Electronic Medical Records

Why Your Electronic Medical Record Upgrade Feels Like A Downgrade

All software undergoes periodic upgrades. This may happen every few years (think Windows or the Macintosh operating systems) or every few months (think Microsoft Word and Powerpoint). Electronic medical records are no different. Sometimes, software upgrades are for improved security, sometimes for better user-friendliness, and sometimes to provide additional features. But whenever they happen, they cause temporary disruption in user efficiency.

Every few years, the grocery store that I shop at re-organizes all of the aisles and all of a sudden, the cans of tomato sauce is where the paper towels used to be and the bacon is where the produce used to be. For a couple of weeks after the re-organization, the manager will post employees throughout the store to help customers find the new location of all of the stuff that they came there to buy. Every time they do this, it feels like my world has been turned upside down, I get angry with the store, and I swear that I’m going to start taking my business to a different grocer down the street. And then after a few months, I’ve figured out how to navigate the new aisle configuration and life is back to normal again.

The same thing happens with electronic medical records. When there is a major upgrade, it immediately becomes hard to navigate the system: orders have to be entered differently, progress notes are organized differently, and a lot of the features that you used to use regularly are seemingly nowhere to be found. All of a sudden, your 15 minute patient encounters are taking 20 minutes and your frustration mounts exponentially. That is the moment that you think that the EMR upgrade was really a downgrade.

Eventually, just like at my grocery store, you get used to the new version of the electronic medical record and life goes back to normal again. But one of the things that is unique about electronic medical records is that doctors don’t have a choice in using them. If you can’t stand the re-organized grocery store aisles, you can take your grocery business to a different store. If you don’t like the new model of the Toyota Camry, you can keep your old one or buy a Honda Accord instead. But with your EMR, you have no alternative, you have to use the new version.

I think that is what makes EMR upgrades so unique – that we have no control. As physicians, we can’t just switch our individual practice to a different EMR and we can’t just decide to individually opt-out of the new version. We have to use the new version and there is no going back. So, what can we do?

For the electronic medical record designers:

  1. Resist software changes that are done simply for change sake. EMRs are not like fashions – with clothing, new styles come out every year to attract new customers and sell more clothes. EMRs are totally different, hospitals generally stick with the same EMR that they have been using and don’t change EMRs every year based on the newest style. If the EMR upgrade was done simply because the new software programmer at the EMR company needed something to do, then it is a downgrade.
  2. Upgrades should prioritize reduced numbers of keystrokes and mouse clicks to perform tasks. Every keystroke adds time and opportunity for data entry errors. If the EMR used to require 10 mouse clicks to order a chest x-ray and with the upgrade it now takes 13 mouse clicks, then it is a downgrade.
  3. Navigation in the EMR windows should always be designed from the perspective of physicians. Doctors think differently than computer programmers – for the programmers, the EMR is their life’s work and passion – their entire work day revolves around the EMR. But for physicians, the EMR is just a tool that we use for the larger purpose of taking care of patients. If navigation within the EMR is done just because the program designer liked a similar configuration in the latest version of Fortnite, then it is a downgrade.

For the physicians:

  1. Don’t put your head in the sand and pretend that an EMR upgrade is not coming. The time to learn about the upgrade is not on the day that the upgrade rolls out.
  2. Lighten your load on the first day. If you double book your outpatient clinic or agree to cover one of the other hospitalists’ patients in addition to your own on the morning of the upgrade roll out, you are going to have a very, very bad day. You are better off leaving a few empty outpatient visit slots on your schedule or bringing in an extra physician or nurse practitioner to help with inpatient rounding that morning.
  3. Practice ahead of time. Most EMRs will have a practice version of new upgrades available that physicians can use with make-believe patients in order to get used to the new program before it rolls out. A few years ago, our family took a trip to rural France for a week – before the trip, I got on Google Maps street-view photos and practiced the route that I was going to be taking in the rental car from the train station to the town that we were staying in 30 miles away. I was glad I did because when we got there, I was half-brain dead from jet lag and the train trip so knowing which lane to be in at turns and what the street signs should look like kept me from getting lost in the French countryside.
  4. Take advantage of “superusers”. These are people who have already been trained in the new upgrade – often IT personnel – who wander around the hospital and the clinics for a week or two after an upgrade to assist doctors and nurses in figuring out how to use the new version of the EMR program. In our health system, they wear easily identifiable red jackets and we call them “redcoats”. They can save you time and prevent you from undergoing spontaneous combustion when you can’t figure out where all of the vital sign reports went to.
  5. Take heart, it will get better. In 1969, Dr. Elizabeth Kübler-Ross published her book On Death and Dying and in it described the 5 stage of grief when confronting a terminal illness: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. You are going to go through exactly the same stages when confronting an EMR upgrade. Eventually, you are going to accept it and you might even find that once you get used to it, that you wouldn’t want to go back to the old version. The only problem is that by then, there will be a new version of your EMR and another upgrade.

August 17, 2019

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital