• Rosalind Kaplan, MD

Bad Attitude

I set an intention to be calm and cool, to have a good attitude, around the EMR (Electronic Medical Record) this week. I've now been using some form of EMR for 10 years. At first, I kicked and screamed at the intrusion of the computer into my doctor-patient relationships. I spent lots of time fuming about that, and then I learned to touch type well enough that I could make eye contact and still write notes or enter lab orders much of the time. I tried to make peace with the fact that I spent more time with the impassive, blinking computer screen than I did with my patients and colleagues. And though I never quite reached that place of peace, I finally did come around to believing that the EMR is a necessary evil, and that the potential of an EMR to organize and access and share patient records is a good thing. That was probably five years ago. I was hoping that the potential of the technology would soon come to fruition.

But now, five years later, the progress, like many other kinds of progress, seems glacial.

Last week, when I started a weekly volunteer position at a multidisciplinary clinic, I had to learn how to use their rather clunky, outdated EMR. It is the 7th EMR system I have trained on. THE SEVENTH. And that's not including the multiple versions of some of the systems. Yes, back in 2012 I learned how to use a small-practice EMR platform called eClinicalWorks. It was relatively simple, but when you're used to paper charts and prescriptions, there's a steep learning curve. We had a week of in-office training, and then I struggled with it for months before becoming adept. When I left my small practice for an academic health system, I was trained on the big-guns, Mercedes Benz of digital health records, EPIC. EPIC training consisted of home on-line modules, then a couple days of training in a computer lab in the basement of the hospital, followed by 'support' in the office from an EPIC trainer. At first it was a little bit fun- there were lots of bells and whistles, and when you log on, a message pops up telling you that you are 'JUMPING TO HYPERSPACE.' Then a space-themed background, complete with stars and planets, appears. You can personalize backgrounds and colors and the positions of various icons. But the novelty dissolves pretty quickly, once you realize that ordering a single lab study for a patient requires somewhere around 10 clicks, and a medication order might require even more. It became quickly apparent that my patient visits would be dominated by these keyboard acrobatics, and that any other time I had would quickly be filled with in-box tasks and data entry. Oh, well. I tried to embrace EPIC. I really did.

I got proficient at using the system. Only to have to learn yet another system, known as All-Scripts, when I changed jobs 3 years later. Then another year later, my new employer launched EPIC. I thought I'd adjust instantly, but it turned out that the particular version of EPIC differed significantly from the one I'd previously used, and I again spent weeks feeling like my head would explode as I searched for the icons I needed and learned the complicated processes that were supposed to simplify my work (though we all know the truth: it wasn't built to simplify our lives; it was built to maximize billing).

At present, I am using a third version of EPIC for office visits at Urgent Care, a specialized telehealth EMR for telephone visits, and the clunky, awkward system at my volunteer job, which is called RhythmMD or MDRhythm, but certainly seems to have no rhythm, as well as having no rhyme or reason.

My intent to have a good attitude yielded to frustration today, when I was writing a note on RhythmMD. I failed to click on 'SAVE' for the 85th time during the creation of one patient note, and lost all the work I'd already done.

The sad part is that all these different systems that I, a digital immigrant and avowed Luddite, now know how to use, do not communicate with each other. An office or hospital using EPIC can access patient information from other institutions using EPIC, and fortunately many large health systems do use it. But Epic and eClinicalWorks and Allscripts and MDRhythm don't talk to each other. The grand idea behind EMR's was that they would eliminate duplication of services and make care safer, more efficient and more thorough by sharing information across providers, hospitals, pharmacies, labs and other medical facilities. Yet in the two decades of EMR use, fragmentation is still the norm. And knowing how to use one system doesn't mean that you will know how to use another. We physicians do more work than ever since the advent of the EMR, and because we all have computers at home, we can't ever get away from our work.

Maybe I'd have a better attitude if I knew that all the extra training and work that doctors put in because of the EMR, and the loss of the intimacy of a patient visit without a screen between us, and the eye strain and brain drain and the desire to rip the hair out of my head on occasion was improving patient care. But nothing bears that out.

For now, if I have to accept the very imperfect realities of the EMR, I am also going to accept my own bad attitude. Trying to 'be more positive' just makes me feel more negative.

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