Are Electronic Medical Records Helping or Hindering Medical Legal Reviews? Patient Care?

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by Jane D. Heron, RN, BSN, MBA

 

If you can tell me what it says, I will pat you on the back.

 

computer-medical-record-garbled

Scenario: Mrs. Smith sustained multiple trauma including a severe brain injury after a fall. She was minimally responsive and had severe contractures of all her extremities seven months after her fall. She was totally dependent on the staff for her every need.

Unfortunately, Mrs. Smith’s rehab record was electronic. I say unfortunately, because the electronic nursing records contained hundreds of pages of very little helpful information. It was difficult to create a true picture of what Mrs. Smith endured. She was severely contracted, yet that was barely mentioned throughout these records. Only one nursing entry mentioned “cervical dystonic posturing”. Examples of meaningless, almost nonsensical, entries, which were often repeated, included:

1) “ADLs Safety: Call device within reach” Just below this entry: “Demonstrates ability to use call light successfully: No”. (NOTE: Why put a call light within reach of a patient who cannot use it due to her cognitive limitations and contractures of her arms?
2) “Urinary Elimination: Voiding, no difficulties”. Just below this entry: “Voiding difficulties – Incontinence” (NOTE: How can she have no voiding difficulties in one entry, and have voiding difficulties in the next entry?!)
3) “Gait/transferring: Normal, bedrest, immobile” (NOTE: What does this mean? Are they saying she has a normal gait?)
4) “Mental Status: Forgets limitations” (NOTE: This woman was unaware of her limitations and could not communicate well enough to even tell the staff she forgot something.)
5) “Grooming: Patient does only 1 of 5 tasks or no tasks” (NOTE: Well, which is it? And by all other documentation available, I could see Mrs. Smith was unable to perform any tasks.)
6) “Environmental Safety Implemented: Encourage personal mobility support item use” (NOTE: This woman could not walk so this entry is nonsensical.)
7) “Environmental Safety Implemented: Personal items within reach” (NOTE: Don’t get me started again…)

I actually found myself getting angry reviewing these records. Are nurses wasting valuable time away from patient care to enter useful information that comes out useless? Or is inputting useful information so difficult and time consuming that there are many errors trying to input the data? I got more out of brief, handwritten notes such as, “WDWN in NAD. VSS. OOB to chair.” At least I knew the person was well developed, well nourished, in no apparent distress, her vital signs were stable, and she could get out of bed to a chair. And I could find this out by reading a short entry, rather than hundreds of pages of disjointed entries.

Am I saying there is no useful information in these records? No. It’s just become much more difficult to find it. It seems we have exchanged the problems of illegible records due to poor handwriting with unintelligible records due to computerization. Is it a good trade off? What do you think?

This is the opposite of the GIGO (Garbage In, Garbage Out) principle. This is Good (info) In, Garbage Out. It seems that many of these electronic medical records programs focus on data entry, and not on information output. Or is the output deliberately unclear and difficult to follow?

It seems reasonable to me that if all this information is computerized, we should be able to request the format that it is printed in. For example, why can’t we ask for the records to be printed in chronological order, from the beginning of the history (oldest records) to the end (most recent)? When records are printed with the most recent information first, it is like trying to read a book backwards.

It seems that before this big push for electronic medical records continues, there should be tremendous attention placed on whether the information output is useful…and accurate. Having a medical record that shows entries such as those above for an unfortunate patient with severe functional and cognitive impairments is totally unhelpful.

Are you finding that electronic medical records now take much more time and effort to review? Do you feel you are left with many more questions than answers?

jane_heronJane D. Heron, RN, BSN, MBA is a legal nurse consultant at Med League, which is owned by Pat Iyer.

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11 Responses to Are Electronic Medical Records Helping or Hindering Medical Legal Reviews? Patient Care?

  1. I posted this on the linkedin conversation but it worth putting it here as well.

    I think there are a few things that fall through the cracks here. As an informatics nurse I have a passion for data and making sure that system are easy to use and meaningful. In fact, the whole meaningful use initiate is meant to ensure that data is meaningful. And what I can tell you in my experience is that the people who “have” to have the data for reporting requirements are able to get what they need. The problem is that meaningful use doesn’t focus on the ability of the nurse to get the data he or she needs but rather for the government agencies to get the data that they need. So while there is gobs and gobs of awesome information that is being put in and spat back out it’s just not getting to the people who are caring for the patients.
    Many hospital IT departments are struggling to keep up with government requirements so much so that providing useful information to clinicians that serve the patients can often go by the wayside. This isn’t so everywhere, but it happens.
    Also, you can’t judge the effectiveness of an electronic medical record based upon the printed documents you can get out of it. There is not medical record system any where that produces fabulous paper records. They weren’t designed to do it, so if you are frustrated because you can’t get a single piece of paper with all you need you might as well get over it because it’s never going to happen.
    However, most medical records are built with initiative dashboards and that put all pertinent information you need in one central location with links out to additional information you might want to review. If you will try to forget what it was like to chart on paper and pretend you are learning where to locate data and chart for the first time this will really help. The biases that you developed about the superiority of paper are clouding your ability to see an EMR for all that it can be. EMRs save time, costs, improve patient safety, and patient outcomes.
    Albert Einstein is often quoted as saying the following “Everybody is a genius. But if you judge a fish by its ability to climb a tree, it will live its whole life believing that it is stupid.” This is exactly what many are doing with EMRs.

