Fixing, not fighting, electronic systems

Even health information technology (IT) experts get angry at their electronic medical records (EMRs). “I personally have wanted to kick the computer before. It's a source of increasing frustration,” said Julie Hollberg, MD, chief medical information officer (CMIO) and hospitalist at Emory University Hospital in Atlanta.

The solution, however, is not to toss your computers but work with them, Dr. Hollberg and fellow CMIO Brian Clay, MD, told attendees at Hospital Medicine 2016. “You couldn't pay me enough to go back to paper, but we do need to mitigate the phenomena we see,” said Dr. Clay, who is also a hospitalist at University of California, San Diego.

Photo by Thinkstock
Photo by Thinkstock

The 2 experts analyzed the challenges of EMRs, especially note bloat and alert fatigue, and offered some solutions.

Note bloat

Physician notes have dramatically changed in the electronic era, both speakers noted. “I certainly never copied or wrote an entire echo report into my note, and I certainly didn't include the entire CT scan and the echo report and the consultant's note for 5 days in a row. The question comes, ‘Why do we do that now?’” said Dr. Hollberg.

The answer is not that it's the computer's fault, she added. “Remember and acknowledge as authors we have 100% of control of what goes into our notes. The technology doesn't make us do anything.”

There are a number of factors that push physicians to bloat their notes, however, explained Dr. Clay. One is legal concerns. “How often have we heard, ‘If it's not documented, it wasn't done?’ That is a driver of having more and more information in the chart,” he said.

Concerns about getting paid also encourage more documentation. The evaluation and management billing guidelines were last revised in 1997, before the advent of EMRs, noted Dr. Clay.

“And so the 8 bullet points and 12 body systems and all of that that we have to remember to make sure we get paid every day doesn't necessarily reflect the reality of a comprehensive electronic medical record. In the EMR, all that information is available, but may not need to be replicated in a given note,” he said.

Trainees are particularly susceptible to this pitfall. “One of the prime directives of residents and students is not to get negative feedback from their attendings on rounds. The common approach is to put more in the note rather than less, because they are concerned about getting feedback that the note is insufficient for billing purposes,” said Dr. Clay.

They may also gather information in the note for their own purposes. “I get feedback from resident and student users often that ‘I actually use the note to think through the patient's issues. The reason that I have so much information in my note is that it helps me aggregate everything in 1 place, and then I think through and decide how I want to proceed with their care,’” Dr. Clay said.

Finally, although technology doesn't require note bloat, it has made it much easier. “The cost of importing information into a note in most modern EMR vendor systems is near zero, especially if you structure a template that you can fire every day that links all the labs, all the vitals, and all the history into the note,” said Dr. Clay. “Copy/forward and copy/paste—it facilitates adding to the note, rather than evolving it.”

The disadvantages of these lengthy notes appear when anyone tries to read them. “We want to downsize putting all that stuff in our note, not because we're spending all the time doing it but...everybody else has to spend all that time fishing through that stuff to find the message,” said Dr. Hollberg.


To help these frustrated readers, think about telling a story with your note. “Don't use canned text, don't use structured data, don't use excessive detail—just tell the story,” said Dr. Clay. “Use prose for [the history of present illness] and medical decision making.”

Also keep in mind how much of the story your audience actually needs. “That tag on the top of the note: This is a 75-year-old male with whatever diagnoses who presents with x and y symptoms...On hospital day 5, you can just summarize the patient as a 75-year-old diabetic with pneumonia,” he said.

Note that the tag was probably copied from a previous note. “The best practice is really to write a note de novo on the patient every day,” said Dr. Clay.

Copy-and-paste repetition is particularly common in consulting fellows' notes, he pointed out. “The follow-up notes every day are sometimes just [the initial] note, with an additional sentence at the bottom. They won't get rid of all that other stuff that's already been documented, even though it's no longer needed. You have to scroll down to find out—are they going to take them to endoscopy today?”

Rather than copying and repeating data, physicians should know how to easily access that information in its original location, he said.

Another way to avoid so much scrolling is to put the most-used parts of the note at the top, known as the APSO (assessment, plan, subjective, objective) format. “There's no magic about SOAP [subjective, objective, assessment, plan]—it doesn't have to be in that order. Everything just has to be there somewhere,” said Dr. Clay. His program has further reduced scrolling by making their notes 2 columns on the screen.

Another secret to shortening notes is to know how to get paid without copying all those test results, Dr. Clay said. “Say, ‘I looked at the CT, the patient has a PE,’ and that means tons in terms of medical decision making and credit for acuity and how much you can bill....Have things in your template like ‘I have reviewed today's labs, and the pertinent findings are...’ rather than putting it all in the note,” Dr. Clay said.

