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EMR at the doc office visit today - anon

Posted: Aug 09, 2010

Went in for annual OB/GYN today and saw the NextGen EMR monitors everywhere! NP comes in the room and starts typing, althought it takes her forever to get through screens. I asked about my records from my high-risk pregnancy 10 years ago. She says they will be "somewhere in storage" but will never be assessible at any office visit from now on. What??? I thought that was why EMR was going to be SO GREAT! So we could access our medical records from the past and from anywhere? She said only the past 2 years will be available to access. I can only imagine what someone with a chronic or life-threatening disease is going to have to deal with if that is true.

I guess my huge paper chart is about to be thrown out. Then she says she can't give me my 2 prescriptions today because there is was no MD there to sign for them. Um ok!? She says she can E-scribe it to a pharmacy, but I have to use mail order for which they weren't set up for my mail order company yet and had no idea how to set it up. So no records, no Rx's, only God knows what is in my medical record now. I was trying to read the screen but there was a big glare:(

I finally said I'll come back tomorrow for written and signed Rx's which I will mail in myself the old-fashioned way. She looked very relieved. This EMR has been pushed on them without little training or support. She said transcription is all being done with point and click, and this is a large medical system in our area, so I assume the entire medical system has adopted this NextGen program.

I also explained to her what was going on with offshoring and India. She had absolutely no idea, and she's in the medical field! I swear I don't think even half of the doctors/NP/nurses know what is going on out there.

Sorry for the rant...just had to tell someone my experience who would understand the frustration.

EMR and patient care and doctors - and transcription

[ In Reply To ..]
The EMR-information-gathering can be very inconvenient for both patient and provider. I remember my (resident) family physician hunting for the "2 siblings" option under "family history." Good heavens. Siblings? Male? Number of--? Female? Number of--?

EMR is not a one-size-fits-all program, though. The people who install the EMR system work with the doctor and staff to decide what information is available on the menus. Sometimes, in their effort to include every possible option, they over-complicate the process of inputting information. On physical exam-- Ears-- there's a problem-- left or right? TM or canal? Mildly, moderately, severely? Swelling, erythema, exudate? So if anything is OUT of the ordinary on exam, you can painfully narrow down your choices until you have pinpointed the problem. Left ear canal mildly edematous, without exudate. Whew! EMR for providers, may be like VR for us-- they are thinking "cripes, it would be easier just to type it in." We are thinking, "cripes, it would be easier just to type it in." However-- I do think EMR always includes a "free text" option for variations from the template, i.e. the left ear problem.

The OP's question about the old records is true. EMR makes everyone dependent on it, not always in a good way. How many times (in the hospital) have I heard a doctor dictate, "The EMR is down, so I do not have information about her admission medications." It is scary. EMR seems to go down a lot, at the large clinic where I worked, and at the hospital. It seems to go down, in fact, WAY more often than an essential lifeline of healthcare information should go down. In that way, it is not only blocking access from past records (at the hospital, everything before 2003 is gone from the records)-- but it blocks access from current information-- at random times and with no predictability. Just when the doctor needs to find out, "What dose of beta blocker is this lady on--" Poof. No information at all. No backup records. Doc, check back in half hour or so, it may be up by then, we are working on it. So many overhead announcements at the hospital, that we transcriptionists could ignore, but I was sure were wreaking havoc on the medical floors-- in a nutshell, "For the next hour, or until further notice, you will be seeing inpatients and doing consultations with no information from their medical record. We are working on the problem and will let you know when it is resolved." What can the docs do? They're not making the switch-to-EMR decisions, they're not involved in IT. They just need the records to be there, and the records disappear spontaneously from time to time.

Of course, the benefits of EMR outweigh the disadvantages. ("John, this record shows that you were seen at ABC Hospital, 70 miles away, just two days ago, and you received 30 Percocet. Now you are coming here with the same complaint, and asking for the same medication...")

But, as OP pointed out, EMR has big disadvantages. Old paper records are the same as no records at all. If there is not a huge effort made to transfer the information from paper to EMR (which often does not happen), the history just disappears into old dusty stacks, never to be seen again.

Old records - Aspiring coder

[ In Reply To ..]
Those old records can be scanned and included in the EMR if anyone wanted to take the time to do it. It's no different than having things on microfilm, don't know if you remember those days, it's always been a storage issue. I think the statute of limitations is 7 years for retaining hospital records, I'm unsure of clinic/outpatient records. You seem surprised that a CNA or MA would not be aware of outourcing to India. Quite a few of them probably have no idea about what goes on in MT and I really wouldn't expect them to. I don't know what they do either but I doubt they'd be offended or surprised. It's going to be a while before EMR gets sorted out and runs smoothly, if ever. Coders are working hard to get up to speed as well.

Been using EMR for years - actually nice for me

[ In Reply To ..]
My records are right there on the screen, quick to pull up, and my rx's are sent to the pharmacy right away. All my referral stuff is there where he can see it. Pretty nifty, really. Sounds like your office is just learning how to use it.

I know many in a major hospital who have been - using an EMR system for months and hate it

[ In Reply To ..]
... they have no choice but to use it since the hospital spent millons on the thing, but it is very disliked, goes down at times, and slows down everything for them. I have heard of no one who appreciates the system there, no one.

Mine didn't like it at first, but - they do now.

[ In Reply To ..]

EMR - Tara

[ In Reply To ..]
I have had a couple bad experiences already and of course it seems even worse for me because of the line of work I'm in. I went to a fairly busy clinic to have my 2-year-old son seen by a specialist and he comes into the room late, as is usual for doctors, BUT then sat down and was pointing and clicking the whole time while asking questions. Rarely looked at me. It took ten times longer than it would have if he were taking notes. Not much fun with a 2-year-old and a 2-month old in tow. It took an hour and a half for an appointment that should have taken 15 minutes because it took him so long to type everything, chicken pecking of course. UGH!!! Rewind about a month previous and I had had my son at the emergency room at 2:00 a.m. and of course it was taking forever and he was crying and I had my other kids with me as well and the nurse comes into the room and tells me that I will have to wait to be discharged because their computer system is down. I had already been there for an hour. Like heck I'll wait. I told her I didn't care if she had to handwrite the discharge papers, but I was not waiting for the computer system to come back up at 3:00 a.m. with 4 kids sitting there waiting to go home to go to bed. Ugh how is everything accessible anyway? Can you tell me that if a patient goes to the hospital for a suicide attempt that they can pull up the records from their mental health clinic visits? I highly doubt it, that would be a HIPAA violation. The same person is responsible for sending records to a facility when needed as they were with paper records. I don't see how this is efficient or helpful at all. If the reports are typed on the computer, that makes them electronic. Get rid of these job stealing, time consuming, unpersonable, and unreliable systems ASAP before someone ends up dead due to computer error!!

wait, you are just Guessing your paper chart will be thrown out? - why would you think that?

[ In Reply To ..]
of course we still have paper charts stored in Medical Records. Nobody is going to transfer everything in our paper chart onto the electronic file, and our paper medical records are not just going to be thrown away. Exactly where did you get that idea from?

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