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Archive for June, 2010

The Electronic Medical Record–What It Should Be, and What It Isn’t

Posted by MDViews on June 12, 2010

Doctors, hospitals, small and large software companies have tried to tap into the large medical market since desktop computers became available, but with grumbling and resistance from doctors, the most important users of the medical record. Now the government is giving billions to doctors who adopt electronic charting. But why the resistance? Why the billions needed for “encouragement?” Doesn’t the electronic medical record (EMR) have huge pluses?

As an aside, allow me to throw out a few myths about the EMR.

Myth #1. EMR’s save money over paper records. They don’t. In fact, they are much more costly than paper records. Software, hardware, networks, IT professionals, upgrades of hardware and software on a regular basis cost money and continue to cost money. It’s the gift that keeps on costing.

Myth #2. EMR’s prevent errors that would occur with paper charting. Wrong again. The only consistent error prevention from EMR’s is the transmission of doctors orders. The EMR’s have been shown to be more error-prone in several other areas. Also, if an erroneous entry in made in a patients chart, it spreads at the speed of light and can be difficult to find and eliminate.

Myth #3. EMR’s are more efficient. No. Doctors are less efficient with an EMR and can see fewer patients.

Myth #4. EMR’s improve coding of doctor and hospital visits. That coding for more complex visits increases with the EMR is noticed by all companies who have adopted and EMR. They think it means “better capture” of what the doctor has seen, heard and done. Wrong. Doctors, at least what I’ve seen, do no more than before, but, with preformatted templates, information can be added to the note with a click, information not seen, heard or done at the visit. Higher code charged. More money. Sweet. I call that invisible fraud.

There are more, but I’ll stop there.

Many are convinced doctors resist change because they are old-fashioned, don’t like computers, are slow to adopt new technology and, by golly, just don’t like change. In fact, when a large medical corporation adopted outpatient computer charting, the software company told administration the doctors would complain, but just smile and nod because they would get used to it. But doctors are not afraid of new technology and certainly not afraid of change. Doctors love change. Doctors pounce on change. New medicines, new procedures and new technology are adopted quickly. Robotic surgery, new classes of antidepressants, acid inhibitors, online continuing education, webinars, computer viewing of scans, x-rays and MRI’s, new surgeries for treating incontinence and heavy bleeding, minimally invasive surgery—none of these available when I started practicing! Many doctors are computer nerds like me. So why resist the EMR? Well, it’s because the EMR does poorly or not at all the important parts of doctoring crucial for good patient care. Then, what should the EMR do that it doesn’t would be the obvious question which I will answer from my perspective.

My notes should be a narrative. My notes are a story, your story. I listen to your story and from your story eventually reach a diagnosis. I probe the present illness. I obtain past history and review your medicines to see how it affects your present illness including medicines and previous or current medical problems. I ask about family and personal history including stresses, work environment, family situation, smoking, alcohol if needed. I ask about the other organ systems to find other clues. I concentrate on the problem area with the physical exam, which may be cursory or extensive, depending on possible diagnosis. I may order blood work, scans or even perform procedures and then put that all together to make a diagnosis. But people are complicated and each person unique and a diagnosis often uncertain and elusive. In such a situation, I may put “Rule out” several diagnosis because of uncertainty. Lack of a focused narrative makes a correct diagnosis more difficult to reach. You, my patient, may end up with the wrong diagnosis without the narrative.

The EMR loses the narrative unless I type it or dictate it, just like I did before computer charting. But with the EMR, a focused, concise story is difficult and so is not done or poorly done. The EMR doesn’t allow questionable diagnosis because diagnoses with the EMR are concrete statements without reflecting the uncertainty which is often present. The doctor’s thinking becomes difficult to discern. EMR templates tend to be wooden, inflexible, boilerplate documents often with limited or absent narrative which frequently bring in extraneous data I don’t need and leave out important data I do need because it doesn’t fit the template. I’m not the only one who thinks this way. As Gordon D. Schiff, M.D., and David W. Bates, M.D. in the March 19, 2010 issue of the New England Journal of Medicine (NEJM) state,

…EHRs [electronic health record] can foster thoughtful assessment is by serving as a place where clinicians, together with patients, document succinct evaluations, craft thoughtful differential diagnoses, and note unanswered questions. Free-text narrative will often be superior to point-and-click boilerplate in accurately capturing a patient’s history and making assessments, and notes should be designed to include discussion of uncertainties. Documentation of clinicians’ thinking must be facilitated by streamlined text-entry tools such as voice recognition.” [I use voice recognition]

I couldn’t agree more.

My care for you is complex and the medical record should reflect the complexity of my thinking. To say medical care is complicated would be a huge understatement. Medicine is possibly the most complicated human interaction there is. The decision tree I intuitively use to reach your diagnosis boggles the mind in its complexity and size. There is no efficient template for that. Even a focused questioning and exam can go multiple directions and lead me to evaluate several areas at once, each with their own complexity. Templates are a clunky, inadequate, sometimes misleading and poor substitutes to record the multiple roads my thinking travels before reaching a diagnosis.