Problem lists could also often be condensed, the experts said. “Do you really need to have all 27 problems? Can you just highlight the top 5?” asked Dr. Hollberg.

“If you have a well-maintained problem list, it is a lot easier to keep track of what's going on with the patient,” agreed Dr. Clay. “The problem list in an EMR is collectively owned by all the doctors, so problem-list hygiene and etiquette has to be something your institution has a vested interest in.”

Physicians might also want to discuss whether the medication list should be put in the note. “I didn't used to and now I do,” said Dr. Clay. “Most systems don't have another good way to record what the medication list looked like at that time [the note was written]....I put it at the bottom.” The bottom of the note is a good place for information that you want to include but others might not often read, he noted.

In addition to this list of to-dos, Dr. Clay advised against 1 potential strategy: trying to block users from copying and pasting. It won't work, he said. “You may be able to disable the copy function in the EMR, but you can't really turn off the operating system of the computer it's running on...basic Windows control+C, control+V.”

Alert fatigue

Clinicians might also be tempted to turn off all those alerts that pop up every time a drug is ordered, but Dr. Hollberg doesn't think that would work out, based on a conversation she recently overheard. “One of the interns said, ‘Do you have to renally dose Dilantin?’ And the other intern says, ‘I don't know, but don't worry, if you do, the computer will pop up and tell you.’”

As frustrating as they may sometimes find alerts, physicians are becoming increasingly dependent on them, and that should guide the approach to improvement, Dr. Hollberg said. “All of us would be a little bit hesitant to say that we should get rid of alerts entirely....If we're going to be dependent on them, then we actually have to stop and maybe take an extra half a second and read the message on the screen.”

On the other hand, no one wants to spend hours reading and dismissing alerts. The goal of clinical decision support is to present the right info to the right person at the right time, which is not happening perfectly in most systems yet, she noted. “Even if you turn your alerts down to only the highest level severity, you get things like potassium and Lisinopril that pop up,” Dr. Hollberg said.

Unlike note bloat, the most likely solutions to this problem are systemic. “This is 1 of those places where we've really got to have our vendors work with us to create better end-user interfaces,” said Dr. Hollberg. “Very few institutions have decided to scrap the whole thing and completely build custom 1 at a time what they want to add back in.”

Pharmacists may be a solution to physicians' alert fatigue, she suggested. “Often the same alerts that we get, the pharmacists get, and the pharmacists have a much different culture than we do where they pay a lot more attention to this. One of the questions to ponder in our health care systems, as we practice as teams, is should more of these alerts be going to the pharmacists instead of us?”

System designers are also looking for a way to make alerts less interruptive. “You're seeing recommendations coming out, particularly from the folks in medical and clinical informatics, [for] alerts to be noninterruptive. Is it possible to have drug/drug interaction alerts that are less severe come to you at a later date? If so, is that still valuable?” said Dr. Hollberg.

There are also decisions to be made about what types of concerns merit alerts—only patient safety or financial priorities, too? “With all the 2-midnight rule stuff, we certainly have an alert in our system that hardstops people if there's not an admit order in the chart. That's of financial benefit to us, but I'm not sure the hospitalists feel like that's a significant enough benefit to interrupt them,” Dr. Hollberg said.

Hospitalists' role

Hospitalists should be proactive in helping resolve these problems for their facilities, both experts said.

That means first honing one's own skills on the EMR, with formal training, if necessary. “It's not like your iPhone where you can sit and mess with it until you figure it out. You might accidentally order the wrong medication,” said Dr. Clay.

The next step is getting involved in the development and modification of these systems or at least communicating with those who are. “It is incumbent upon us to be engaged,” said Dr. Clay. “Know who your clinical colleagues are in IT. If there aren't some physicians or hospitalists involved, get some hospitalists involved.”

Physicians and IT specialists can work together to solve EMR-related problems, he added. “If lots of providers are coming into my team saying this workflow doesn't work for us, then we are certainly incentivized to change it to make it better. We can build all kinds of tools for you that don't come out of the box.”

Hospitalists who get involved in their hospitals' health IT often have the opportunity to test out the new tools once they're developed. “Be willing to beta-test,” said Dr. Clay. “The tools are getting more fun.” (Expect a lot of upcoming testing to involve mobile versions of the things you currently do at a workstation, he noted.)

Whether you find your EMR fun or not, it's time to make the best of it, because it's not going away, the experts agreed. “In this day and age, there's no way to do a quality improvement project, there's no way to do a research project, there's no way to do quality measures or anything else without engaging the EMR in some way,” said Dr. Clay.