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Electronic Medical Record: Friend or Foe?
The Resident Viewpoint:
As a recent cardiothoracic surgery residency graduate, and having trained at multiple hospitals (those with electronic medical records and those with paper medical records), I believe I have a unique perspective on electronic medical records (EMRs). With our tech-savvy culture, it is no surprise that the medical record followed suit, evolving from a paper to electronic system. It is important to note that mandates were initiated years prior, which tie electronic medical record use to Medicare and Medicaid reimbursement. Much like the old adage, “bigger is not always better,” I have found myself questioning: “Is electronic better?” This topic has been much of a debate at my training institution as well, and it deserves more attention. As such, below are outlined what I believe to be the top three positives and negatives of the EMR. Maybe this will help settle the debate: Is the EMR our friend or foe?
Votes for “Friend”:
Portability 
Centralized data
Having easily accessible, legible data is vital in caring for our patient population. You never have to guess what a providers are trying to write in their notes in the EMR (no hand-written notes). Most EMRs allow laboratory data, imaging, and notes to be viewed using one platform. Capabilities such as trends of vitals and laboratory values are useful to providers as well. As noted above, providers no longer have to physically gather laboratory slips or imaging films. Having centralized data for each patient saves on a provider’s time.
Standardization of orders
This has to be one of the greatest attributes of the EMR, especially when considering a teaching institution where trainees are constantly learning. Whether a provider orders Tylenol, a thoracic angiogram, echocardiogram, or a diet for a patient, the order is standardized. With medication orders, the usual dose is provided, along with other important information (renal dosing suggestions, etc.). Pharmacists and nursing staff do not have to worry about the legibility when reading and performing medication orders, for example.
Votes for “Foe”:
Cumbersome
There is no question that there is a considerable amount of time that adds up when logging into the EMR, entering orders, and writing notes. That time does not include any restarts or rebooting that can occur, not to mention the various “warnings” that pop up during each of the processes (e.g. creatinine level for all contrasted imaging studies or patient allergies). Depending on the type of note a provider writes (free text versus standardized format) a note can seem to require endless “clicks” to get to the end. Sometimes you find yourself wishing to just have a pen and paper.
Reliance on technology
When data gathering and documentation is centered on a computer, focus often shifts from the patient’s bedside to a desk. Although “computers on wheels” and computer stations positioned throughout the intensive care unit and ward have helped move providers closer to the bedside, a significant amount of time is still tied to the computer itself. Further, review of patient information on a computer is absolutely no substitute to bedside evaluation of a patient, especially in our line of work.
Lack of single EMR
I have lost track of the number of times I have been frustrated by this fact. At tertiary care centers, we often receive patients that had initial treatment or surgery at another institution. Full detail and information from those prior visits is usually not available. As a result, many tests (laboratory and imaging) have to be repeated. As stewards of health care cost, we do no justice by simply repeating each test. Unfortunately, given the “business” aspects of EMRs, a single EMR, which all providers can access, is not in our near future. This is unfortunate, as I strongly feel it would improve communication among providers across cities/states, and reduce health care costs (one example being the elimination of repeating tests).
As one can see, EMR offers a great deal but still has serious shortcomings. In my mind, the jury is still out. Hopefully as we refine the current models of EMR we will get closer to the ideal EMR: one that continues to be portable, can house centralized data, and allows for standardization of orders but at the same time offers efficient use, thereby decreasing the time tied to a computer, and is accessible to all providers.
Dr. Eilers is a general thoracic surgeon at the University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery.
The Attending Viewpoint:
Some of us embraced the idea of the EMR while others resisted until failure to use one led to financial penalty. Even so, it is absolutely clear that EMRs are here to stay. As is true of all technology, there are pros and cons to their deployment.
Pro EMR
Notes can be read. We have all suffered the indignity of trying to read illegible handwriting to guess what a consultant has recommended, or as the consultant trying to understand the question you are being asked. Even more than handwriting issues, with the paper chart there was always the challenge of finding the chart or the note walking around in a resident’s pocket awaiting rounds with the attending. With the EMR, what is written is legible and it can be found/reviewed remotely before going in search of the patient. This has the potential to save time and offers the consultant the advantage of knowing about the patient prior to the visit. In the academic setting, the EMR affords the attending opportunity to review and amend a resident’s note for accuracy that sometimes leads to a “teachable moment.”
Communication among providers can be shared more efficiently. To the extent that the patient’s providers access the same record this is very useful. On completion of any procedure or note, the outcome can be promptly sent electronically or by fax to other providers with the need to know. This can really optimize health care in many ways.
