Interpreting the Electronic Medical Record Pitfalls, Advantages and Risks. Alan L. Nager MD, MHA Children s Hospital Los Angeles

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1 Interpreting the Electronic Medical Record Pitfalls, Advantages and Risks Alan L. Nager MD, MHA Children s Hospital Los Angeles

2 No Financial Disclosures $ $ $ $ $ $ $ $

3 NOT a Lecture on: Pitfalls of billing A lecture on HIPAA issues Comparison of paper vs EMR One EMR system vs another

4 Lecture is on: The meaning behind the ED Electronic Medical Record

5 Clinician Process

6 Decision-Making Process Medical education has always been focused on content, rather than medical decision making BUT now Clinical reasoning Medical problem solving Diagnostic reasoning Critical analysis Bias reduction

7 Watch out for Cognitive Errors Faulty hypothesis generation failure to consider the question and/or if the data fits Faulty context formulation hypothesis is too narrowly focused; may be related to lack of knowledge and experience Faulty information gathering and processing - Is the problem common or uncommon - Anchoring: reliance on insufficient information and making decisions too early - Vertical line failure: failure to consider other diagnoses with same symptoms

8 Cognitive Errors (cont d ) Premature closure: failure to consider reasonable alternatives after the initial diagnosis is made Faulty verification: failing to use a final check to ensure causal relationship - If the diagnosis doesn't fit, don t use it! - Can be altered by physician fatigue, inability to access data, end-of-shift rush, cost considerations, reliance on others, inadequate or lack of communication, etc.

9 A thorough and detailed process MUST be in sync with ALL the components documented on the EMR (not partial, sort of, almost, close to )

10

11 EMR Documentation Garbage in Garbage out

12 Published Issues EMR s provide improved safety and quality and better outcomes for patients EMR s are vulnerable to crashes and need for repairs Systems are not designed for individual complex patients - systems are made for the masses No one reporting system to track problems, shortcomings and pitfalls with the EMR

13 Published Issues (cont d) Institute of Medicine (IOM) has recommended that all software manufacturers be required to report deaths, serious inquiry or unsafe conditions related to information technology EMR technology is being pushed without patient notification or consent, raising ethical considerations EMR s makes it too easy to come to conclusions without demonstrating the thinking process

14 Benefits Readable Can be learned More efficient More accessible Less expensive

15 Benefits (cont d) Accurate billing Track trends QI tracking Searchable

16 Benefits (cont d) Research options Editable note Triggers warnings Multiple users

17 Detractions Timeconsuming Poorly designed Lack of organization General templates Downtimes

18 Detractions (cont d) Stimulus overload Human slowdown Long fix-it time Visible to others

19 Detractions (cont d) Cyberhacking Timestamped entries Technical glitches Note bloat

20 Personal Factors Influencing Risk Time constraints Template efficiency Acuity of patients Electronic agility Baseline knowledge Linguistic clarity Consult notes Notes on wrong patient

21 Personal Factors (cont d) Missing records e.g. arrest RN-MD inconsistencies Incomplete orders (fluids, etc.) Pharmacy mistakes Handoff errors All systems negative Ignoring alerts Non-chronological notes Process not translated to EMR

22 Personal Factors (cont d) Reliance on trainee notes No or incomplete progress notes NOT PROOFING EMR

23 System Factors Influencing Risk System does not eradicate human error (omissions, deviations or failures) System limitations, such as: no max drug doses, no fluid limits Difficult to determine clinician entries if multiple Issues related to sudden downtime Difficulty if supervising/documenting trainees work Drop-down menu not always accurate

24 System Factors (cont d) Reliance on templates, but risk with free texting Risk on pediatric patients using adult templates Not all systems incorporate labs, vital signs or nurses notes System does not highlight abnormal results System may be logical but not medically friendly Some documents may not be electronic (DNR, AMA, consents, arrest records)

25 System Factors (cont d) Person, not system must integrate all documents System doesn t demand timely notes Can use copy/paste which carries risk System doesn t know who is typing on an open computer EMR s DON T PROOF ONLY HUMANS DO

26 Risk Management Risk management refers to strategies that reduce and minimize the possibility of an adverse outcome, harm or loss Risk management techniques improve patient care, consider safety and reduce the chance of an adverse outcome or malpractice claim

27 Let s Play What s the legal risk???

28 Simple Risk Errors Adrenoleukodystrophy - S P BMT Diagnosis: Altered mental state Chronic Back Pain Diagnosis: Lower back pain Lumbosacral disc herniation Osteoporosis Discharge Instructions: Ice Inguinal Hernia Gastrointestinal: Soft, mild tenderness to palpation in periumbilical area and RLQ. No guarding. Genitourinary: Normal

