Scrubbing In: E-records not so easy

It typically takes me about 15 seconds to write a prescription. Last week, it took about 2 minutes. Multiply that by 10. What used to take me 2 minutes, now takes about 20.

What happened? Maricopa Medical Center, where I am working as a rotating resident in Phoenix, rolled out its electronic medical record.

That's right. No more paper. All charts and prescriptions are done in the computer.

Was this good timing or what? I just wrote a column about the value of electronic medical records and their role in making medicine more efficient and cost-savvy. So, in theory, I am a huge proponent of this new way of charting.

But in practice, the electronic medical record can be ugly, especially at the beginning. I knew it right when I walked into the clinic because the IT staff had brought in a box of doughnuts for us doctors and nurses learning the system. A small sweetener for what was to come.

Things were, one might say, a struggle. First off, I turned my computer on but the electronic program called Epic wouldn't start.

We pushed a couple of buttons and finally it came alive.

Then, my login didn't work. Thankfully, plenty of IT staffers were on hand and after a few phone calls, I got into the program.

Next came using the system. This should be a cinch. I'd already had 12 hours of training. Plus I'm from the computer generation. I had an Apple IIe in middle school. I can handle this.

Well, it wasn't so easy. On the main page, several tabs run down the left side, with about a dozen more running up top. Then there are another dozen tabs running behind those original ones. Ahh, the simplicity of the paper chart. I missed it.

Each tab meant something important that I needed to remember. It got easier for each patient, but I was literally fumbling through a dizzying array of options for each chart.

And inevitably, I'd miss some important details.

"Don't forget to click on the box 'mark as reviewed' and then link in your 'smart text' to the final note," my computer trainer reminded me.

"Oh, and you forgot to 'close your encounters.' Please go back and do that for all of your morning patients," she politely told me. Or the clinic wouldn't be able to bill for these office visits properly.

By the end of the morning, I was exhausted and had seen only half the typical number of patients.

All great paradigm shifts have growing pains. I can't imagine that Henry Ford's River Rouge factory pumped out a perfect Model T with slick efficiency on Day 1. The elegance of mass production took time to orchestrate.

Kaiser Permanente, the California-based HMO and hospital organization, has already invested about $4 billion in the electronic health record, but has encountered some serious snafus. On one day in 2006, labs could not collect data, run tests, or provide test results for six hours. Another time, users were unable to check in patients for an hour across the system, causing a gridlock in waiting rooms.

It will take time to work out the kinks and get used to an all-encompassing electronic system. Ophthalmologists, for example, like to draw pictures of the things we see, such as corneal ulcers or retinal detachments.

We now have to click on a button to open up a template to draw on, then click on the pencil for drawing, then pick a color, then click on another button for commenting on the picture. It's a lot of steps compared with picking up a pencil.

But I can already see a lot of benefits. I see many diabetics and always ask them about their Hemoglobin A1C, a number that reflects their average blood sugar over the last three months. It's the rare patient who knows that number. But now that I have access to all of their labs, I can tell what it is with one or two clicks.

My favorite part of the system is e-prescribing. I can click through a prescription and then send it directly to the patient's pharmacy.

But that's not foolproof either. One patient needed a scrip for antibiotic drops for her corneal ulcer. I put one in through the system and it went right to her pharmacy. She arrived to pick it up but the store didn't stock it.

So she had to come all the way back to our clinic. I then went back to my computer and clicked on her prescription and printed it out. Memo to the future: We'll always have paper.