Realizing EHR potential, or avoiding patient endangerment?

I noted an interesting comment posted in the comment thread of Bob Wachter's post "Putting the “A” Back in SOAP Notes: Time to Tackle An Epic Problem."

The comment by Dr. Christine Sinsky reads (there seems to be no way to link directly to it):

Great post Bob.  Ambulatory records are equally in need of brevity and clarity. These notes are often 6 pages of mostly nonsensical boiler plate, formatted on a billing template, leaving the reader asking your question: “but what is going on with the patient?”

After 10 years with our clinic’s EHR (McKesson HAC) and 9 years with our hospital EHR (Cerner), the most important issues I’ve encountered have been

• The time costs of data acquisition: Remember the graphic on a clipboard at the foot of the bed? It was a concise and convenient source of information that has not been reproduced in our EHR. It is now a laborious process to unearth this same information. I/Os and daily weights have become lost data points.

• The time costs of data input: One night on call I did a time trial on six of my admissions: it took an average of 73 seconds to record the admitting orders on paper vs 17 minutes to enter the same orders electronically. And in the electronic world I find myself at higher risk of forgetting the orders I meant to write, as the rigid sequence mandated by the EHR is not always the logical clinical sequence in my mind, and it requires parking orders in my mind until I finish marching through laborious tick boxes.

• Diminished situational awareness. Nurses, doctors and others have a more myopic view of the patient, as it is harder to see trends and to see the big picture. Nurses may only know the meds and the orders that pertain to their shift for example.

• Barriers to synthesis: I find it harder to synthesize the diverse sources of data for a patient when each data bit is tucked away in hard to reach electronic silos, often down long navigational pathways. Sometimes one has to scroll both vertically and horizontally (without freeze frames, so the column and row headings disappear while you scroll) creating a cognitive nightmare.

EHRs will continue to be an important tool going forward; improved usability and a better alignment with clinical workflows are needed if we are to fully realize their potential.

I thought the bullet list not at all surprising, and added the following comment in reply to amplify an implied but unstated point:

Re: “EHRs will continue to be an important tool going forward; improved usability and a better alignment with clinical workflows are needed if we are to fully realize their potential.”

You just described what could indisputably be called serious impediments to care. 73 seconds to 17 minutes? Loss of easily accessed data on I/O and daily weights? Diminished situational awareness?

Perhaps it’s time clinicians stopped sugar coating their statements with PC [politically correct - ed.] niceties such as "... if we are to fully realize their potential”, and were more forceful with a more apt “improved usability and a better alignment with clinical workflows are needed if we are to avoid patient endangerment.”

Disruptive effects like these, in my view, lend more import towards speaking of the latter than of the former.

-- SS