    ps. The gibberish about is a print driver issue and not the fault of the EMR. 🙂

    • Hi Brittney,
      Thanks for your added insights. I guess in my role as a per diem RN I just can’t get used to documentation time that isn’t primarily done to enhance patient care. This seems like a fundamental barrier to gaining the most from EMRs that we could. Sigh….this, for me, rings true with the state of healthcare in general. What’s the primary purpose? Health? Care? Profit? We’re so fragmented and squeezed for time that even learning new systems and processes that would eventually help us to do our work better is perhaps an overwhelming challenge at times. By the end of a shift, when I finally have a chance to put doctor’s orders I am so tired. Having to call IT for expired password, or look for something that I would normally know where to look for but can’t seem to find, or not be able to describe something in the way I want to…well…it is hard not to be frustrated. HOWEVER, I do think your voice is a crucial one for optimizing the infomatics in a way that professionals can use and improve safety and quality. I also know your new book that is coming out will make a huge contribution to that! Please bear with us who are frustrated trying to make it work! Beth

  2. The problem is very simple. The software/commands etc. were built by people who clearly do not understand the end requirements of the user and patient, as well as the needs to source the data in different mainstreams.

    • I agree in the simplicity of your assessment, Robert! A chronic lack of listening to frontline and respecting the reality of the work. I think solutions are attainable and require open and respectful communication and collaboration. Another selling point for Medical Improv and other experiential methods that build these skills.

      • Guys this is usually not the case. Most hospitals and EMR software vendors realize the importance of having clinicians involved with building the software. I believe they are just struggling to keep up with the ever changing demands of regulatory requirements. Also, the business needs always win out over the needs of the nurses. I think this is more to “blame” than anything.

        • And as long as business needs are more important than nursing needs it is hard to see how care will ultimately improve. Don’t you think this undermines the potential of EMRs? bb

  3. Hi Jane,

    Thanks for your post. I think it is a wake up call for us and our processes around developing, implementing, and continually improving EMR/EHRs. We need more and ongoing input from users. I think we’ve been trying to make clinical information fit the computer programs rather than have the software be responsive to clinicians. And it is a tricky balance to have checklists and boxes AND opportunities for narrative notes and judgement.

    We need to make sure that the records are helping us to communicate and document changes in addition to the focus on safety and liability.

    As a per diem RN, I can’t tell you how frustrating it is to try to FIT things in boxes that involve judgement. Not to mention, (but I will 🙂 ) issues like passwords expiring, login issues, calls to ITS with being on hold or recorded messages and call backs only frustrate and interrupt clinicians who are already squeezed for time. Not everything fits in a box!

    Using EMR/EHRs holds much promise, but maybe we need to take stock and do some rework!

    Beth

    • Tennisdoc says:

      Unfortunately it is not a wake up call for the patient, in fact too many are not waking up and it seems we that the vast majority have taken their eye off the ball. The ball being patients that become well.
      being compliant is not the objective in IMHO.
      Thomas

    • Beth,

      In order to use EMRs effectively nurses really have to retrain their brain on how the document. Discrete data (inside a box) is what can be reported on. Because of government regulations this is here to stay. Nurses should be doing very little in the way of narrative notes. If you can change your mindset around your “style” of documentation you would be much happier with EMRs.
      Many nurses waste too much time double documenting. They check the box then the write a note that says the same thing. Stop doing this! It’s wasting your time and making you frustrated.

      • So true, Brittney. Maybe the learning curve on top of already overburdened nurses adds to the challenges.

        Lots of double work for me with computer system too…after I enter doctor’s orders I have to print out two copies, (after I locate the right printer…) and sign both and put one in the hard copy chart and one in a note book of orders….and also print out a copy of the administration record to put in the MAR. Ironically, the system doesn’t have the oncall doc names in it so I have to cross out the name and write in the correct one. I guess IT could use more support too! 🙂

        I think I can work on this style a bit. I wish also there was a field for clarification so I could add an independent thought or observation….as well as a clear way to offer feedback. Thanks again for all of your feedback!! Hey, how about a ‘success story” re: EMRs/EHRs? Lend some balance?

        Take care,
        beth

What are your thoughts?