Play Nice in the EMR

Posted on: March 14, 2013

written by

Edwin Leap, MD

If I'm learning anything from working locum tenens jobs, it's that there is a wide, mind-numbing variety of electronic medical records (EMR) systems in place around the country. At my primary work site, we use Med-Host. Like every EMR, it has some bugs. But having seen other systems in other places, it's clearly a Cadillac product in a great, big car lot of Yugos.

I'm not going to disparage other systems by name. That would be rude and unprofessional. But some of the EMR products out there are simply, well, cumbersome to say the least. In point of fact, while paper charts with check boxes aren't perfect, and don't tell the story very well, they do allow one to move fairly quickly between patients without log-ins, log-outs, screen changes, and endless highlighted, required fields.

My problem with EMR as a whole is that it isn't really designed for the good of the practitioner or the patient. It seems to exist to capture data and expedite billing. Anyone who looks over an EMR-generated chart will find, to their dismay, that the layout makes it very difficult to interpret what happened. Sometimes it makes it difficult to even find the chief complaint in the sea of screening exams, re-examinations, pain scales, and whatnot.

But I digress from my point. If you are going to take a locum tenens job, it is a good idea to learn as many systems as possible, and make that known on your CV. When deciding which doctor to hire, it just makes sense facilities will choose the one who knows the system and will be easier to integrate into shifts.

Furthermore, if it's possible to dictate notes into the EMR system, by all means dictate. It allows you to tell a story, and much of medicine is the recording and interpretation of narrative. If there isn't dictation, and you know how to type, then type as much as possible. I find that it's faster to type a story with the salient details than to sort through all of the redundant check boxes.

The reason for this (and I encourage EMR designers to pay attention) is that the history of present illness usually has boxes for associated symptoms, which contains boxes that are virtually identical. When all is said and done, it can be tough to differentiate between documentation for your physical  and documentation for your history or review of systems. They all look and sound so much alike, in my experience, you can think you've done one, when in fact you've done the other. Especially when tired or very busy, “respiratory: no dyspnea” sounds a lot like “'lungs: no respiratory distress.” I have found it all too easy to confuse them.

Mind you, the complexities of modern medical billing and core measures require some boxes be checked. So learn the critical ones, and make sure you hit them. Things such as the time you saw the patient or the time you ordered the head CT should always be reported. And don’t forget the ever-important, “nurses notes reviewed and I agree” box or the fields that show your lab and X-ray interpretations.

And for those very complex cases, use the hospital dictation system or type some additional notes. By complex, I mean resuscitation, trauma, sexual assault, stroke, and other things requiring meticulous attention to detail.

In the end, you have to learn to be flexible and play nice on the EMR. I know, I know. It's awful.  It makes us into highly compensated data entry clerks. And the developers of these “time savers” frequently seem to have no idea at all what physicians and nurses do, nor do they understand the time constraints we face. But it doesn't seem to be going away. However, if you do locums, at least you get to try different systems and leave behind the EMR programs you hate.

So click away, brothers and sisters. Or scribble on your paper charts. But however you do it, hit the highlights and tell a good story. And learn to make your chart lean, but full of meaning, for the next doctor who looks it over and for the underpaid person coding it.

What are your thoughts on EMR systems? Tweet us @bartonlocums!

About Edwin Leap, MD

Dr. Edwin Leap is an emergency physician who lives and practices in South Carolina. He has worked in the same department for nearly 20 years, and has recently embarked on part-time locum tenens work. He is also a writer whose column, Second Opinion, appears monthly in Emergency Medicine News. In addition, he writes for a regional newspaper and his writing is published at various online sites. He is the author of three books, Working Knights, Cats Don't Hike and The Practice Test, all available in print or electronic format at Dr. Leap is married, and the father of four home-schooled children. You can follow his blog at, where he posts much of his work.

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