Look, up in the cloud, it’s EMR, come to save the day

I suspect that anyone reading this blog post has also read too much about the missed case of Ebola in the United States. As it turns out, the nurse who initially assessed the patient did comment on “recent travel” to a high risk Ebola area in the world. But because the nurse recorded the information in the nursing section of the electronic medical record [EMR], the doctor did not see it.

I have read so many defenses of this mistake, that it makes me ill. As I have said many times before, doctors are human and will miss, even critical, diagnoses. The purpose of an EMR is to literally compensate for the failings of a human, and occasionally to force the human doctor to attend to a critical medical matter. In essence, the purpose of an EMR may be at times to remove, from the doctor, the freedom of practice, and thus force the doctor to follow guidelines no matter what.

One of the excuses given for this mistake was that the doctor did not see the nurse’s note. I read a number of comments about this fact, and that it was the nurse’s failing not to have directly approached the doctor and to have forced him to acknowledge the patient’s recent travel. This is insulting to the nurses and absolutely ridiculous.

The whole reason for having an EMR is to improve efficiency. If the doctors do not read the nurse’s notes, then the problem is not just Ebola. I can only now imagine how many patients have been mistreated by physicians in that hospital, because the doctors did not read the nurse’s notes. This is also likely an endemic problem across the entire United States, for anyone who is using this EMR [which apparently has nursing notes on a separate tab from doctors’ notes].

I wholly agree that the EMR could be better designed, but only because the doctors clearly fail to follow the most basic protocols, i.e. to see what the nurse wrote. Nevertheless, were I the designer of this EMR, I would immediately consider a redesign of the doctor interface, so that nursing notes are clearly evident to the physician before he or she begins to document their own comments on the patient.

As I have also commented in the past, the purpose of an EMR is to, literally, force the doctor to follow protocol. There was an article related to this issue that appeared in JAMA last month. JAMA is considered one of the top medical journals around, and any article that appears in it, would be considered basic reading for any physician. The title of this article was “Overprescribing and inappropriate antibiotic selection for sore throat in children”. You do not need to be a healthcare professional to understand this title.

Despite countless articles that have appeared throughout the medical literature specifically on this topic, doctors are clearly either ignorant to or disinterested in providing proper care for such a common and basic medical condition. Despite clear recommendations and detailed guidelines that dramatically limit the situations in which it is appropriate to prescribe antibiotics for sore throats, physicians continue to prescribe antibiotics in 60% of visits with the complaint of sore throat. The number should actually be close to 0%.

There is the very effective throat culture test which can effectively eliminate the need for overprescribing antibiotics. Nevertheless, physicians continue to flood the human population with antibiotics which unquestionably contribute to overall antibiotic resistance. Should the patient develop a severe reaction, to the antibiotic given unnecessarily for this condition, it would even be grounds for a lawsuit for malpractice. There is literally no excuse for doctors to overprescribe in this situation.

From what I have read, every possible attempt has been made to inform doctors of this issue and to reduce overprescribing. To quote a reviewer of this article in JAMA, “sadly, we seem to be losing ground in the battle against inappropriate antibiotic prescribing for pharyngitis”, i.e. suspected infection of the throat.

In my previous place of employment, the EMR that I wrote was constantly being updated by myself and my colleague. One of the updates that I made, was to enforce a system of justification whenever the doctor wished to prescribe antibiotics immediately for a sore throat. In practice, if the doctor prescribed antibiotics without a clear typed explanation of the reason for doing so, the doctor was contacted by a senior physician and asked again to justify the use of the medication.

Using this system, I was able to help the medical staff dramatically reduce the overprescribing of antibiotics for sore throat. I would venture to say that inappropriate antibiotic prescribing for sore throat was mostly eradicated in my previous place of employment. This was simply due to the fact that the EMR was designed to literally fight against the doctor whenever he or she tried to act inappropriately.

“Sore throat” was not the only condition that merited such an EMR response. In fact, there were a whole range of conditions that demanded clear and professional documentation by the treating doctor, all in an attempt to stop inappropriate medical practice.

As a physician who has successfully dealt with this issue, it truly hurts me that American doctors continue to ignore solutions to this problem. And I suspect that even lawsuits that are specifically due to such incorrect practices, will still fail to change physician behavior. It is my opinion that the only way to improve medical care, in a whole range of situations, is to remove choice from the doctor and to enforce established protocols. This is definitely draconian, but if the EMR does not watch over the doctor, then who will?

Thanks for listening

(For those of you who are as old as me: a blast from the past)

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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