The Unfortunate Therapeutic Myopia of the EMR

There’s a lot you can say about an electronic medical record (EMR).  Some of it is good: it’s more legible than a written chart, it facilitates billing, and it’s (usually) readily accessible.  On the other hand, EMRs are often cumbersome and confusing, they encourage “checklist”-style medicine, and they contain a lot of useless or duplicate information.  But a recent experience in my child/adolescent clinic opened my eyes to where an EMR might really mislead us.

David, a 9 year-old elementary school student, has been coming to the clinic every month for the last three years.  He carries a diagnosis of “bipolar disorder,” manifested primarily as extreme shifts in mood, easy irritability, insomnia, and trouble controlling his temper, both in the classroom and at home.  Previous doctors had diagnosed “oppositional defiant disorder,” then ADHD, then bipolar.  He had had a trial of psychostimulants with no effect, as well as some brief behavioral therapy.  Somewhere along the way, a combination of clonidine and Risperdal was started, and those have been David’s meds for the last year.

The information in the above paragraph came from my single interaction with David and his mom.  It was the first time I had seen David; he was added to my schedule at the last minute because the doctor he had been seeing for the last four months—a locum tenens doc—was unavailable.

Shortly before the visit, I had opened David’s EMR record to review his case, but it was not very informative.  Our EMR only allows one note to be open at a time, and I saw the same thing—”bipolar, stable, continue current meds”—and some other text, apparently cut & pasted, in each of his last 3-4 notes.  This was no big surprise; EMRs are full of cut & pasted material, plus lots of other boilerplate stuff that is necessary for legal & billing purposes but can easily be ignored.  The take-home message, at the time, was that David had been fairly stable for at least the last few months and probably just needed a refill.

During the appointment, I took note that David was a very pleasant child, agreeable and polite.  Mom said he had been “doing well.”  But I also noticed that, throughout the interview, David’s mom was behaving strangely—her head bobbed rhythmically side to side, and her arms moved in a writhing motion.  She spoke tangentially and demonstrated some acute (and extreme) shifts in emotion, at one point even crying suddenly, with no obvious trigger.

I asked questions about their home environment, David’s access to drugs and alcohol, etc., and I learned that mom used Vicodin, Soma, and Xanax.  She admitted that they weren’t prescribed to her—she bought them from friends.  Moreover, she reported that she “had just taken a few Xanax to get out the door this morning” which, she said, “might explain why I’m acting like this.”  She also shared with me that she had been sent to jail four years ago on an accusation of child abuse (she had allegedly struck her teenage daughter during an argument), at which time David and his brothers were sent to an emergency children’s shelter for four nights.

Even though I’m not David’s regular doctor, I felt that these details were relevant to his case.  It was entirely possible, in my opinion, that David’s home environment—a mother using prescription drugs inappropriately, a possible history of trauma—had contributed to his mood lability and “temper dysregulation,” something that a “bipolar” label might mask.

But I’m not writing this to argue that David isn’t “bipolar.”  Instead, I wish to point out that I obtained these details simply by observing the interaction between David and his mom over the course of ~30 minutes, and asking a few questions, and not by reading his EMR record.  In fact, after the appointment I reviewed the last 12 months of his EMR record, which showed dozens of psychiatrists’ notes, therapists’ notes, case manager’s notes, demographic updates, and “treatment plans,” and all of it was generally the same:  diagnosis, brief status updates, LOTS of boilerplate mumbo-jumbo, pages and pages of checkboxes, a few mentions of symptoms.  Nothing about David’s home situation or mom’s past.  In fact, nothing about mom at all.  I could not have been the first clinician to have had concerns about David’s home environment, but if such information was to be found in his EMR record, I had no idea where.

Medical charts—particularly in psychiatry—are living documents.  To any physician who has practiced for more than a decade or so, simply opening an actual, physical, paper chart can be like unfolding a treasure map:  you don’t know what you’ll find, but you know that there may be riches to be revealed.   Sometimes, while thumbing through the chart, a note jumps out because it’s clearly detailed or something relevant is highlighted or “flagged” (in the past, I learned how to spot the handwriting of the more perceptive and thorough clinicians).  Devices like Post-It notes or folded pages provide easy—albeit low-tech—access to relevant information.  Also, a thick paper chart means a long (or complicated) history in treatment, necessitating a more thorough review.  Sometimes the absence of notes over a period of time indicates a period of decompensation, a move, or, possibly a period of remission.  All of this is available, literally, at one’s fingertips.

