Electronic medical records (EMRs) are a source of angst for practicing emergency physicians everywhere.

Why should this be, given the great promise they hold? And how do we keep our sanity amid all the insanity?

The beginning is a good place to start.

A Brief EMR History

Not many decades ago, a patient’s medical record resided on a 5”x8” card in a filing cabinet in a general practitioner’s office. That was good enough for all concerned until more people wanted to access that record. Insurance companies, government officials, statisticians, and many others wanted the data the general practitioner possessed.

With the coming of the Internet, the EMR was born.

The result was more useful data but also more extraneous information—more signal and more noise with a less-easily located patient story.

The EMR software that evolved, which was intended for billing, was less than successful in documenting patient care. It is no secret that EMRs are a source of stress to physicians, pushing some to the breaking point.¹ This significant contribution to wearing down physicians needs to be addressed. How do we, as emergency physicians, navigate our way through such challenges?

Solutions

Start with the patient:

• Practice etiquette. Sit down in the patient’s room; there’s a reason the computer is called a laptop. Face the patient over the top of the screen so you can see the patient’s face and eyes.
• Learn keystroke shortcuts. This will let you look at the patient while your fingers get that old document or lab. Don’t know your software shortcuts? This may be the time to meet with your super-user in the department or check out www.makeuseof.com/tag/windows-8-keyboard-shortcuts.
• Take notes. Have a document page open, and take your own shorthand notes on the computer while you talk to the patient. (You can acknowledge the computer’s presence; patients will understand.)

If you can’t beat technology, join it—exploit some of the other tech tools available to put the EMR back in its cage:

• Pick up the Dictaphone. Use Dragon dictation software, save a simple .wav sound file to the record (comes bundled with any modern operating system), or use Google’s Speak. Dictate a short summary note. Skip the preset templates and just talk or type:
  • Why the patient came to the ED
  • What you found
  • What you did
  • What you want the patient to do
• Hire a scribe. There is a huge literature base on this topic that clearly shows scribes will pay for themselves. Hospital won’t do it for you? Then hire one yourself. You can afford it, and you can’t afford to let this stuff drive you crazy!
• Get mobility. How do you handle the software that you must use during the visit? Go mobile. If the hospital won’t buy a tablet, get one yourself. You may need to use remote access from within your own facility, but it’s worth it.
• Make a favorites file. Create a file that is useful and arranged the way you think. (Therapeutic drug class? Chief complaint? Odd or critical workups? Special tests that are buried in the mass of entries?) Store what you need to remember for treatment of hyperkalemia in one place. Chest pain is just begging for its own directory.
• Use macros/shortcuts/preconfigured order sets. These repetitive functions are the real strength of using a computer. Invest the time to set up your own macros. Copy or share those developed by your colleagues. Your information technology staff or department super-user is there to assist you, and it will only cost you a sincere thank you.
• Keep your common tests in the root directory of your favorites file. These include CBC, basic electrolytes, urinalysis, etc. Optimally, a modern EMR would push your most common tests to the top.
• Use a laptop or a computer on wheels. Load the PACS onto it to bring the radiology study to the bedside. Patients love to see the images, and it’s a major time-saver for you.
• Learn how to access a graph of lab results. A line showing the downward trend in the hemoglobin for a GI bleed is much faster than trying to explain numbers.
• Show off your knowledge of past events. Have prior visit dates and diagnoses pulled up on your screen.

What if you still are frustrated with computers? Be optimistic. Someday the software will catch up to your expectations, or you may be able to customize your program. Be sure to share your EMR coping strategies with others, especially the new doc joining the department.