Lost in Transition: why residents use EMR and the rest of us don't

A large US survey of EMR adoption was published today in the New England Journal of Medicine. It found that "fully functional EMRs" exist in only 4% of practices.

Welcome to medicine in the 21st century: information starvation in the midst of data plenty.

It is still too hard to implement an EMR, and full implementation continues to be the exception instead of the norm. In the NEJM article, younger physicians were more likely to adopt (same as for the Canadian National Physician Survey); perhaps it will be the next generation of physicians who will practice in an electronic office, and not us.

We have two residents who started today in my practice: one starting with my new partner, and another one starting with me and my "old" partner, who is away this week. The new residents will be with us for two years; most of the time, they are in the practice for a half day a week.

Here is what it took to get the residents set-up: a computer for them, a registration in the EMR with permissions set at the Resident level, a log-on ID and a security FOB. I bought a Tablet for residents two years ago, as my department recognized that this was needed for teaching practices, and funded an extra computer for learners. I know how to set up all the basic log-in, so it did not take long, but it still needs to be done by someone (either a physician or a clinic manager). There is extra work for EMR set-up, which does not exist for paper-based practices.

My new resident came at lunch time, and my clinic manager oriented him to the practice; she gave him his security FOB. We logged him on to the resident Tablet, and he set up his PIN. I set his basic chart preferences to make sure that they were the same as mine; I don't know if I have the "ideal" preferences set-up, but it seems to work for me, and I'll be showing him how to use the software.

My resident followed me for the rest of the afternoon. I showed him how to load encounters and CPPs. He took his Tablet in, so that there were two computers in the exam room. He saw how I was using my Tablet, which helped give him a sense of how the EMR works and can be used in a patient encounter. He could also load screens on his Tablet during the encounter, since he had the same electronic chart open as me, but on his own machine.

He saw me touch type while talking to patients, write prescriptions, do a consultation letter while in the exam room, look data up in various areas of the chart (CPP, DI, labs, flowsheets), order labs and Diagnostic Imaging electronically, respond to pop-up alerts and other care reminders, and use e-messaging and Office Actions sent to staff. While he was there, an electronic message came in from our clinical pharmacist via remote access from another site; she had reviewed a problematic case for me and sent some suggestions in the patient's chart. She had also emailed me a relevant article via regular email.

My resident had never been in an office using EMR. He will only use EMR while working with me; there is no choice, since there are no paper charts. I spent at least as much time teaching him the EMR as discussing clinical matters. I don't think that's bad for the first day, since his care will depend on his familiarity with the chart.

On the other hand, he has access to all my saved favourite drugs, all my batched labs, all the CPPs are in the EMR, and drugs automatically go into the encounter. There is also a lot of knowledge in the office about what to do when computer problems happen.

I simply cannot imagine that he will be willing to revert to paper after two years here. Many of our residency teachers affiliated with my hospital have now switched, or are in the process of switching to EMR. We have 8 academic Family Health Teams in Toronto, and these are the teachers of family medicine. Although not all have implemented, three now have (including our FHT); all units have either bought or are considering buying EMRs. I don't know if EMRs are more common in practices that teach, but this is worth exploring. I think many teachers are modeling EMR use for our new physicians.

We get new residents every two years. While one resident will be exposed to the initial pain of transition, the next one will see the EMR at a later stage.

I think many residents will use EMR during their training, and will then start working in practices that have computerized. The rest of us will have far more difficulties.


My practice partner is away this week. He decided to spend the week at home, and use some of his time to catch up with his work. I sent him aan EMR message about whether he wanted me to look at his results during his week off, and he emailed me back (in the EMR, via remote) that he would take care of them. He is now used to looking at the EMR via remote access, and can see all his labs and scanned reports. A student started entering his CPPs as of yesterday. Remote may well be one of the most useful features of the EMR for him.

Michelle