Con EMR
The worst thing about the EMR is the separation of patient from provider at all levels! In the “old days” we were all at the patient’s bedside. Today I often find decisions made based on limited data in the record without benefit of seeing the patient. Failing to observe whether the patient is breathing comfortably, feel whether the feet are warm, or notice whether the pressure transducers are appropriately placed in relation to the patient takes away the real art of medicine. Worse, decisions are made and interventions selected that may be quite inappropriate. It seems that nurses spend more time in the hallway on their workstations clicking away to satisfy documentation demands than spending time assessing and knowing their patients. The patient becomes “Room 920” not “Mr. Smith.” I see this as a real tragedy of our reliance on electronic media.
Data can be reviewed remotely sometimes. This is indeed a two-edged sword in that it separates us from our patients too easily. The ultimate time saver of the computer too often becomes a time sink with the need to negotiate multiple securities to access the EMR at all. Also, we must often seek information in more than one source to review relevant data from the in- or outpatient environment, from a referring doctor in another system, or to review an actual image rather than just the report. It becomes an expensive endeavor when we need additional staff to track down data, images, and other records.
Overall, I am very happy to be practicing with the great technology we have today. I am excited to watch as all these technologies evolve to make better our health care delivery. In reality, the EMR is not our enemy. It is a friend with a bad temper.
Dr. Carpenter is an adult cardiac surgeon and program director, Thoracic Surgery Residency, at the University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery.
The Resident Viewpoint:
As a recent cardiothoracic surgery residency graduate, and having trained at multiple hospitals (those with electronic medical records and those with paper medical records), I believe I have a unique perspective on electronic medical records (EMRs). With our tech-savvy culture, it is no surprise that the medical record followed suit, evolving from a paper to electronic system. It is important to note that mandates were initiated years prior, which tie electronic medical record use to Medicare and Medicaid reimbursement. Much like the old adage, “bigger is not always better,” I have found myself questioning: “Is electronic better?” This topic has been much of a debate at my training institution as well, and it deserves more attention. As such, below are outlined what I believe to be the top three positives and negatives of the EMR. Maybe this will help settle the debate: Is the EMR our friend or foe?
Votes for “Friend”:
Portability
Centralized data
Having easily accessible, legible data is vital in caring for our patient population. You never have to guess what a providers are trying to write in their notes in the EMR (no hand-written notes). Most EMRs allow laboratory data, imaging, and notes to be viewed using one platform. Capabilities such as trends of vitals and laboratory values are useful to providers as well. As noted above, providers no longer have to physically gather laboratory slips or imaging films. Having centralized data for each patient saves on a provider’s time.
Standardization of orders
This has to be one of the greatest attributes of the EMR, especially when considering a teaching institution where trainees are constantly learning. Whether a provider orders Tylenol, a thoracic angiogram, echocardiogram, or a diet for a patient, the order is standardized. With medication orders, the usual dose is provided, along with other important information (renal dosing suggestions, etc.). Pharmacists and nursing staff do not have to worry about the legibility when reading and performing medication orders, for example.
Votes for “Foe”:
Cumbersome
There is no question that there is a considerable amount of time that adds up when logging into the EMR, entering orders, and writing notes. That time does not include any restarts or rebooting that can occur, not to mention the various “warnings” that pop up during each of the processes (e.g. creatinine level for all contrasted imaging studies or patient allergies). Depending on the type of note a provider writes (free text versus standardized format) a note can seem to require endless “clicks” to get to the end. Sometimes you find yourself wishing to just have a pen and paper.
Reliance on technology
When data gathering and documentation is centered on a computer, focus often shifts from the patient’s bedside to a desk. Although “computers on wheels” and computer stations positioned throughout the intensive care unit and ward have helped move providers closer to the bedside, a significant amount of time is still tied to the computer itself. Further, review of patient information on a computer is absolutely no substitute to bedside evaluation of a patient, especially in our line of work.
Lack of single EMR
I have lost track of the number of times I have been frustrated by this fact. At tertiary care centers, we often receive patients that had initial treatment or surgery at another institution. Full detail and information from those prior visits is usually not available. As a result, many tests (laboratory and imaging) have to be repeated. As stewards of health care cost, we do no justice by simply repeating each test. Unfortunately, given the “business” aspects of EMRs, a single EMR, which all providers can access, is not in our near future. This is unfortunate, as I strongly feel it would improve communication among providers across cities/states, and reduce health care costs (one example being the elimination of repeating tests).
