E-Patient Update: When EMRs Make A Bad Process Worse

Posted on August 14, 2017 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Last week, I wrote an item reflecting on a video interview John did with career CIO Drex DeFord. During the video, which focused on patient engagement and care coordination, DeFord argued that it’s best to make sure your processes are as efficient as they can get before you institutionalize them with big technology investments.

As I noted in the piece, it’d be nice if hospitals did the work of paring down processes to perfection before they embed those processes in their overall EMR workflow, but that as far as I know this seldom happens

Unfortunately, I’ve just gotten a taste of what can go wrong under these circumstances. During the rollout of its enterprise EMR, a health system with an otherwise impeccable reputation dropped the ball in a way which may have harmed my brother permanently.

An unusual day

My brother Joey, who’s in his late 40s, has Down’s Syndrome. He’s had a rocky health history, including heart problems that go with the condition and some others of his own. He lives with my parents in the suburbs of a large northeastern city about an hour by air from my home.

Not long ago, when I was staying with them, my brother had a very serious medical problem. One morning, I walked into the living room to find him wavering in and out of consciousness, and it became clear that he was in trouble. I woke my parents and called 911. As it turned out, his heart was starting and stopping which, unless perhaps you’re an emergency physician, was even scarier to watch than you might think.

Even for a sister who’d watched her younger brother go through countless health troubles, this is was a pretty scary day.  Sadly, the really upsetting stuff happened at the hospital.

Common sense notions

When we got Joey to the ED at this Fancy Northeastern Hospital, the staff couldn’t have been more helpful and considerate. (The nurses even took Joe’s outrageous flirting in stride.)  Within an hour or two, the clinical team had recommended implanting him with a pacemaker. But things went downhill from there.

Because he arrived on Friday afternoon, staff prepared for the implantation right away, as the procedure apparently wasn’t available Saturday and Sunday and he needed help immediately. (The lack of weekend coverage strikes me as ludicrous, but it’s a topic for another column.)

As part of the prep, staff let my mother know that the procedure was typically done without general anesthesia. At the time, my mother made clear that while Joey was calm now, he might very well get too anxious to proceed without being knocked out. She thought the hospital team understood and were planning accordingly.

Apparently, though, the common-sense notion that some people freak out and need to be medicated during this kind of procedure never entered their mind, didn’t fit with their processes or both. Even brother’s obvious impairment doesn’t seem to have raised any red flags.

“I don’t have his records!”

I wasn’t there for the rest of the story, but my mother filled me in later. When Joey arrived in the procedure room, staff had no idea that he might need special accommodations and canceled the implantation when he wouldn’t hold still. Mom tells me one doctor yelled: “But I don’t have his records!” Because the procedure didn’t go down that day, he didn’t get his implant until Monday.

This kind of fumbling isn’t appropriate under any circumstances, but it’s even worse when it’s predictable.  Apparently, my brother had the misfortune to show up on the first day of the hospital’s EMR go-live process, and clinicians were sweating it. Not only were they overtaxed, and rushing, they were struggling to keep up with the information flow.

Of course, I understand that going live on an EMR can be stressful and difficult. But in this case, and probably many others, things wouldn’t have fallen apart if their process worked in the first place prior to the implementation. Shouldn’t they have had protocols in place for road bumps like skittish patients or missing chart information even before the EMR was switched on?

Not the same

Within days of getting Joey back home, my mom saw that things were not the same with him. He no longer pulls his soda can from the fridge or dresses himself independently. He won’t even go to the bathroom on his own anymore. My mother tells me that there’s the old Joe (sweet and funny) and the new Joe (often combative and confused).  Within weeks of the pacemaker implantation, he had a seizure.

Neither my parents nor I know whether the delay in getting the pacemaker put in led to his loss of functioning. We’re aware that the episode he had at home prior to treatment could’ve led to injuries that affect his functioning today.  We also know that adults with Down’s Syndrome slip into dementia at a far younger age than is typical for people without the condition. But these new deficits only seemed to set in after he came home.

My mother still simmers over the weekend he spent without much-needed care, seemingly due to a procedural roadblock that just about anyone could’ve anticipated. She thinks about the time spent between Friday and Monday, during which she assumes his heart was struggling to work “His heart was starting and stopping, Anne,” she said. “Starting and stopping. All because they couldn’t get it right the first time.”