I Like My Electronic Health Record: An Emergency Physician’s Perspective

Jennifer Zacharia, MD

As an Emergency Physician, my shift begins when I log into the Electronic Health Record (EHR) and open the trackboard listing the numerous patients awaiting to be seen. First, I assign myself to a 75-year-old man presenting with shortness of breath. With just a few clicks through the patient’s chart, I gain a comprehensive overview of his medical history including a problem list nine miles long, prior presentations to the emergency room for congestive heart failure exacerbations, outpatient cardiology visits detailing an ongoing plan to titrate his diuretic dose, and prior echocardiograms demonstrating a reduced ejection fraction. As I head towards the patient’s room, EMS wheels in a 57- yearold man with large-volume hematemesis. I pull up the patient’s chart and discover alcoholic cirrhosis listed on his problem list, as well as a prior endoscopy revealing gastroesophageal varies. My focus is immediately redirected.

In the fast-paced and often chaotic setting of the emergency room, the EHR is an important tool that enhances my efficiency in gathering pertinent information to formulate my diagnostic and treatment plan. I always perform a chart biopsy before entering a patient’s room so that I can tailor my history and exam accordingly. I am constantly meeting patients for the first time and have come to expect that most of my patients, particularly in moments of pain, confusion or distress, will not be reliable historians of their own medical histories and medication lists. Fortunately, with instant access to a patient’s prior records and test results displayed in a well-organized format, I am able to gather information and collect data expeditiously. One of my favorite shortcuts is the search function, which enables me to rapidly filter through years of records to retrieve the specific information I need.

The EHR is much more than just a record-keeping system; It enhances safe and effective healthcare delivery through facilitating physician-to-physician communication and collaboration. A shared EHR enables emergency physicians, primary care physicians and specialty care teams to coordinate care by updating and exchanging a patient’s clinical data with each visit. This information- sharing helps to streamline transfer of care, reduce duplicate testing and prevent conflicting clinical advice.

The EHR also facilitates physician-to-patient communication by allowing patients to access their health care records through online patient portals. Patient portals provide the opportunity for patients to gain a better understanding of their medical conditions, review diagnostic studies and adhere to their treatment plans. A major benefit of this accessibility and transparency of information is that patients can be collaborators in their own health care management. Patients may also discover erroneous information in their chart and alert their provider to make corrections. Unfortunately one of the shortcomings of this immediate access to clinical data is the potential for patients to discover grave diagnoses before the provider has a chance to discuss the results and provide counseling. I recall a patient of mine who viewed his CT scan results revealing pancreatic cancer on his smartphone while sitting alone on a stretcher in a busy hallway. I made preparations to bring the patient and his wife into a private family room to deliver the news, but as I approached his stretcher and noticed his eyes glistening with tears, I realized I was too late.

The practice of emergency medicine is a high-stakes endeavor with each patient encounter involving unique circumstances, yet with multiple interruptions to the workflow there are ample opportunities for errors and oversights. The EHR has the potential to reduce medical errors and improve the quality of patient care through integrating clinical decision support (CDS) tools. CDS tools synthesize and present information to the physician at the time of order entry to support clinical decision-making. These tools vary from simple alerts to prevent administration of inappropriate medications to patients with allergies or renal insufficiency, to pop-up windows suggesting an alternative imaging modality to reduce radiation exposure and costs. These tools also include more complex order sets that improve detection and management of specific conditions such as sepsis and diabetic ketoacidosis in accordance with evidencebased guidelines. CDS tools have been effective in increasing emergency physician guideline adherence and improving patient-centered outcomes including reducing 30-day mortality among patients with pneumonia and reducing unnecessary head CTs in patients with mild traumatic brain injury. (1,2,3) A drawback that must be mitigated is pop-up or alert fatigue, which cultivates override behavior and leads to a low rate of utilization of these tools despite positive outcomes.(4) Therefore these tools must be implemented judiciously and reevaluated, taking into consideration user feedback and associated health outcomes.

The EHR is certainly not a perfect system and there are several problems that require resolution, including reducing the time burden for documentation and safeguarding data security. However the EHR has evolved to provide numerous benefits beyond record keeping that have enhanced the efficiency and quality of healthcare delivery.

Jennifer Zacharia, MD is an Emergency Physician and Toxicology fellow at UMass Memorial Health.

References:

1. Patterson BW, Pulia MS, Ravi S, Hoonakker PLT, Schoofs Hundt A, Wiegmann D, Wirkus EJ, Johnson S, Carayon P. Scope and Influence of Electronic Health Record-Integrated Clinical Decision Support in the Emergency Department: A Systematic Review. Ann Emerg Med. 2019 Aug;74(2):285-296.

2. Dean NC, Jones BE, Jones JP, et al. Impact of an Electronic Clinical Decision Support Tool for Emergency Department Patients With Pneumonia. Ann Emerg Med. 2015;66:511–520.

3. Ip IK, Raja AS, Gupta A, Andruchow J, Sodickson A, Khorasani R. Impact of clinical decision support on head computed tomography use in patients with mild traumatic brain injury in the ED. Am J Emerg Med. 2015;33:320–325.

4. McCoy AB, Thomas EJ, Krousel-Wood M, Sittig DF. Clinical decision support alert appropriateness: a review and proposal for improvement. Ochsner J. 2014 Summer;14(2):195-202.