Health Record Systems Affect Patient Care

I started a rotation at San Francisco General Hospital at the beginning of February—my first one there since the summer of 2011. I had been avoiding the county hospital mostly because of the inconvenience of commuting to Potrero Hill from my home in the Outer Sunset, but maybe there was a part of me that had been eluding SFGH because of the constant feeling of inadequacy that comes from trying to provide quality care from within a clumsy healthcare system that seems so implausible in the year 2014.

To summarize record keeping there, progress notes and consultations are done either on paper or are dictated and transcribed a day or two later. Some people put new paper notes at the front of a chart, some at the back. Penmanship varies. The chart itself may be on its appropriate rack or it may be floating around with someone on the floor.

The emergency department, the intensive care unit, standard hospital wings and radiology images are all on different computer systems that don’t share log in information, and there are a host of other special sheets that may or may not need to be filled out depending on whether an order originated from the computer entry system or a printed out set of orders during a patient transfer.

I find the five short beeps setting on my pagers to be the least annoying setting I can count on to wake me up. At 12:42 a.m. I find out the acute care ward is not able to administer insulin to my diabetic patient because I had initialed to continue the insulin order from when she was in the intensive care unit, rather than rewriting the order from scratch. If you were planning on getting to the hospital by 6 a.m., would you drive in right now to fix the order? Would that depend on the nurse’s description of how the patient was doing clinically? Should it?

Our oral surgery clinic functions on a collection of loose-leaf papers stuffed into a folder. Each page has the patient’s information and a date on it, and one copy will eventually be added to their full medical record in chronological order. In real time however, in this patient population that is already complicated for medical and/or social reasons, the arduous process of combing through the pages to find out what patients actually need has almost certainly contributed to errors occurring.

Add to this the fact that just a couple clinicians and a handful of students are treating dozens of patients, the vast majority of whom are miserable and moaning from their pain, and it can be difficult to keep one’s head on straight every moment of the day. The hospital has tried to address the error-prone processes, but this often is done by adding forms and protocols to an already piecemeal system, perhaps addressing one problem but often creating another.

At UCSF’s Parnassus campus, the rollout of Epic/APEX (a unified electronic health record) was not without complication. It took me over two hours to discharge my first patient in the summer of 2012. I’m sure there have been more logistical hang-ups than I could ever know, but I support the dedication to the concept that a hospital should use a single system that is complex enough to meet the needs of its various users and intuitive enough to facilitate its use. I know I’m much more likely to look through everyone’s daily notes, scroll through every image, and think harder about what I write when it’s all in the same place. Further, as many patients seek care both at UCSF and at SFGH, it only makes sense that they should be on the same system.

So what has held us back? I challenge anyone to say it has been anything other than the cost of the upgrade. Someone crunching some numbers has done an analysis that shows that the errors made in the clumsy system are able to be cleaned up for less additional money than the cost of changing everything to the system that would lead to fewer errors in the first place.

The hardworking clinicians and staff at SFGH toil furiously to provide appropriate care to the patients in front of them, but as long as they avoid disasters, a diligent bean counter doing his/her job properly would never be able to justify buying the new system. I hope that during my training here at UCSF, the intrinsic value of smoother care will be quantified in such a way as to help SFGH make the technological leap into the 21st century that the rest of UCSF hospitals have made successfully.