Computer Madness: Is Physician Order Entry the Next Big Threat to Resident Education?

Guest blogger, Bradley Carter, MD, shares the challenges of computerized physician order entry (CPOE) and how he refuses to allow this new—and often cumbersome—form of communication and documentation interfere with teaching new physicians. Dr. Carter is first-year Program Director for the University of Oklahoma Anesthesiology Residency Program. If you have any questions for him, please leave them in the comments.

 

Last July, we were forced to make sweeping changes to our curriculum—including losing a rotation—to accommodate the new duty-hour restrictions. When I had a resident two weeks ago, I couldn’t do any teaching because I had to devote every ounce of my attention to computerized physician order entry (CPOE) on our hospital’s EMR.

 

CPOE has been the biggest change I have faced in my career. It has caused many problems, but it’s not going away. Here are some tips that are helping me survive in this new environment:

 

Change your workflow. The age of walking to each floor, finding the chart and completing your note has gone. All the information you need is available on the computer, but you have to know where to look. Finding what I need in the computer to do my note requires complete concentration for me; the worst place in the world for distractions is the nurses’ station. I can complete 95% of my note, either electronically or on paper, remotely—at home, at my office or elsewhere. When I get to the floor, all that’s left to do is talk with and examine the patient and to talk with the nurse. Then, I update and finalize my note and enter orders. Also, I try not to answer my cell phone or return pages until I finish with a patient’s chart since it takes so long for me to find my way again in the computer.

 

The good ole’ days weren’t always good. I figure I am about middle of the pack in handwriting—certainly nothing to be proud of. I’m at the bottom of the pack when it comes to typing. Typing may unmask some poor spellers, but it has already facilitated physician communication. There are certain physicians who have illegible handwriting; I don’t even try to read their handwritten notes. (How dangerous is that?!) Typewritten notes also facilitate “hand-offs” between partners. Sure, you can “cut and paste” meaningless notes from day to day, but it’s embarrassing to duplicate erroneous information. Diligence is required to make sure you are putting out a quality product. Reread your note before signing it. I now take pride in the quality of my notes. That’s something I could not say three months ago.

 

Some things never change. Unfortunately, time spent on medical decision-making has been compressed in the new age. It takes me 60 seconds to determine that my septic, hyperkalemic dialysis patient with GI bleed needs dialysis, vasopressors, antibiotics, Iv Nexium, GI consultation and intubation. It takes me 40 minutes to convince the computer of this. What has not changed is the apprenticeship of medicine and our love of the “great case.” Fortunately, these still exist. Teaching the next generation of physicians links us with physicians hundreds of years ago.

 

Put the computer down. It’s okay to type while a patient is talking to you, but put the computer aside at some point and just listen to the patient. I also religiously honor break time. You have to clear your head for a few minutes every hour or you will become less efficient.

 

These changes were forced up on us. I’m frustrated about it, but I vow not to let it take away from the education of our new physicians.