The current issue of the Journal of the American Medical Informatics Association (JAMIA) contains some studies showing some very positive outcomes related to electronic medical records (EMR’s). But it also contains one study that verifies a feature of the EMR we find disturbing and potentially a setback in time. We have lamented in the past that one of the drawbacks of EMR’s is that they often don’t allow the “big picture” to be readily conveyed to everyone (see our August 26, 2008 Patient Safety Tip of the Week “Pattern Recognition and CPOE”). Now there is another feature commonly encountered in the EMR that is a throwback to a prior era.
The article in this month’s JAMIA we are referring to is one that looked at who writes notes in the EMR and, more importantly, who reads them (Hripcsak 2011). The authors used the detailed audit logs of EMR’s to determine the frequency of notes by various members of the healthcare team, the time spent entering such notes, the frequency with which those notes were accessed, and the distribution of types of healthcare workers accessing those notes. They found substantial variation by user type in the time spent entering notes into the EMR. Overall, most users averaged less than 90 minutes per day authoring notes and 30 minutes per day viewing others’ notes.
But the most striking numbers deal with viewing the notes. While attending notes and resident notes were viewed 97% and 99% of the time, that was not the case for notes authored by other members of the healthcare team. In particular, fewer than 20% of nursing notes were read by attendings and residents and only 38% of nursing notes were read by other nurses. Note that nurses have several other means of communicating with each other (standardized handoffs, etc.). Hopefully information from nursing was also communicated to physicians when nurses are included in daily rounds as well.
And 16% of all notes were never read by anyone!
This seems like a journey into the past! For the longest time, hospitals were divided in how they partitioned the medical chart. Some hospitals kept notes by physicians, consultants, nurses, therapists, dietitians, etc. segregated from each other whereas other hospitals intermingled all the notes in the “progress note” section. We can recall medical staff meetings where some disgruntled physicians indignantly ranted “I’m not interested in seeing the *#!&ing social work note”. Generally, as the value of teamwork became increasingly appreciated and a culture of safety adopted, most organizations migrated toward the “intermingled” model.
But with the advent of the EMR we have seen a trend back to the “partitioned” model. The statistics above mean that most physicians seldom read notes by anyone other than physicians. No wonder we have so many adverse events where communication breakdowns are identified as root causes or contributory factors.
Some of the problem may be related to the “newness” of the EMR. Most EMR’s do allow some degree of customization of what is displayed and how and where it is displayed. So a user might choose to keep all clinical notes together or to sort them by provider type. In some cases, the “default” setting is the partitioned one and the physician may not even realize he/she can choose the intermingled model.
And, of course, we really have no idea of how often notes were read in the paper chart. Just because the notes of various healthcare workers were intermingled does not mean they were actually read. Undoubtedly some physicians were blind to the notes above their own daily progress notes if they were written by someone other than themselves. We know that from reviewing charts and seeing notes that omitted important information from those previous notes or even contradicted what was in those previous notes. But we also know that physicians are generally more likely to read nurses’ notes (or notes of other healthcare workers) if they are intermingled with their own notes.
The Hripcsak study only looked at specific “notes” in the EMR. It did not assess the frequency that users looked at graphically represented information such as vital sign charts, I&O charts, or other flow charts. We’ll bet you’d be surprised at how few times those are accessed in the EMR as well.
Aside from the impact on teamwork and quality and patient safety, think of the potential liability issues from failure to read nursing notes on your patients. “Doctor, why didn’t you know the patient was complaining about ___? The nurse’s notes clearly state he complained about ___ daily.” Try explaining that to a jury in a malpractice hearing!
In the Hripcsak study there was also a disparity between medical residents’ perceptions of the time they spent documenting in the EMR and that which was recorded by the audits. Whereas two thirds of medical residents in surveys felt they spent over 4 hours daily writing chart notes, the audits found they spent about 65 minutes per day on average entering medical notes into the EMR.
So while the audit tools were incorporated into the EMR’s primarily to provide surveillance for HIPAA privacy-related issues, they do provide other potentially valuable information about our daily workflows and interactions with other members of the healthcare team. It’s even conceivable that someday we might be able to use parameters like those in the Hripcsak study as proxies for measures of “teamness”.
We are concerned that such a potentially valuable innovation as the EMR might inadvertently be causing a regression to an old model that denigrated the value of the entire team. The EMR should theoretically improve communication between healthcare workers, not create barriers to such communication. Designers of EMR’s need to consider ways to string together multiple progress notes from various healthcare workers in a correct time sequence. Most current EMR’s typically require the user to click into one progress note, then click out, search for another note and click into that note. That obviously reduces the likelihood that one user will look at the notes from other members of the healthcare team.
We encourage you to take a look at the way clinical documentation is displayed in your EMR and whether you can change that display. Also consider using your audit tools to see how often each member of your healthcare team pays attention to the work of other members of that team.
Hripcsak G, Vawdrey DK, Fred MR, Bostwick SB. Use of electronic clinical documentation: time spent and team interactions. JAMIA 2011;18:112-117