Saturday, August 13, 2011

The 4 Stages of EMR Adaption

Stage 1: Naïve anticipation
Last summer, as we began the process of choosing which EMR (electronic medical records) system that we would buy, I was filled with my usual optimism. Despite the naysayers, I was sure that our efficient office would have no trouble adapting from paper charting to computer charting. Above all else, I was convinced that Moi, ‘Ms. Computer Savvy Blogger' would love EMR. In the months leading up to the transition, I began to look condescendingly at our cumbersome paper charts and our 3x5 card tracking system for abnormal labs, as I anticipated their retirement. They seemed quaint relics, like cassette tapes or Ms. Pac-man machines. I could hardly wait for the charts to be replaced by information at my finger tips and the promised fool proof tracking systems that would improve quality, while making my life easier. Though my partners voiced trepidation about what we were to endure, I had little doubt that we would be paper free in just a few months. It would take work and there might be a few hiccups along the way, but I knew that if we put in the time and effort, the transition would go smoothly.
Stage 2: Adaption Angst
We decided on Greenway, a system that was specifically marketed for OB/GYN. Training was scheduled for early November, with the plan to ‘GO LIVE’ the following week. Leading up to our training, I (as self appointed EMR point person) had several conference calls with our trainer. It was during these calls that the first inklings of doubt began to set in.
Every question I posed to our trainer was answered the same way, “Oh, yeah, that is SUPER easy, I’ll show you next week.” Her voice was high pitched and bubbly, like an excited Barbie doll. While I was naïve enough to think that the transition would go well, I was not an idiot. I knew that not every aspect of EMR would be, as she repeatedly intoned to me, “SUPER EASY!”
Training week did not flow well. While we all did manage to learn the basics of charting notes and navigation of the software, any question outside of basic charting was met with a blank stare from our Barbie doll trainer.
“How do we order labs?”
Blank stare.
“How do we track labs?”
Blank stare.
“How do we fax?”
Things weren’t quite so “super easy” anymore.
She abandoned us after a two weeks. That’s when the fun began.
Stage 3: Self Pity/Anger/Denial
While I did learn the EMR fairly quickly, my biggest disappointment came in the realization that it did not make my life any easier. On the contrary, it added at least an hour to my day. Everything just takes longer.
It took us several months to figure out the extremely cumbersome tracking system for labs. I began to look longingly at the 3x5 note card boxes that I had previously scorned. It takes me 14 clicks to sign off a lab, IF ITS NORMAL! While it used to take two seconds to make a quick signature, now it takes 14 clicks. My nurse also has several extra steps involved with routing documents back and forth. If there is an abnormal lab, I then have to open multiple documents to decipher the plan, task it to the correct staff and turn on all the tracking mechanisms.
Home has always been my sanctuary, unless I was on call. Now I find myself leaving work before my charting is completed, so I can attempt to be home for dinner. After the kids are asleep, I dial in to finish charting. Home is no longer a safe haven. I really hate the fact that I can ‘work from home.’
I began to relish the last few paper chart patients. When I would see a paper chart in the door, I would get that giddy excited feeling, like when a patient brings in hot fresh chocolate chip cookies for you at three o’clock on a Friday afternoon. I realized that it is so much easier for me to remember the patient details by leafing through a paper chart, rather than clicking on 17 different documents in the electronic file. Paper charts were nostalgic for me. I would flip through and see the handwriting of previous employees; coffee stains of the day I was running late and the smiley faces I would draw on the lab results when a patient’s cholesterol finally came down or their Chlamydia finally cleared up. Paper charts are full of physical, tangible memories in a way that an electronic file can never be.
I felt betrayed by Miss ‘Super Easy”. Yes, the actual charting was not difficult, but it was time consuming and the orders tracking system was cumbersome. Most importantly, I didn’t HAVE an extra hour in my day for charting.
And did I mention the FOURTEEN CLICKS?
Stage 4: Acceptance
Slowly, things have become slightly better. I will admit that being able to READ everything is very much a benefit (the computer gets bonus points for penmanship!). Also when on call, it is great to be able to pull up charts at home to review the patients history while talking to them. There is no more hunting down prenatal records when someone goes into labor on a weekend. As patients come back for return visits, it definitely gets easier. EMR still adds time to my already packed work day, but slowly I am figuring out how to make it work for me.
It was the following encounter that convinced me that I had to truly accept EMR and stop my grouching about it:
Last week I was seeing a young girl for a check up before she left for college. She was having issues with her birth control pill and wanted to switch.
This is the type of encounter that makes me hate EMR the most. While in the room with the patient, I have to attempt to look through her old chart which is in a zillion different saved files in her new electronic chart. So as I’m clicking on each file, attempting but failing to find the one that tells me which pill she was on before this one, I make some smarmy comment about how I hate my new computer.
“That’s Ok,” she says in a slightly patronizing voice,” My Grammy is a nurse, and she has a hard time learning computer stuff too!”
At this point my jaw literally dropped. It took every ounce of self control to maintain my composure at that moment.
Ummmmm did she just compare me to her GRAMMY? I am 36 years old!
After a few deep breaths I regained my composure, found the file I needed and sent her on her way with a new script. Sent by e-prescribe, of course.
From that day forward I have vowed to never complain about EMR again. Not even the fourteen clicks. No its not perfect, but it is here to stay.
Every time I get frustrated and want to complain, I just take a deep breath, smile and whisper the word, “Grammy.”


  1. We're switching to EMR in 2012. I'm dreading it. When I was working at the VA, the EMR was awesome because it was so easy to use and intuitive. But I've also used a bunch of EMRs where I had to call tech support any time I wanted to do anything. I have this bad feeling it's going to be the latter at my hospital.

    Plus the unit where I work has four computers total. I have no faith that new computers will be purchased to keep up with the demand for electronic charting.

  2. 14 clicks for labs! ACK! I was really fortunate to come into a practice that started EMR (All Scripts) 6 years ago, so I just had to learn the system (everyone else had it down!) It has its issues, but for the most part is fairly intuitive. We still use paper charts for our OBs, but that will go electronic eventually. The only problem for me is that during a busy day, while I can do paper charts quickly between patients, the electronic ones cater to my OCD so much that I don't have time to put as much detail as I like, so they don't get done until the end of the morning/afternoon.

  3. Good post. We are knee-deep in EMR / EHR drama ourselves.

    When I started at my practice they had already been using an EMR...which is great but does NOT satisfy the CCHIT thing, the "meaningful use" thing which gives practices money for adopting electronic records. I probably have the details wrong about that, but basically we had to switch to Allscripts Pro, which was a nightmare (with all the clicking that was required). So THEN we had to switch again! Three EHRs over a year.

    If you guys are ever in the market for a new EHR, I recommend Athena, which is what we're using now. Some learning curve is involved but we're on our 4th week and it's coming along nicely. I've got a feeling we'll end up loving it big time.

  4. Kellie (General Surgeon)August 14, 2011 at 11:02 AM

    We went live on our EMR 6 years ago. It wasn't easy at the beginning and I think most people feel it has added time to the day, but things that are great are being able to read everyone's notes (some docs here have horrid handwriting and I would hate when I'd see one of their patients), prescriptions (most of the time). Not sure what they were thinking with labs, but we have 1-2 clicks, depending on whether or not you also send the results to the patient.

    We use Epic. Thank goodness we didn't have to pay, our hospital did.

  5. We went live on epic in our MFM practice last fall... It's getting better, but we are on a Family Practice platform which has served us poorly! It is nice that it syncs with the hospital though!

  6. Yup. The hardest part for me was the fact that I now could do work at home and was expected to! Before, I would do my best in work hours then pick up the next day. Now I feel that I have to put in some time after the kids are down because I can....Terrible how it plays on my mommy guilt for leaving at an hour to eat dinner with my kids.

  7. I love EMR as a pathologist because it takes me outside of my little microscope box and into your world, which helps support my diagnoses after I make them, or check them if it doesn't correlate. I love going to my small town hospital because all the local clinics are piped into the hospital EMR system - even more information to prevent me from having to make a phone call.

    I can appreciate all the headaches, though, and sympathize with you guys. I once read a post where a patient wrote about lamenting that her oncologist never looked at her anymore, only his computer screen, clicking away. She played Angry Birds. That sucks.

    Great post Grams (ha ha I'm 37 so I am Grammy-er than you).

  8. Yes, part of my frustration has been has been how expensive everything is. Our hospital has not helped absorb any of the cost and we are approaching $200 K. We are in the process of meeting our meaningful use and applying for stimulus money, but will see how that all works out :)

  9. I quit my last job (almost) for a sole reason of EMR inconvinience. Patients were so entitled they were raging if you were not looking at them every moment of your encounter, and you had to do 12-15 clicks for one function just like you described. It added so many ungodly hours to my day. As soon as I put kids in bed at 8 pm I was on computer charting till 11 pm. And did I mention I was getting 15 minutes per patient - that divided between nurse rooming patient (also charting on EMR) and me, which my employer was kind enough to mention to me at each and every evaluation. Yeah, and do not forget, doctor, 15 minutes is not all yours...

  10. You forgot suicidal.

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  12. We are 14 months into a paper->EMR transition (the program is "Profile" by Intrahealth, a company based in New Zealand) and the hours stolen from my family / exercise / sleep time by this process are too numerous to contemplate without descending into despair. I too think that suicidal warrants its own stage.


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