A Promise Unfulfilled

What exactly was the promise of the electronic medical record? The tool that was supposed to make life easier, workflow faster, quality of care better, and patients’ lives healthier has pretty much turned into a face-plant; a promise unfulfilled. Although there are some notable exceptions, the market has shifted to the large electronic health record companies, and medical record content and speed and quality are not their highest priority. Physician satisfaction with these instruments is abysmal.

The Road Ahead for Electronic Medical Records

What should the EMR do for practitioners, and even more importantly, for our patients? The chasm between the status quo and the possibilities is immense. Ironically, the solutions are easily within our grasp today. The EMR tool should be fast, improve workflow, and be mobile. Human Factors Engineering should lie at the heart of it. It should be molded to the human condition. It should help practitioners think; working on it should be a pleasant experience because it is fast, improves quality, and reduces medical error and the failure to diagnose.

We Are Only Human

In 1998, the Institute of Medicine published its groundbreaking article “To Err is Human,” our first national glimpse at the medical error problem.¹ (1) We know from more recent publications and the tabloids that medical error is one of the leading causes of morbidity and mortality.²  (2) Insurance company and large healthcare system data indicate that in many medical specialties, the most common error is the “failure to diagnose.” ³

Here are a few examples demonstrating why being human can lead to medical errors and the failure to diagnose. In each case, the inability to have this information front-of-mind and immediately accessible can and has led to patient injury and death.

1. A 24-year-old male presents with an abrupt onset of severe chest pain. What are the risk factors that would predispose this patient to a thoracic aortic dissection?
2. What key risk factors should you address in a neonate with a fever?
3. A 40-year-old woman presents following a motor vehicle collision with multiple lacerations on the back of her left hand. What are those tendons and how you would examine each? How would you repair them?
4. Posterior circulation stroke can be very difficult to diagnose. What are the key signs and symptoms in a posterior circulation bleed?
5. What are the 5 criteria for a diagnosis of Kawasaki syndrome?

Every one of these data points may be required during a single shift in a busy emergency department. Challenge your favorite medical colleague! This is not esoterica; this is Making a Diagnosis 101.

We are only human, and the vast knowledge base required to keep patients safe is simply well beyond the intellectual capacity of most mortals. An interesting publication from four insurance companies combining their emergency medicine claims data indicates that cognitive errors are at play in 98% of emergency medicine claims! ⁴

The EMR serves many masters, but the top priorities are medical error reduction, improving patient safety, and avoiding the failure to diagnose.

The Road Ahead

The Sullivan Group has been modifying and redesigning EMRs and EHRs for 17 years. We have clearly demonstrated that the EMR can dramatically impact compliance with evaluation and documentation at key points in the diagnostic process and that such compliance with key elements in high-risk presentations can reduce the failure to diagnose. ^5,6

The literature contains articles warning of the dangers of EMRs, such as macro generation, copy–paste and alert fatigue. Well, hello! This is simply growing pains. These are work-arounds, not solutions. The point is that EHRs and EMRs are crawling out of the primordial ooze and are advancing the mission of quality healthcare at a snail’s pace.

It is Time for a Quantum Leap

We believe that the following are some of the keys to real success in the EMR world. We can’t share all of our secret sauce, but these are critical aspects required for the leap.

Template Design

Since we are only human, template design must support the human condition. It should be specific to a chief complaint but allow flexibility for multiple complaints. The key point is that critical data elements for the 60-year-old chest pain patient or the 3-week-old with a fever MUST be present as part of the data workflow.

For the febrile 3-week-old infant, this means that critical past history relating to strep or herpetic exposure must be part of the flow of the template. Addressing this risk history should be addressed on 100% of febrile neonate charts; there is no room for error. And humans simply are not 100 percenters, especially in the middle of a busy ED or urgent care or a typical day in the clinic.

Although practitioners tend to want to see the same “look and feel” every time, it is simply impossible to create a short, concise template that includes what is required for the wide variety of ED, urgent care and primary care patient presentations. In order to be as fast as possible and support a rapid workflow, templates must be specific and address only those items that are relevant to the presentation.

Human Factors Engineering

Human Factors Engineering is a fascinating subject. It is essentially an analysis or measurement of the human body (anthropometry), evaluation of the environment, and understanding the possibilities and opportunities of information technology. When all of this is blended together artfully, the result is a beautiful creation. Human Factors Engineering is what will make the EMR world start to turn; not programs designed to fit all and then forced into your location, but programs designed with you and your environment at the heart of the development.

Don’t Stop the Flow

Don’t have anything pop up! Twenty pop-ups on a chest pain case and you feel ready for an early retirement. Seriously, practitioners are retiring when faced with the prospect of 3 more hours of documentation after a busy shift in order to complete documentation on the current popular EHRs. Pop-ups are and have always been a bad idea unless they come out of the toaster. There must be a way to inform the practitioner regarding a threat to life or limb, but it’s not a pop-up.

