with pre- and  aftermarket surveillance
will maximize the possibility of achieving the potential of the
technologies.

Additionally, when I use these electronic ordering systems and
 libraries of medical information, they fail to keep up with the
agility and nimbleness of my mind as I seek ‘random access’ to pieces of
data to formulate and synthesize diagnoses and therapeutic strategies.

The EHRs are too slow, do not have a robust (if any) search function,
randomly and whimsically store key information with ever changing
formats, and generally obfuscate what should be simple. They are
cumbersome and disable the ability to simultaneously and
contemporaneously compare myriad data points.

They get an “F” as
enablers of complex diagnostics.

Paper, since it can be organized as needed and set out on a desk to be
seen and compared as quickly as the eye registers the data, gets an “A”.

The EHRs  are impediments and disrupters of communication.

Example:
Just today, I was witness to the fact that a stat EKG was ordered by CPOE  on a heart patient yesterday at or shortly after 4:30 pm. The
intended recipient of the order (heart station) never got it because
they close near 4:30 pm and there was no warning to the ordering health
professional that was so.

Thus, the EKG was never done, and this
morning, when the requisition was seen, no one did it because it was
ordered stat “yesterday”, and the techs asked themselves “what good
would it do for a ‘stat’ to be done now, a day late?”

I do not know what
happened to the patient.  I have many other examples of such delays
facilitated by the CPOE and EHR systems that I am required to use at numerous
facilities.

They facilitate ‘stealth’ alterations in care.  Also just today, a
disease-critical test ordered 3 days ago was not done because it was
cancelled in ‘stealth’ (automatically “expired”) without warning to me
by the lab responsible for doing it.

There is the “silent silo” syndrome as you’ve called it.  Also just
today, a disease critical test ordered 5 days ago came back with
results, but the results were posted in the information ‘silo’ of 5
days ago. The lab screen default on the EHR only goes back 4 days (so
unless I knew to look for it, it would not be seen or acted on), further
obfuscating data and delaying treatment.

The EHRs lose data and orders.  Also just today, I found that blood
coagulation monitoring tests that were ordered to be done with kidney
dialysis (3 days per week) on a patient somehow got “lost” and were not
being done for 5 days, putting my patient at risk of bleeds – or stroke
if the blood was not ‘thin’ enough.

I just walked in to examine a hospitalized patient with multi-organ
failure and diabetes, on multiple meds including insulin, and recovering
from respiratory failure.

The nurse anxiously informed me that the blood sugar was dangerously low. I ordered treatment stat.

I see patients in the morning before labs come back, and depend on nurses to review labs and notify me.

Turns out that the patient was hypoglycemic on yesterday morning labs
that arrived in the EHR ‘silo’ after I left the hospital; and was also
low in potassium, but the tests just laid there comfortable in their
silos; and were not communicated to anyone like in the old days when a
human ward clerk or other undistracted human received them and
disseminated them to the appropriate professionals.

Thus, instead of getting less insulin, the patient got the usual dose with near catastrophic adversity.

Misidentifications are facilitated by EHRs.  I  noticed that on
several critical clinically significant changes that arose on my
patient that were entered as such in an EHR silo by the RN, it was
stated that they called attending physician ‘Dr X’, which was not
me…obviously a case of EHR-facilitated misidentification.

Here is a misidentification variant:  yesterday, someone (non doctor but not
clear who) ordered a specialist consultation on one of my patients under
my name. I did not order it nor was it needed, yet it showed up as an
order for me to sign.

Like you, I agree this is representative of a toxic impact of these systems on
medical care and I feel like the care environment is foul, like a
cesspool, compared to what has been replaced.

These systems of medical devices cannot be trusted in the care of
sick patients. Perhaps, they are OK for managing hang nails.

I offer no additional comments other then if I am sick, I do not want my care interfered with in this manner by IT.

Rest assured, though – there are IT hyper-enthusiasts out there (http://hcrenewal.blogspot.com/2012/03/doctors-and-ehrs-reframing-modernists-v.html) who would see little problem with this, as any accidents that occur are “anecdotes”, “learning experiences” or “bumps in the road.”

That’s if they don’t simply blame the user.

— SS