My care for you should be private. Very private. You tell me things about yourself you don’t even tell your family or spouse. I agreed to follow an oath, the Hippocratic Oath (most doctors now follow a code of conduct) to keep your information private. In the old language of the Hippocratic Oath,

“Whatever I may see or hear in the course of the treatment or even outside the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.”

This oath, this vow is at the very core of medical care. Without the trust you put in me to keep your information safe, you may not share important information with me and your care will suffer. EMR records need to be confined to your doctors office or your hospital and only accessible to those directly involved in your care. But currently, your EMR chart, your most private information stored electronically at large health care organizations is on the internet and available to thousands of people legally without your knowledge or permission. The government intends to make your private record available to all doctors and hospitals in the county. The EMR mocks my promise to keep your record private.

As an aside, consider yourself a pro-life, conservative woman politician three days before an election. You are leading by a small amount in the polls. A liberal doctor in your city (I could do this now. I have complete access and the ability to alter tens of thousands of charts in the twin cities.) accesses your chart and adds two induced abortions to your past history, adds that you told your doctor you were a closet alcoholic, that you were being treated for serious depression. The record could easily be printed and handed to the media. Before the fraud could be sorted out, you would have lost. Better, stealing a password is now frighteningly simple with digital web cams placed on a pen in a pocket turned toward the computer keyboard. Logging in under a different password would mean the wrong person would be fired or prosecuted!

Are you listening, Michelle Bachman? If I were a politician, I would be shaking in my boots!

My care for you requires clear and concise communication of your condition and diagnosis to other doctors who may assume your care. When I refer you to someone, or you move and see someone else, your narrative concerning your problems or multiple problems should be simple, direct, clear and to the point for your new doctor to get up to speed . The cut-copy-paste and boilerplate templates rarely do that. Extraneous information clutters the notes, often making them so difficult to decipher that they are ignored. (Private communication with other doctors and personal experience) That doesn’t help you one bit.

My care for you which is recorded in your chart should be recorded in a way decipherable to all doctors. The medical chart must be designed by doctors because doctors are the only ones using all the information in the chart to help the patient. Everything else on the chart, however important, is ancillary. Therefore, the EMR should be designed by doctors as medical records have been for thousands of years. With coders, corporations and lawyers contributing to medical software company designers, it is no wonder the EMR doesn’t fit what I do very well. The EMR is more in tune with enhancing billing and “covering all the bases” to prevent a malpractice suit.

My care for you must be honest. With my narrative and doctor-understandable diagnosis, honesty is easy. Notes reflect accurately what I heard, saw and did. I concentrate on the problem at hand and my note reflects that. It takes too long to add extraneous data to my note and the only reason I would do that would be to pad your bill. But with the EMR, doctors can include in your note things he or she has not heard, has not seen and did not do, literally everything under the sun about you with a click. Such charting harms your care and allows doctors and coders to easily and with a relatively clear conscience greatly pad your bill.

My care for you must reflect a diagnosis which other doctors can understand. With a narrative, the diagnosis makes sense to other doctors. But coding a diagnosis for billing is complicated. A coder goes to the CPT manual, a book about three inches thick with literally hundreds of thousands of diagnosis in it and fits my diagnosis into a slot with a code for billing. But the EMR I use requires the diagnosis and code be found (can take significant time) and recorded by me before I can close the visit. So the diagnosis recorded in the problem list of the chart is as it appears in the coding manual, a technical and confusing phrase often meaningless to me and other doctors reading your chart. Fortunately, my narrative which is separate from the diagnosis page continues to reflect a doctor-understandable diagnosis.

My desire for improvement of the EMR falls on deaf ears where I work. I’ve been told, “That ship already left the port. The EMR is here. Get used to it.” But for medical care to be what it should be, the best for you and the best for me, all the “should be’s” I listed should be met. The computerized care should be recorded as a narrative. The EMR should communicate to other doctors clearly and concisely and should be designed by doctors, not coders and lawyers. The EMR should be free from easy fraud, and most importantly, be private and off the internet, confined to your doctors office or your hospital where it should be accessible only to those directly providing your care.

The best computer minds in the country have been trying to fashion an EMR which doctors will be able to use since the desktop computers where invented. Multiple medical corporations, medical software companies, doctors, other medical professional, hospitals and more have tried now for 25 plus years–and still, nothing any good. Only 17% of doctors offices use the electronic medical record. If only 17% of doctors offices use the EMR, the same doctors who adapt to changes in medicine regularly, doctors who can tell when something will work or if something won’t work, doesn’t that say something? I would contend that current EMR’s are woefully inadequate to handle medical care and until it can meet the challenges I’ve listed, the EMR in its current form should be abandoned.

I love computers and what they can do. I’m a bit of a computer geek myself. But more than that, I’m a good doctor and will do everything I can to fight those processes which hinder my ability to provide good care. I took my oath seriously. You, my patient, are worth it.

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