Every now and then an airliner in otherwise perfect flying condition flies into the side of a mountain or crashes at sea. A review of the flight data recorder invariably shows that the crew neglected to look out the window to see what was obvious but instead became engrossed in the multitude of computer screens and indicators that make up the so-called “glass cockpit,” paying for this distraction with their lives and the lives of their passengers.
Modern Emergency Medicine has the same risks as new distractions to patient care multiply at an alarming rate. It has come to the point that, at my current hospital, three-quarters of my time is spent in front of a computer or the clipboard trying to wrestle the patient into the paperwork and very little of this time has anything to do with actual medical care.
Take, for example, ordering medications. I vividly recall (because it wasn’t that long ago) that we used to write orders on a simple green order sheet that required nothing more than a time and a signature. The patient’s allergies were entered at the top of the sheet and using a little bit of judgement I could enter even the most complicated orders quickly and efficiently. We pulled a flag on the chart to alert the nurse or just flagged her down, she drew the medications, gave them to the patient, and signed off on the order sheet with a time.
Now that we have an Electronic Medical Record ordering medications involves a complicated trip through menus and check boxes. First I open the patient’s chart on the computer and scroll to the orders section at which point begins the lengthy process of selecting medications, drilling down the menu for doses, and jumping to a separate menu to document obvious instructions to the nurses.
Medication selected, I hit the “done” button and then am lead through a byzantine socratic dialogue as the program spits pages of information detailing all of the possible interaction of the medication with every other medication the patient is taking, asking me in the process several times for each medication if I am sure, really sure, really really sure I want to order it. And I’m not talking about allergies to that class of medication; today I must decide instantly if the risk of some very rare side effect that I have never heard of and which to truly understand requires reading through two pages of information is worth the benefit; and for every interaction I decide to ignore I must enter a reason why I am being such a damn fool.
Every medication, by the way, interacts with every other one. There is no end to it.
In practice we just “hammer click” through all of it. And I typically just enter my initials in the “reason why” box. Consider that where previously it took me ten seconds to write an order, each individual order now takes three times as long and this time adds up. I currently spend an hour-and-a-half per shift just wrestling with the computerized order entry system for the 200 hundred orders I enter and this time would easily double if I was as conscientious as the bureaucrats who infest the place require me to be.
Keep in mind that paperwork is an elaborate trap designed to pin the blame on the doctors and nurses if something goes wrong. One day my flippant disregard for the check boxes is going to come back to haunt me but what can I do? To be completely and honestly compliant with all of the paperwork would slow the department to a crawl, consequently most paperwork is entirely fraudulent as it documents things that were not actually done in the strictest sense according to the rules. As I mentioned in an earlier post, the nurses whose paperwork burden is terrifying to contemplate, usually have an end-of-shift documentation klatch where all of the useless forms are filled out in an assembly-line fashion.
Orders done, I start my chart. At my hospital patient’s information is stored on two separate computer systems. One is an ancient “DOS” based dinosaur with a 1990s-style rudimentary interface grafted onto it. To obtain vital signs, allergies, and medications for the patient requires a complicated series of keystrokes after which I am rewarded with page after page of useless information through which I must carefully sift for the essential facts. In the year 2012, not unlike a Babylonian scribe, I must then copy the important information to my paper chart, itself a model of streamlined bureaucratic innovation.
Reviewing the results of lab work and tests requires another complicated foray into another system and images from radiology are on a separate machine as well. The results are dictated however and to acquire them requires a Long March through the radiology phone menu.
Our charts are pre-selected templates with check boxes ostensibly because it is easier and faster but nobody fits into the check boxes nowadays. There is no template for Headache, Cough, and Vaginal Pain, for example, and our patients seldom have the decency to have typical symptoms of common diseases. It’s to the point where, on walking out of the patient’s room, my first thought is not about their care or diagnosis but how I’m going to fit it into a chart.
Patient care, the diagnosis and treatment of medical problems is not generally very difficult. I agonize over the paperwork, however. It crushes my soul, inhabits my dreams, and is giving me an ulcer.
Not to mention that while we remain fixated on the flashing lights the patient may be flying into a mountain.