“EMR, Do I Love Thee? Let me Count the Nays”
Does that line sound familiar? “How do I Love Thee? Let me Count the Ways” is the opening line to a sonnet often attributed to Shakespeare (but actually written by Elizabeth Barrett Browning). Ms Browning certainly knew nothing about electronic medical records—EMRs. She and Mr Shakespeare were both lucky.
While there are some things I do like about EMRs, it’s much more fun to talk about the things we all hate. Here are 4 examples from my own files.
#1. EMRs have a tendency to overdocument “stuff” that is not clinically relevant and makes a medical note way longer than it needs to be. Here is an example from the note I received from an urgent care center when a 4-year-old patient of mine hurt his toe after falling off a slide:
► The review of systems was very complete, with 55 listed negative items including denials of “depression …contact lens use …rectal complaints …penile discharge.” Now, did the provider really ask this 4-year-old or his parent if the child had a penile discharge? I don’t think so. And even if we were talking about a 25-year-old man, should the ROS include questions about penile discharge for someone with an injured toe? The family history section was also very detailed with all sorts of medical problems (cancers, heart disease, allergies) noted in grandparents, cousins, and so on, none of which had any relevance to an injured toe from an accident—a playground accident. None of us wants to wade through pages of useless information
#2. EMRs tend to load templates into a note that are not relevant to the case for one reason or another, that are then not corrected by the provider. In addition to the example noted above (I have been practicing pediatrics for more than 30 years and have not seen a lot of depression or contact lens use in 4-year-old children), here is another example of a non-pediatric-friendly EMR result:
► I sent a 5-day-old to ENT for tongue-tie and got a note back that said, under the physical examination, “Ability to communicate: normal. Inspection of teeth revealed normal dentition.” I might be willing to agree that crying is a form of communication, but “…normal dentition?” Seriously?
#3. EMR language tries to "sound" like our old handwritten notes and falls a little short of the mark more often than not. Here is one of my favorite examples and it comes from a copy of an office note from a pediatric urologist who had seen a 4-month-old patient of mine for unilateral cryptorchidism.
► His note begins: CC: “I have an undescended testicle.” I wonder if ICD-10 has a code for precocious speech, clearly a problem for this 4-month-old boy.
#4. EMR notes just look stupid. It’s not really the notes’ fault; they simply do what the programmer told them to do. I recently received some printed medical records for a 3-year-old transferring into the practice. This particular EMR note includes a section in addition to ROS, HPI, PE, etc., called “other problems.” Sounds like a good idea until you realize it simply lists diagnostic codes from previous visits.
► Included in this child’s “other problems” were “MMR vaccination” and “3 -year well child visit,” neither of them things that most of us would consider an “other problem.” Or, in this HPI section of a well visit was the sentence, “Parent concerns include none.” I am not sure how “none” can be a concern. I don’t mean to pick on programmers, but their strengths in school were not likely in the language arts.
True confessions: I use an EMR system in my office practice and most of these offenses I am railing about I have also committed. While I don’t miss having to try to read someone’s handwriting, I do miss the compact handwritten notes such that 3 office visits could be included on a single page. Now a simple office visit fills up 3 pages. This is not progress. A good handwritten hospital “H and P” would tell you all you needed to know and, equally important, nothing that you did not need to know. One could follow the thought process of the admitting physician. Now with point and clicks in the EMR you follow the thought process of a non-clinician and end up with text that would drive your 8th grade English teacher totally bonkers.
At the risk of breaking this Web site, what do you hate (or, love) about your EMR? Please leave a comment below...