Written by: John Lynn
Guest Post: I got the following story that someone wanted to share about the challenges of EMR and workflow in a hospital. I love reading first hand experiences with EMR. Reminds me of a great experience that Neil Versel documented at an urgent care during HIMSS. I look forward to hearing your comments on the story.
Last month, my wife felt some discomfort in her chest. They weren’t pains, nor were they indigestion so much as a gurgling sensation. After two days and no change, she called our family physician. He told her she could come in for a blood enzyme test, but the lab result would take four days. Instead, he said to go to an ER where they could get the result in half an hour.
That evening, a Friday, we went to the nearest ER, at Large, Modern, Suburban DC hospital (LMSDC.) We walked right up to the triage nurse, a woman in her 60s who stood there and took down my wife’s info on paper: Name, Chief Complaint, Age, and Triage Class, a 3. We were handed the paper, the only copy, and sent to the first of what would be three exam rooms.
The room was for EKGs. It was equipped with a machine, bed, etc., and a desktop PC. After a few minutes, a tech came in and ran the test. I asked how the scan got into my wife’s record. She told us it was sent electronically to imaging where it would be reviewed and put in the record, but she didn’t know how it was entered, electronically or scanned in.
We had three more visitors, two nurses and an admissions clerk. Admissions came in with a COW, a computer on wheels. She started asking demographics, insurance, etc., but was called away. The first nurse came in went over why we were there, about meds, etc., took a blood sample and did something on the room PC and left.
The second nurse came in, went over symptoms, meds, etc., again, and scribbled the information on a scrap of paper in her hand. We never saw either nurse again. While waiting for the next step, I saw that the first nurse had logged into the PC, but not logged out.
We were then moved to a small exam area with five beds to wait for an attending and to wait for four hours until time for another blood sample. The area was run by a tech I’ll call Sam. Sam was a remarkable multitasker. Among other things, we saw him:
• Arrange patients and families in the cramped space
• Look for other staff
• Take blood
• Check orders
• Organize a stack of loose forms into their patient clipboards
• Change bed sheets
• Check the EMR for updates
• Check on patient moves
Sam did all this, and from what I could tell, was the only person who was actually followed the different aspects of his cases.
At first, the area was at capacity with crying children, their worried parents and others typical of a Friday night in an ER. While Sam directed traffic, the admissions clerk caught up with us and finished my wife’s record.
Around nine, an attending came in. He stopped midway in review for a half hour cell call and then returned. He recommended that she should go on a heart monitor and stay overnight. After the attending’s visit, we settled down to wait for a room. Sam checked every now and then to see where it stood, but it went nowhere.
About eleven, while making my second run to the ER vending machines, I saw the attending and mentioned that it was getting pretty boring waiting for a room and a monitor. Surprised, he said he’d ordered the monitor and that it should have been put on in the ER. With that, he checked with the charge nurse to get it done. The charge nurse came to see us and had us move to another area with a monitor, which a nurse started. Just after midnight, still waiting for a room, my wife sent me home. She called about one to say she’d been moved to a medical floor and was on a monitor.
I knew that LMSDC adopted an EMR three years ago and, indeed, it was clear that meds, complaints, orders, etc., were being entered into it. However, it was also clear that their system was a receptacle not a workflow tool. Apparently, LMSDC simply overlaid the EMR on its paper system, eliminating some parts, but keeping others. These other elements persist in their own parallel world. For someone such as Sam, who tries to keep his patients current it means more work not less. This explains why he had to deal with the EMR and constantly sort and organize paper forms into their proper patient clipboards.
Even that is not LMSDC’s major ER workflow problem. The heart monitor problem shows there is no shared task list. That is, once the attending entered the order, and I believe he did, the order is in the EMR. However, who is to carry it out and when should become a task that all others can see. Thus, the conversations among the attending, the charge nurse, Sam, my wife and me should have been unnecessary.
A couple of gratuitous points. LMSDC’s system is heavy on desktop machines. It cries for laptops or pads. Nurses, techs, attendings spend their time flying from one desktop to another, logging in and, sometimes, out. It’s a machine centric rather than a user centric system. Users never have their own workspace. They are always in hit and run mode. Even if they have a good system workflow and a good shared task list, they spend enormous time and energy logging in and out of room machines. It’s no wonder things get lost in the cracks.
LMSDC’s system runs both patients and staff ragged in another way. We moved three times, no record I expect. Nurses came and went. The attending should have been on skates. The only one with a dedicated space was Sam which explains why he could get so much done without exhaustion. How much easier their difficult lives and their patient’s lives would be if the patients came to the staff rather than endure the ER’s fast action minuet.
What’s so amazing is that despite their poor IT support and their constant motion, the staff was invariably professional, focused and friendly.
Best of all, after a night in the ER and a morning on a medical floor, my wife was discharged. She’s fine.