Evidence-Based Medicine in the Workflow

In certain cases where evidence-based medicine (EBM) exists, the practitioner should use it and document it. Rather than have to go to a website to find the latest EBM, it should be built into the workflow. For example, based on practitioner input, the program should insert the evidence-based rule in/rule out PE algorithm into the workflow for chief complaint of chest pain and for a patient with a prior pulmonary embolism.

Practitioners absolutely want to follow the evidence. However, without a reminder to use it and the immediate availability of the PE risk stratifiers, it simply won’t be used with adequate frequency. This is another 100 percenter issue.

On the other hand, if it is artfully inserted into the workflow, the practitioner will welcome it, use it, and determine if further evaluation for PE is required or if the patient can avoid an inappropriate use of the radiation that goes with imaging, thus giving the patient the highest level of care possible.

Medical Decision-Making (MDM)

Help us out here! If the chest pain template is properly constructed and it recognizes that thoracic aortic dissection should be a consideration, then the program should seamlessly lead to documentation of all the critical elements from the history, physical exam, chest X-ray and other parts of the patient record.

And assuming that is the case, why not auto-create an MDM note that makes it perfectly clear that a complete analysis has been done, including the elements of that analysis and that TAD is or is no longer being considered.

No one should have to write that note. The chart should automatically make it abundantly clear that with no abrupt onset, no risk predisposition, no blood pressure differential, no aortic murmur, no chest X-ray findings, etc., TAD is no longer a consideration. No one will take the time to write that note, but think about it. What a beautiful thing. And give the practitioner the option to accept it, modify it, become aware that all critical elements have not yet been documented, or ignore it. Human Factors Engineering hard at work!

Connect the Dots

It is so easy to look at the sky and pick out the Big Dipper. But try and find the Libra scales of justice! Not so easy. Try and identify a trend in a large table of vital signs! Humans are not great dot connectors. But combine the human interest in dot connection and harness information technology, and the possibilities are endless. Seemingly disparate pieces of data scattered throughout the health record may point directly to a syndrome or condition that may not otherwise have been recognized. Evaluating trends in vital signs that surpass a critical threshold is child’s play for any program. How to build that artfully into the workflow is the critical issue.

One day, hopefully soon, you will feel the power of natural language processing and clinical rules. Once again, they must be artfully developed and seamlessly dropped into the workflow.

Clinical Decision Support

Most practitioners require clinical decision support. Perhaps not the orthopedist who limits practice to hip replacements or knees; however, if you deal with trauma, abdominal pain, chest pain, febrile children, and dozens of other high-risk complaints in your typical day, you probably need help - help that is artfully incorporated into the EMR. It is obviously available inside the user interface, but only when it’s needed and only what is needed; not in your face, but a single touch away. If you need a username and password and have to navigate an index, use will be limited or non-existent. But employ Human Factors Engineering, and decision support will be your best friend.

On Mission

Enough for now! This is an important area for The Sullivan Group on our road to medical error reduction and improving the patient condition. It is perhaps the most powerful manifestation of our mission.

• Risk, safety and quality immediately available at the bedside during the patient encounter.
• Quality and safety reports available real time, but perhaps no longer relevant because the nurse/medical practitioner/EMR team has addressed all the relevant issues and provided the highest quality care together, real time, with outstanding documentation.

We want you to know that we have special expertise in the EMR arena, but we also want to raise the awareness of the opportunities as well as the sad state of many of our current EMR tools. Help us bring in the tide and raise all the boats!

References:

• Kohn, Linda T, Janet Corrigan, and Molla S. Donaldson. 2000. To err is human: building a safer health system. Washington, D.C.: National Academy Press.
• Erin P. Balogh, Bryan T. Miller, and John R. Ball. Authors: Committee on Diagnostic Error in Health Care; Board on Health Care Services; Institute of Medicine; The National Academies of Sciences, Engineering, and Medicine. Washington (DC): National Academies Press (US); 2015 Dec 29.
• CRICO. 2011 Annual Benchmarking Report. Malpractice Risk in Emergency Medicine.
  Kachalia, et al. Missed and delayed diagnoses in the emergency department: A study of closed malpractice claims from 4 liability insurers. In the February 2007 Annals of Emergency Medicine. 49(2); pp. 196-205. February 2007.
• Pasha, Crockett, et al. On-Line Risk Management Combined with Template-Based Charting Improves the Documentation of Key Historical Data in Patients Presenting With Chest Pain. Annals of Emergency Medicine. Volume 36, Issue 4, Supplement. October 2000.
• Hafner JW Jr, Hubler JR, et al. Quality in Emergency Department Care: Results of The Sullivan Group’s Emergency Medicine Risk Initiative National Audit. Annals of Emergency Medicine. Volume 46, Issue 3. September 2005.