The digital age

A while back, our EMR system went down. It happens to everyone eventually. Servers have downtime, and sooner or later, you have an outage. Sometimes it's brief, sometimes it's long, but without fail, when it occurs, the frustration is instantaneous and furious. And the old guard bemoans how terrible EMR's are, and how they cripple our ability to care. And that is ludicrous. So let's take a step back and remember the days of paper. I remember them well. There are a few wonderful events that everyone who remembers paper charts should recall, and then find themselves resigned to saying that electronic records really are better.

Handwriting is far and away the most obvious issue with paper charts. When I was in residency, there was a cardiologist with such bad handwriting that anyone who could read his handwriting was often called to interpret, whether or not they were on that patient's case or even whether or not they were in the hospital. I have uttered the words, "That loop looks like a H, so I think we should start heparin." I spent a measurable part of my day as a resident simply deciphering the terrible handwriting of other care providers.

Much more troublesome than handwriting was late charting where people would carry around their notes and then insert them into the chart later in the day, or even days later. I got into an argument with a patient before because he was convinced he saw the neurologist, but there was no note from him. Two days later, a chart note mysteriously appeared. Or nurses would chart an entire shift of vitals at the end of their shift. It was so much trouble fighting for the chart that it was just easier to chart your information some other time, and so it was often impossible to get up to date information. And that's not even accounting for paper reports, like labs or x-rays. It wasn't even worth referring to the chart for those. You'd go to the lab database or the radiology database, or if you were supremely unlucky, some poor loser sacrificed his morning by getting curbside reads on all the chest x-rays from the radiologist.

On the devious side, people would sometimes misrepresent their charting by where and how they did their notes. Some people would slip their note in several days beforehand, or date/time their notes to misrepresent when the work was done. I've seen things charted in different sections so that it would likely be ignored by medical/legal but would be safe for billing.

And then there's the missing pages that would inevitably occur, much more terrible in the outpatient setting where you might lose a note from 7 years ago that suddenly you need. However, I remember losing preliminary cardiac cath results so that we had to go down to transcription and put a rush on the dictation, since the cardiologist went home and we couldn't reach him, and needed the report to determine if we could discharge the patient.

But nothing was worse than the missing chart. I have had a student walk off with the chart to the study lounge for 2 hours and we were in full fledged hysterics. I had an intern take the chart to dictate a transfer note and the patient coded, and we had no idea what was going on or anything about the patient. I had outpatient encounters where another clinic was sitting on the chart (another doc hadn't done notes for weeks), and we sent people over to that clinic to get into a chart fight.

Sure I get frustrated with EMR systems that I've worked with. They all have their drawbacks. But thank God we don't use paper charts anymore. What absolute hell.