A Country Doctor Writes:

(A tedious topic)

“Then it’s me and my machine
For the rest of the morning,
For the rest of the afternoon
And the rest of my life.”

“Millworker”, James Taylor

It’s Friday afternoon, 4:30. I am sitting in front of my computer. My last patient is gone, my prescriptions are done, my messages answered, my office charges submitted and my office notes completed. Now it’s time to tackle the incoming laboratory results.

Opening up the list of completed comprehensive chemistry profiles, my heart sinks. As usual, out of 20 or so CMPs, every single listed patient name is red, which means they all have abnormal results.

My EMR displays results in three colors. Unreviewed normal results are blue, abnormal ones red and anything already signed off is black.

But abnormal is only statistical; there is no distinction between clinically insignificant results and clinically critical ones.

A high creatinine means kidney failure, but a low one is good news. A high CPK means muscle damage, but an extremely low one means nothing. My million dollar system doesn’t make any distinction. Because laboratory normals are defined as the statistical mean value plus-minus two standard deviations, the average patient has one abnormal result in each 20-item chemistry profile or complete blood count. That means a red alert is the rule, rather than the exception on every provider’s computer desktop.

As I and every other doctor click through all the meaningless red alerts in our “orders to sign off”, our senses are sometimes dulled by all the false alarms and we run the risk of missing clinically significant abnormal results.

A peculiarity with my EMR is that the color coding of test results only works in a window that displays three values at a time (only one if I log in remotely from home), so I am forced to scroll my way through each profile to find the abnormal values.

There is a full-screen result window, but it is several clicks away from and back to the Sign-off button, and comes only in black on white. It takes even longer to use.

As I glance at the numbers and the patient’s name, my right index finger is ready to move the trackball and my right thumb clicks the scroll down and Sign-off buttons again, again, again. But, as I click away, I suddenly register that a patient’s calcium level was way off – who was that? There is no “back” button. The moment, and the abnormal value, are both irretrievably lost.

I wish there was a way to go back and double check items I just signed off, a work list made up from what I just did. I wish there was a color only for clinically important results. I wish there was a way my nurse could place more important results near the top of my list.

I wish my EMR had a more clinical feel and less of an accounting one.

I wish my system made it faster and safer to review results, instead of slower and more hazardous.

I guess I just got a touch of the blues, seeing all those meaningless red numbers.

James Taylor, further along in his song, “Millworker” continues to paint the picture of alienation:

“I’m waiting for a daydream
To take me through the morning.”

Well, here is my own daydream about the machine at my work station:

I imagine a better machine, one that shows me the information I need in order to best use my skills to care for my patients. I imagine a machine that shows me results with clinical significance before it shows me the statistically abnormal ones with unlikely significance. If a patient usually has a creatinine of 1.6 and suddenly it is 3.5, that means a lot more than if it goes from 1.6 to 1.5, even though it is still abnormal. Simpler computer programs than an EMR can handle such logic, so why not EMRs?

I imagine seeing a whole chemistry profile in one screen shot, and I imagine the patient’s next appointment displayed right next to the results panel, so I don’t have to click my way over to the next appointment screen. I imagine when I open up a patient’s “chart”, that all new and pending information is visible in the same screen as my office note. I imagine a system that makes my job easier every step of the way. I imagine a system as intuitive as a smartphone.

Interesting thought….I imagine Apple and Google entered the EMR business. Now that’s a daydream with potential.