EMRs are far more restrictive.  In David’s case, the EMR was my only source of information—apart from David himself.  And for David, it seemed sterile, bland, just a series of “check-ins” of a bipolar kid on Risperdal.  There was probably more info somewhere in there, but it was too difficult and non-intuitive to access.  Hence, the practice (adopted by most clinicians) of just opening up the patient’s most recent note—and that’s it.

Unfortunately, this leads to a therapeutic myopia that may change how we practice medicine.  EMRs, when used this way, are here-and-now.  They have become the medical equivalent of Facebook.  When I log on to the EMR, I see my patient’s most recent note—a “status update,” so to speak—but not much else.  It takes time and effort to search through a patient’s profile for more relevant historical info—and that’s if you know where to look.  After working with seven different EMRs in the last six years, I can say that they’re all pretty similar in this regard.  And if an electronic chart is only going to be used for its most recent note, there’s no incentive to be thorough.

Access to information is great.  But the “usability” of EMRs is so poor that we have easy access only to what the last clinician thought was important.  Or better yet, what he or she decided to document.  The rest—like David’s home life, the potential impact of his mother’s behavior on his symptoms, and environmental factors that require our ongoing attention, all of which may be far more meaningful than David’s last Risperdal dose—must be obtained “from scratch.”  If it is obtained at all.

23 Responses to The Unfortunate Therapeutic Myopia of the EMR

  1. Mariam Cohen, MD says:

    The problem in this case is not just the EMR, which seems to function more for fulfilling bureaucratic requirements, but the lack of continuity of care. No matter what you add to his EMR now, if you were to see him again at a reasonable interval, you will remember that the home environment is a problem. If you were working in a real team situation with a therapist, a social worker, etc., you would not just add to the EMR but you would walk over (or pick up the phone) and say, Hey, do you realize this is going on? Should we do something? However, it seems that the only thing the next person in the so-called team will see will be your EMR note.

    • stevebMD says:

      Mariam,

      That’s a very good point. Teamwork is important in any situation– particularly in this one, where the individual actually is receiving additional services. I was able to communicate my concerns to his case manager (as well as write it in the chart) after the appointment. To me, however, it doesn’t excuse the fact that certain salient features of a person’s history really ought to be accessible at the point of service (and to whoever is providing that service), and most EMRs fail at that. Unfortunately, I don’t really have a solution.

      A good analogy is selecting a book to read. When you’re browsing a bookstore, you can pick up a book, thumb through it, maybe read a few passages, look at the writing style, illustrations, index, etc. But when you browse Amazon, you see the cover and a few pages that they choose to give you. Okay, Amazon also provides user reviews, etc., which are valuable; but with an EMR, such niceties just don’t exist…. you have the page on the screen and that’s about it.)

  2. Written records are often just as bad as the EMR’s you describe. I often hesitate to send for records because of how uninformative they usually are. Medications are changed, but no reasons given. Diagnoses are made or changed, but no diagnostic criteria are described. The content of delusions is rarely clarified, and covered with vague words like “paranoid.”

    There is often almost no social history or description of the patient’s home environment.

    For inpatient stays, I usually have to send for the nurses’s note to actually get a full description of the patient’s symptoms and behavior on the wards. Patients diagnosed with mania often have nurses notes from the very first day that say the patient was was sleeping on Q 1 hour bed checks and relating normally to the other patients during the day. Patients diagnosed with major depression are described as having “eaten 100% of meals” and of “socializing appropriately on the ward.”

    • stevebMD says:

      David,

      I agree entirely with what you wrote, including the inconsistencies in inpatient notes and the vague terms used in written records.

      I guess the point I was trying to make was not so much that the notes themselves are necessarily that much better in a paper chart, but that everything is (usually) readily accessible, through the admittedly low-tech procedure of just thumbing through pages. (God gave us thumbs for a reason, after all.) Even with a full, 3-inch-thick chart, you can always find the one or two notes that give some detail that you wouldn’t find elsewhere. Sure, you might miss other notes, but the yield-per-second-of-search is far higher with a paper chart than with even the best EMR.

      Of course, maybe it’s just because we’re in a transition period. Maybe after several years of EMR implementation, they’ll add Google-like search tools to allow us to do context-dependent searches (is that the right term?), such as: “Search David +mom +mother +abuse” or “Search David +'start Risperdal'” and find notes that mentioned these factors together. But given the headaches that I’ve already encountered with numerous EMRs, I’m not holding my breath.

      • I agree with you as well. You just described why I prefer written charts (as well as actual articles and books to electronic documents – although search functions are improving). Much easier to find what you are looking for.

