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More Joys of Electronic Medical Records

HistoryGo up to your favorite emergency department staff member and ask them what they think of “twofers.”

Depending on that person’s mood, chances are that you’ll get anything from a scowl to a punch in the gut in response. Two patients from the same family both needing emergent medical care at the exact same time? It still happens … car accidents, fires, maybe a stomach bug. But it can be frustrating. There’s a saying in emergency medicine that the likelihood of a true emergency is inversely proportional to the number of patients in the family registering to be seen.

That being said, a “fivefer” will raise the hairs on the back of the neck of pretty much any emergency department personnel. When the complaint is that everyone in the family has a cough, three of the five family members smoke, and none of them got their flu shots … well … you get the picture.

One of the frustrations with scenarios like this is the charting involved. The nurse and the doctor are literally stuck at the computer for 30 minutes each, both entering useless information about different patients over and over again – instead of taking care of other patients. The medical records won’t let you proceed without entering the information.
Is there a fall risk?
Is there a risk for tuberculosis?
Does the patient smoke? Nurses have to enter this information even on infants to satisfy government regulations.
Is there a risk of danger in the home?
Is there evidence of abuse?
When entering an order for IV fluid, if the patient has a sulfa allergy, doctors have to acknowledge that there is some potential interaction between saline and the patient’s allergy and describe why we would dare to give salt water to a patient with an allergy to sulfa.
And on and on and on.

So I tried something that sounded easy when I thought of it, but was technically quite difficult when I tried to actually do it. I tried to log the number of times I clicked on different check boxes and the number of different screens I had to navigate in order to document on and discharge/admit a patient.
This is easier said than done.

I never realized how quickly I am able to navigate a byzantine array of computer screens. After clicking on one button to order a medication, I found myself subconsciously moving the mouse to the area of the screen where the next “OK” button would pop up. I had to literally slow myself down to count the clicks and the screens. I’m sure I missed a few in the process.
The number of data points in each aspect of a patient’s history is quite large. There are 144 data potential points to click on just for a patient’s physical exam. The screen to the right is what must be navigated for each and every patient’s history. Each line in the white fields is a data point that must potentially be either right- or left-clicked depending on whether it is positive or negative. I didn’t even bother counting up how many potential data points could be clicked upon, but it numbers in the several hundreds – depending on the presenting complaint.

So I set out to log the clicks and screens. The first few times I tried, I wasn’t able to do it. Finally, when it wasn’t so busy, I made a conscious effort to stop on every screen and mark down clicks and screens. I use some basic templates, so the amount of clicking that I do is actually less than someone who doesn’t use templates.

For a patient with an upper respiratory infection (i.e. a cough) and no labs, the total number of clicks was 37 and the total number of screens I had to navigate was 17. I also had to enter my system ID and password twice. All these screens and clicks were in addition to all of the information I had to enter by typing.

For a patient with a wrist fracture who needed medications and a splint, I clicked on 52 different variables and had to navigate 41 screens – in addition to the information I typed. On this patient, I had to enter my system ID and password four times. Many of the screens that popped up contributed to alert fatigue, asking me why I was ordering Norco on someone who already uses Norco and forcing me to acknowledge the duplicate medication order and then explain why I was doing it (because the patient hadn’t used the Norco in 3 months and didn’t have any more). I was not allowed to proceed with the patient care until I answered the questions.

The final patient I attempted to log clicks and screens on was a patient with chest pain. I was able to keep things going up until the time the patient was ready to be admitted. Then I had to quit the logging as it was taking too long and a bunch of new patients showed up. Just entering the history, the exam, and the orders amounted to 62 clicks and 27 screens plus 2 episodes of ID/password entry. Admission order entry and result entry were significantly more clicks and screens.

Next time that you wonder why your doctor or nurse always seems to be on the computer, chances are that it isn’t because they’re checking Facebook.

Think about how long it would take you to navigate to 41 different web sites and enter information on each one before being able to complete your work. Oh, and if you accidentally enter incorrect information on any one of the 41 web sites, you could be subject to a federal investigation for overbilling, have to pay for an attorney to defend you, and could be sued for triple damages. That’s what we go through with just about every patient we see.

Makes you happy that the government is pushing all medical providers into electronic medical records, doesn’t it? I know I feel safe realizing that my medical providers spend more time entering information on their computers than they do providing me with medical care.

Although I created this post before the article was written, this whole topic segues nicely with an article written yesterday in the Daily Caller by Mickey Kaus about the significant detriments that have occurred since our government began pushing medical providers to implement electronic medical records. (with a hat tip to Walter Olson at Overlawyered.com)

Also see these other medical record productivity posts here and here.


  1. Sounds like your EHR is just awful. Using our IT department’s version of EPIC did not require so many clicks when I worked as a medical scribe! Twofers and above were still a doozy to document though.

  2. What is your EHR (so I never take a job at a place with this EHR)

  3. I’m more interested in what happens during outages, both to the patients and to the doctors’ litigation exposure. I presume you can’t just stop treating people because the computers are down.

  4. To Kipper….I can tell you our process when the systems are down….DOUBLE WORK! We “paper chart” and then enter all the information into the systems when it are up. No Bueno!!! Needless to say, it takes HOURS to catch-up. :-(

  5. Not when “it” are up….when they are up (multiple systems) (

  6. Ugh. As a nurse, every time this happens I’m just waiting for the moment when I make a medication error. When there’s 5 kids super-close in age and 2 adults all in the same room, and the doc wants to give meds to 2 of the 5 kids, who are all running around the room yelling…pretty easy to give the wrong stuff to the wrong kid.

  7. Ha! If the kids are all “running around the room yelling” they sound pretty healthy!

  8. i once called my Physician’s EMR an “EDMR”…..you can only imagine the jokes from him that followed…..

  9. I worked at two different institutions which both used EPIC. One of them had customized EPIC in a way that was mostly palatable for my use. The other institution’s EPIC was crap :-)

  10. It’s all terrible – add on top of the fact that now that CPOE is live in so many places they (administration) asks “so now that you don’t enter orders. what is it a pharmacist does and why do we need so many”….
    wow, i guess all we used to do is enter orders and the techs fill orders because “why can’t a tech just hit “verify” because that’s all you do”

    uh huh….

    So you do more, and we’re told we do nothing

  11. My hospital does CPOE with meditech, and will be forcing us to adopt pDOC- the meditech charting within the next year. Anybody have experience with this? It looks awful.

  12. i’m late to the party but…

    my doctor’s office is fully electronic, no paper records at all. she clicked the wrong area my last visit and erased all record of me taking blood pressure medication.

    i do not like this totally paperless world…while its good in SOME ways, in others there is SO much room for problems.

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