29 Simple Risk Errors (cont d) Lethargy - Intubated General: Alert, in respiratory distress Cardiac - 3 Surgeries Cardiovascular: Regular rate and rhythm. No murmur or gallop. Normal peripheral perfusion and pulses Anaphylaxis ROS: Allergy/immunologic symptoms: no seasonal allergies

30 Simple Risk Errors (cont d) Liver Transplant - Sepsis Rationale: Given history and exam, will d/w with liver transplant prior to obtaining labs Incomplete History History of Present Illness The patient presents with abdominal pain. Additional pertinent history: 24 hours of abdominal pain in RLQ, vomiting, anorexia, fever

31 Simple Risk Errors (cont d) Chronic Dx Diagnosis: Viral URI with cough *Sickle cell disease/fever Sepsis - Lethargic General: Alert, appropriate for age Cooperative, smiling, well appearing

32 Simple Risk Errors (cont d) Vital Signs x 1 (6 mo old) Temperature Route Temperature Heart Rate Respiratory Rate Systolic Blood Pressure Diastolic Blood Pressure Mean Arterial Pressure Oral 36.9 deg C 83 bpm 18 breaths/min 111 mm HG 64 mm HG 80 mm HG

33 Case 1 5 y/o autistic male with abd pain 1 day F 1 day. Pain is periumbilical, left lower quad, no D, dec po with adequate UOP 38.5, 149, 22, 108/72, exam normal Rationale: patient presents with V, needs UA to R/O UTI Dx: Vomiting, viral syndrome Patient returned and had surgery

34 Case 2 4 y/o with complex history, presents with cough, wheezing and difficulty breathing. Patient has hypoxic ischemic encephalopathy with resultant spastic quadriplegia, trach, etc. Exam multiple finding; 28 diagnoses Summarized medication list includes 36 medications including clonidine 100 µg per/ml suspension 0.4 mg GT, TID Pt admitted for pneumonia and respiratory distress

35 Case 3 15 y/o presents with pancytopenia, rash 2 days, sore throat. Previously seen in hematology clinic and evaluated for lab abnormalities. Working diagnosis there was nutritional etiologies. Plan for possible bone marrow aspiration in the future Exam 39.3, 110, 18, 104/71 with mild abnormalities WBC 2.5, Hgb 10, platelets 30, other lab findings Consulted Heme. Will have follow-up clinic visit

36 Case 4 9 y/o presents with abdominal pain and constipation x 4 days. PMD gave Colace but didn t use it. No F, N, V, D, dysuria, but urinating more,? weight loss. Good appetite, no weight loss Exam 36.8, 90, 24, 99/69 RLQ tenderness UTI, appendicitis workup Dx: Constipation (treated in ED) Home with miralax and follow-up

37 Case 5 15 y/o with high-grade osteosarcoma, left humerus, discharged yesterday after chemotherapy of cisplatin, doxorubicin. Patient has V x20 and abdominal pain, no F, not able to keep down fluids, UOP 1 Exam 36.6, 86, 18, 101/70, very dehydrated Obtained labs, 60ml/kg IVF, discussed with oncology Sent home but returned with complications

38 Case 6 3 mo, 52 day NICU stay, twin gestation; cough wheezing and respiratory distress. Shortly after arrival unresponsive with cyanosis. Exam 39.2, 122, 16, 54/22 unresponsive but perked up with oxygen. Rhonchi and wheezing on lung exam. Difficult IV access, plan to intubate and transfer Intubation challenges

39 Case 7 11 mo presents with F 4 days, D 3 yesterday, no V, one of his testicles look swollen when crying, UOP normal. Exam 37.4, 124, 30, 96/52 mild dehydration Oral fluid tolerated, negative UA, sent home Dx: Viral syndrome, diarrhea Oncology information obtained 2 days later

40 Case 8 3 yo with ADD, severe tantrums on tegretol, clonidine and risperidone presents with 1.5 weeks headache, F, URI, drinking well, acting normal Exam 38.3, 110, 20, 110/66 alert active running around Decision to do labs, LP and admit for observation 2 days later, falling, unsteady gait, HA s Transferred for definitive diagnostic workup

41 Risk Reduction Strategies Educate users on EMR risks Develop quality improvement (QI) program directed toward EMR case evaluation Publicize analysis of cases regarding deviations, omissions and discuss learning points Teach critical analysis regarding cases Provide data trends to end-users

42 Risk Strategies (cont d) Provide intermittent feedback and updates. Easy to fall back into old documentation habits Conduct general risk management training sessions for all EMR users and test risk knowledge

43

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