  3. Anonymouus says:

    Dear Dr. Steve,

    As always, you bring up excellent topics with a very caring edge. However, in this instance, I have my reservations. I recently beccame ill due to a trazadone side-effect. I needed to have my insomnia shot down (3 weeks and no need for sleep) and yes, the trazadone made me sleep, but it also made me so blurry eyed and so water retentive that my husband looked at me while we were in Mass a couple of Sundays ago and said “we’re going to the ER”. Of course, there, they can see all the meds I take for bipolar and what I am allergic to. They also think you are a “head-case” because of this and get sub-par treatment. And, to think, that I actually am on committees to raise money for this hospital!

    I have premium insurance but was still charged $450 just to get through the door and God knows what they charged my insurance company. All this because the med made me un-able to urinate and they ultra-sounded over a litre and a half and then catheterized me and told me to drink peppermint tea. Eight hours later I was discharged. This is a disgraceful waste of time and money for use of an ER. I was a model patient yet treated like I could become dangerous at any given time. Psych meds should be priviledged info if this is what is to be expected from a stable and very well insured patient.

    So, yes EMR are useful, but there needs to be some discretion and perhaps a brief narrative attached. I will not forget the treatment I received from a hospital I support and raise money for in the private sector. It was awful that it happened on a Sunday (of course), and it was an unbelievable wake-up call for those less fortunate than I and the treatment they receive and have come to expect.

    I know you have written about the socio-economic dilemma doctors are often confronted with and if I have anything to say, please doctors, treat the patient as a human being, no matter what you read in their EMR chart. This will most assuredly be brought up in our next board meeting as I am still POed about this and can only imagine how bad it would be if I were less priviledged. Thanks for letting me rant and please keep up your timely and worthwhile commentary on the state of psychiatry.

  4. Carol Levy says:

    It is scary that you cannot access more then the one note, at least at a time, and if added at the last minute there is no time to do a note by note search; but it sounds as though the care this child deserved was lacking. Home environment is always a potential issue, esp with a child. Interactions with the others, much less behavior of the caretakers have definitie impact on emotional state and behavior. Surely someone else who had seen this child hopefully would have noted what you. Then of course there is also scapegoating where the child is the designated “crazy”. Steve, he was very lucky he got you.

    • stevebMD says:

      Carol,

      Re: “…he was very lucky he got you.” Thank you for the compliment, but I don’t know whether he actually was lucky. The point is that even if I do include these relevant details, my note goes back into the rubbish pile that is the EMR, and in six months it’s likely to be forgotten.

      What I did do in this case was to notify the child’s case manager and therapist of my concerns, some of which they shared, too. Frankly, I am optimistic for David. But this all happened “off line,” not in the EMR record. My concern is that, going forward, as providers spend less time with more patients, and we spend our appointment times staring at patients’ EMR charts instead of actually interacting with them (here, the Facebook analogy is particularly apt), a lot of these non-quantifiable (yet extraordinarily relevant) factors get ignored.

      • Carol Levy says:

        I have a dry eye situation, from paralysis left face and anaesthetic cornea). I go to the eye doc often, sometimes once a month or more (right now thankfully been good for some time) and I kiddingly say to the fellows who see me, “Just write ditto. It always the same.” since neither my history nor the eye change much from one time to the next (except for getting worse.).
        They have fellows so every year it is someone new who sees me and invariably, now that they have EMR, they tend to miss some of the information. Luckily Ican fill them in,
        Long story but relevant in that each time this child, or any patient in this situation, does have a change of doc at the last minute for one visit, or his case worker gets a new job, as you say they will not have the relevant info, if received “off line” and the client/patinet continues to get bad (inappropriate) treatment as well as label.
        The FB analogy is perfect. It reminds me of some people I know from the support group I started years back for women in pain awareness. They are very nice folk. I like them from what I know on that page about them. Some tell me they love me (as a friend). I am always taken aback that people think they know what they need to about someone, without the face to face interaction, to form these opinions and attachments. Scary when they do it there. Even scarier when treatment protocols are based on it..

  5. Just another anonymous says:

    My main concern is these security breaches that keep happening – someone takes their laptop home from work, it’s stolen, and everybody’s mental health history and other private health info is all over the place. I have kept my mental problems mostly secret, but I know that in a few years, anyone who googles me will find out I have bipolar disorder, and maybe some more stuff, like my history of hospitalizations for it.

    So far, I have not been mistreated for having bipolar, when I am in for general health problems, but then I rarely go to the family doc etc, knock on wood. That is strange that people would be mistreated for bipolar particularly, because when I lived in an urban area, my psychiatrists said that they had college professors and CEO’s etc. as patients. Those people must be getting health care too. Hmmmm. I guess where I live now, there are so many alcoholics, maybe it is a relief when a bipolar patient comes in to the office? Or maybe I am lucky.