As one can see, EMR offers a great deal but still has serious shortcomings. In my mind, the jury is still out. Hopefully as we refine the current models of EMR we will get closer to the ideal EMR: one that continues to be portable, can house centralized data, and allows for standardization of orders but at the same time offers efficient use, thereby decreasing the time tied to a computer, and is accessible to all providers.
Dr. Eilers is a general thoracic surgeon at the University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery.
The Attending Viewpoint:
Some of us embraced the idea of the EMR while others resisted until failure to use one led to financial penalty. Even so, it is absolutely clear that EMRs are here to stay. As is true of all technology, there are pros and cons to their deployment.
Pro EMR
Notes can be read. We have all suffered the indignity of trying to read illegible handwriting to guess what a consultant has recommended, or as the consultant trying to understand the question you are being asked. Even more than handwriting issues, with the paper chart there was always the challenge of finding the chart or the note walking around in a resident’s pocket awaiting rounds with the attending. With the EMR, what is written is legible and it can be found/reviewed remotely before going in search of the patient. This has the potential to save time and offers the consultant the advantage of knowing about the patient prior to the visit. In the academic setting, the EMR affords the attending opportunity to review and amend a resident’s note for accuracy that sometimes leads to a “teachable moment.”
Communication among providers can be shared more efficiently. To the extent that the patient’s providers access the same record this is very useful. On completion of any procedure or note, the outcome can be promptly sent electronically or by fax to other providers with the need to know. This can really optimize health care in many ways.
Con EMR
The worst thing about the EMR is the separation of patient from provider at all levels! In the “old days” we were all at the patient’s bedside. Today I often find decisions made based on limited data in the record without benefit of seeing the patient. Failing to observe whether the patient is breathing comfortably, feel whether the feet are warm, or notice whether the pressure transducers are appropriately placed in relation to the patient takes away the real art of medicine. Worse, decisions are made and interventions selected that may be quite inappropriate. It seems that nurses spend more time in the hallway on their workstations clicking away to satisfy documentation demands than spending time assessing and knowing their patients. The patient becomes “Room 920” not “Mr. Smith.” I see this as a real tragedy of our reliance on electronic media.
Data can be reviewed remotely sometimes. This is indeed a two-edged sword in that it separates us from our patients too easily. The ultimate time saver of the computer too often becomes a time sink with the need to negotiate multiple securities to access the EMR at all. Also, we must often seek information in more than one source to review relevant data from the in- or outpatient environment, from a referring doctor in another system, or to review an actual image rather than just the report. It becomes an expensive endeavor when we need additional staff to track down data, images, and other records.
Overall, I am very happy to be practicing with the great technology we have today. I am excited to watch as all these technologies evolve to make better our health care delivery. In reality, the EMR is not our enemy. It is a friend with a bad temper.
Dr. Carpenter is an adult cardiac surgeon and program director, Thoracic Surgery Residency, at the University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery.
The Resident Viewpoint:
As a recent cardiothoracic surgery residency graduate, and having trained at multiple hospitals (those with electronic medical records and those with paper medical records), I believe I have a unique perspective on electronic medical records (EMRs). With our tech-savvy culture, it is no surprise that the medical record followed suit, evolving from a paper to electronic system. It is important to note that mandates were initiated years prior, which tie electronic medical record use to Medicare and Medicaid reimbursement. Much like the old adage, “bigger is not always better,” I have found myself questioning: “Is electronic better?” This topic has been much of a debate at my training institution as well, and it deserves more attention. As such, below are outlined what I believe to be the top three positives and negatives of the EMR. Maybe this will help settle the debate: Is the EMR our friend or foe?
Votes for “Friend”:
Portability
Centralized data
Having easily accessible, legible data is vital in caring for our patient population. You never have to guess what a providers are trying to write in their notes in the EMR (no hand-written notes). Most EMRs allow laboratory data, imaging, and notes to be viewed using one platform. Capabilities such as trends of vitals and laboratory values are useful to providers as well. As noted above, providers no longer have to physically gather laboratory slips or imaging films. Having centralized data for each patient saves on a provider’s time.
Standardization of orders
This has to be one of the greatest attributes of the EMR, especially when considering a teaching institution where trainees are constantly learning. Whether a provider orders Tylenol, a thoracic angiogram, echocardiogram, or a diet for a patient, the order is standardized. With medication orders, the usual dose is provided, along with other important information (renal dosing suggestions, etc.). Pharmacists and nursing staff do not have to worry about the legibility when reading and performing medication orders, for example.
Votes for “Foe”:
Cumbersome
There is no question that there is a considerable amount of time that adds up when logging into the EMR, entering orders, and writing notes. That time does not include any restarts or rebooting that can occur, not to mention the various “warnings” that pop up during each of the processes (e.g. creatinine level for all contrasted imaging studies or patient allergies). Depending on the type of note a provider writes (free text versus standardized format) a note can seem to require endless “clicks” to get to the end. Sometimes you find yourself wishing to just have a pen and paper.
Reliance on technology
When data gathering and documentation is centered on a computer, focus often shifts from the patient’s bedside to a desk. Although “computers on wheels” and computer stations positioned throughout the intensive care unit and ward have helped move providers closer to the bedside, a significant amount of time is still tied to the computer itself. Further, review of patient information on a computer is absolutely no substitute to bedside evaluation of a patient, especially in our line of work.
Lack of single EMR
I have lost track of the number of times I have been frustrated by this fact. At tertiary care centers, we often receive patients that had initial treatment or surgery at another institution. Full detail and information from those prior visits is usually not available. As a result, many tests (laboratory and imaging) have to be repeated. As stewards of health care cost, we do no justice by simply repeating each test. Unfortunately, given the “business” aspects of EMRs, a single EMR, which all providers can access, is not in our near future. This is unfortunate, as I strongly feel it would improve communication among providers across cities/states, and reduce health care costs (one example being the elimination of repeating tests).
As one can see, EMR offers a great deal but still has serious shortcomings. In my mind, the jury is still out. Hopefully as we refine the current models of EMR we will get closer to the ideal EMR: one that continues to be portable, can house centralized data, and allows for standardization of orders but at the same time offers efficient use, thereby decreasing the time tied to a computer, and is accessible to all providers.
Dr. Eilers is a general thoracic surgeon at the University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery.
The Attending Viewpoint:
Some of us embraced the idea of the EMR while others resisted until failure to use one led to financial penalty. Even so, it is absolutely clear that EMRs are here to stay. As is true of all technology, there are pros and cons to their deployment.
Pro EMR
Notes can be read. We have all suffered the indignity of trying to read illegible handwriting to guess what a consultant has recommended, or as the consultant trying to understand the question you are being asked. Even more than handwriting issues, with the paper chart there was always the challenge of finding the chart or the note walking around in a resident’s pocket awaiting rounds with the attending. With the EMR, what is written is legible and it can be found/reviewed remotely before going in search of the patient. This has the potential to save time and offers the consultant the advantage of knowing about the patient prior to the visit. In the academic setting, the EMR affords the attending opportunity to review and amend a resident’s note for accuracy that sometimes leads to a “teachable moment.”
Communication among providers can be shared more efficiently. To the extent that the patient’s providers access the same record this is very useful. On completion of any procedure or note, the outcome can be promptly sent electronically or by fax to other providers with the need to know. This can really optimize health care in many ways.
Con EMR
The worst thing about the EMR is the separation of patient from provider at all levels! In the “old days” we were all at the patient’s bedside. Today I often find decisions made based on limited data in the record without benefit of seeing the patient. Failing to observe whether the patient is breathing comfortably, feel whether the feet are warm, or notice whether the pressure transducers are appropriately placed in relation to the patient takes away the real art of medicine. Worse, decisions are made and interventions selected that may be quite inappropriate. It seems that nurses spend more time in the hallway on their workstations clicking away to satisfy documentation demands than spending time assessing and knowing their patients. The patient becomes “Room 920” not “Mr. Smith.” I see this as a real tragedy of our reliance on electronic media.
Data can be reviewed remotely sometimes. This is indeed a two-edged sword in that it separates us from our patients too easily. The ultimate time saver of the computer too often becomes a time sink with the need to negotiate multiple securities to access the EMR at all. Also, we must often seek information in more than one source to review relevant data from the in- or outpatient environment, from a referring doctor in another system, or to review an actual image rather than just the report. It becomes an expensive endeavor when we need additional staff to track down data, images, and other records.
Overall, I am very happy to be practicing with the great technology we have today. I am excited to watch as all these technologies evolve to make better our health care delivery. In reality, the EMR is not our enemy. It is a friend with a bad temper.
Dr. Carpenter is an adult cardiac surgeon and program director, Thoracic Surgery Residency, at the University of Texas Health Science Center at San Antonio, Division of Thoracic Surgery.