    I am going to make one page data sheets for family members, that summarize a lot of stuff, because my husband has macular edema, and his family doc did not know this! Because it was buried in the EMR. It was lucky that I saw in an ad that the diabetes drug he was switched to could not be taken if a person has macular edema, so we called the doc right away. LOL if I ever get to this project. Maybe there are some online that we can all fill in the form.

  6. Mariam Cohen, MD says:

    After some thought, I wonder if the EMR’s could be modified to list what we were taught in medical school — a problem list. So for your patient, the list would always include — Family dysfunction, mother’s drug use — right at the top along with medications that need monitoriing, etc.
    So, when you open the record you would see not only the last EMR note but also the list of problems — and perhaps the last comments from anyone on the time about each of those problems.

    • HelpdeskTech says:

      The EMR used by the hospital I work for contains a problem list that opens with the each patient chart on the first screen.

  7. EMRs?

    The discussion is about EMRs?

    What about a nine year-old being diagnosed with “bipolar disorder?”

    That’s where the dialogue with this post should be directed?
    … Toward the real problem.

    I guess some of you docs are numb to the fact that nine year-olds should NOT be given diagnoses of “bipolar disorder!”

    Never a dull moment online… especially when psychiatrists are involved in the discussion!

    Beam me up!

    Duane

    • Carol Levy says:

      This is the post, EMR’s. I do not recall if another post, say on bipolar, would have been the place for the discussion you want,. Maybe you could nicely ask Steve about posting his thoughts on the subject of child psychiatry and the appropriateness of labels and diagnostic criteria to which then you could add your thoughts about the appropriateness (or not) of these diagnoses.

  8. Keris says:

    EMR’s, EHR’s, PHR’s and HIT oh my!
    You bring up excellent points about the short-comings of medical records in general. As a patient, I’ve read through my paper records in which environmental and social context information is also written. But as pointed out by another comment- I have the same doctor who knows me and has access to the 5 volumes of my paper file. So continuity of care is important. But so is also access by others such as ER who don’t have the 5 volumes or time to read thru them – thumbs or no thumbs.
    What trumps everything (if available – which promotes argument for PHR’s) is the doctors observation, questions and rapid engagement with the person being treated. What can help with EMR’s is the selection of a platform that permits adding fields such as RED FLAGS as well as the ability for the doctor and patient to develop an electronic personal health record that the patient can present as part of their record when seeing a new provider.
    I’d hate to throw the baby out with the bath water on the positive possibilities of the EMR- we just always have to be ahead of the curve on unintended consequences.
    Keris

  9. Altostrata says:

    And when doctors start reading EMRs on their smartphones, their view of the information will be even more restricted and fragmented.

    (Yes, it’s too bad this post isn’t about the little boy’s likely misdiagnosis and drugging for the convenience of his mother.)

  10. Just a tip from a longtime EMR user. Try highlighting the most recent encounter, then holding down the shift key and highlighting the oldest encounter. At that point, the entire group of encounters may open, as it does for me, in one long document that you can rapidly scroll through.

    Of course if what you are scrolling through is just cut and paste and boilerplate, you’ll still have to sift through looking for pearls if they are there.

    Agree there are too many problems with data retrieval from the EMR. Also poor input from docs who don’t take the time to use it correctly.

    I miss flipping through my old paper charts, but admit that even then I missed things. It was my handwritten problem list on the front of my charts that kept me (and my patients) safe.

    Peggy

  11. stevebMD says:

    I appreciate all the comments. Just a brief comment, for those of you still reading.

    Last week I saw a middle-aged gentleman whom I have been seeing roughly every 4 weeks for the last 5 months, after his being transferred to me from a colleague. I won’t give any details here, but he revealed to me a history of childhood sexual trauma which, even though it hardly explains everything he is experiencing today, is a significant factor in understanding the potential origins of his psychological impairments, and might help us to understand his current problem-solving strategies in a much richer context.

    Unfortunately, there is NOWHERE in the EMR to indicate this important new piece of information. It’s not in his intake note (which I was able to find after a few minutes of searching), and if I add it to today’s note it either (a) will not be included in his next note, or (b) will be included, but only as a result of careless cutting-and-pasting (which causes even further problems).

  12. Laura Nathanson, MD says:

    But what’s wrong with the 9 year old’s mother? She sounds as if she has dystonia, athetosis, something physical and weird, that could be genetic or toxic, and either way contribute to the nine year old’s behavior.

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