Electronic Medical Records (EMR) promises to be the holy grail of modern medicine. It aims to deliver us from the Smith Corona era into the digital age. I’m a gastroenterologist who has already been practicing digitally for two decades. I guess I am way ahead of my time
Is EMR progress? Consider these two hypothetical patient assessments. The assessment is a critical section of the medical record where the physician shares his thinking on the patient’s condition. The assessment answers the question, “What do you think is going on here and why?”
The Old Fashioned, Archaic, Fossilized and Sclerotic Assessment
The quality and timing of the patient’s abdominal pain is strongly suggestive of mesenteric ischemia (lack of blood supply to the guts), as the pain consistently develops 45 minutes after meals. The patient has numerous risk factors for this condition. Peptic ulcer disease is unlikely as the patient has been on an effective anti-ulcer medicine for months. The frequency of the pain is not typical for gallbladder disease or pancreatitis…
The New & Improved EMR Assessment
Abdominal pain, unspecified
Our office manager admonished me earlier this week because I was free typing the medical history section, rather than use ‘point and click’ ( P & C). Apparently, if I free type and forego the template entirely, it stymies the coding process. (For non-physicians, coding = getting paid.) While EMR vendors are convinced that medical histories can be recorded using P & C technique, I’m a deep skeptic. The medical history is a narrative, a record of a fluid, and sometimes meandering dialogue between patients and physicians. The history probes in all directions. It wanders. It creates new passageways. The patient’s response to a question often opens up a new avenue of inquiry, a function that cannot be reproduced on a rigid template.
Imagine how our personal conversations would be if we communicated using a P &C template.
Steve: “Jim, it’s great seeing you? It’s been a while. How’s it going?”Jim: “Samantha’s having a rough time with chemo and I was just laid off.”Steve: “Fantastic! Are you free to golf this weekend?“
I do believe that EMR systems in time will fulfill their early promises. They will incorporate excellent voice recognition software. The myriad of EMR systems will be integrated so that a recent emergency room visit will automatically be transmitted to my patient’s EMR record. Patients will have their medical histories, EKGs, medical images, etc., recorded on flash drives, which will load into any EMR system. When this occurs, it will no longer be possible to be an EMR non-believer.
But, some of today’s EMR whistles are whistling in the dark. For example, we physicians all nodded like bobble-head dolls when we were told that we could have access to patient’s records at home after hours. This meant that when we received weekend phone calls from our partners’ patients, whom we did not know, we could access their medical record and give better medical advice. Of course, this makes sense, but is it really true?
First, it’s tough for cyber neophytes like me to boot up the laptop when a patient calls while I am behind the wheel. Secondly, I have been handling patient calls at all hours for 20 years, and I have somehow managed to handle the issues with few catastrophic consequences. Indeed, all practicing physicians have developed this important skill set of triaging patients by phone. Our role here is not to make a diagnosis; it is to decide if a patient needs an emergency room visit or can be seen electively in the office. I’m not suggesting that reviewing record is not useful, only that the benefit of instant access may be exaggerated in certain circumstances.
I’m sure that EMR 2.0 and its descendants will ultimately deliver. So far, it hasn’t surpassed ink on paper in my practice, although it's only been a few weeks. So far, as expected, EMR has not brought me closer to my patients. To paraphrase a past U.S. president, it's a divider, not a uniter.
I realize that there are some physician EMR users who worship the new technology. There are indisputable advantages that they can and will bring to medical care. Some EMR systems may be better than others. However, this has not a downhill sleigh ride for many doctors and patients, at least not yet. Interestingly, the majority of physicans are still content to use paper charts. In the near term, they will transition to EMR, not so much because of a Damascus Road conversion, but because payers will require it.
I admit that with each passing week, it is getting smoother for us. But, it has taken an enormous investment of T & T (training & tweaking) time, which is ongoing. And, we haven't yet incorporated our endoscopy practice into the system. At the start, it may take longer to document a colonoscopy than to do one.
I realize that there are some physician EMR users who worship the new technology. There are indisputable advantages that they can and will bring to medical care. Some EMR systems may be better than others. However, this has not a downhill sleigh ride for many doctors and patients, at least not yet. Interestingly, the majority of physicans are still content to use paper charts. In the near term, they will transition to EMR, not so much because of a Damascus Road conversion, but because payers will require it.
I admit that with each passing week, it is getting smoother for us. But, it has taken an enormous investment of T & T (training & tweaking) time, which is ongoing. And, we haven't yet incorporated our endoscopy practice into the system. At the start, it may take longer to document a colonoscopy than to do one.
For me, blogging is the EMR antidote. It’s open terrain. There are no moats or fences. It’s unpredictable and spontaneous. It’s emotional and creative. It has a point, but not a single click.
Developers of EMR software need to have a full understanding of the process, including the purpose of things such as the H&P, HPI, etc. It sounds like you have 2 processes that are trying to be addressed with 1. Coding draws information from the H&P, but it's a different animal. For an EMR to be successful, the developers must realize these differences.
ReplyDeleteNice site, and useful information
ReplyDeleteThank you
Obama's claim that EMR would free up $20 billion was such a howler that even some of his supporters took him to task for it. It also took his administration about a year to define just who would have their EMR purchases covered by the stimulus and who wouldn't. I still don't trust him, and will just have to get used to the penalty I'll incur for not buckling under.
ReplyDeleteWhile I am not a medical professional and some of the items in this post were difficult for me to understand, I know that in the recent years whenever I go to a doctor, they have a number of my medical records from other offices electronically transferred. It makes things much better and easier for patients, doesn't it?
ReplyDeleteAs long as we are treating human beings, medicine will continue to be clinical judgements made by physicians. Useful medical records need to reflect that fact, a fact often lost on point and click and template EMR that rely on ICD-9 coding. EMR Clinic notes tend to be long, verbose and vague. Useful assesments are those similar to the "sclerotic" assessment above- I know what Dr. Kirsch is thinking about. We have not figured out how to best use EMR for clinical practice, but the government has unfortunately already defined that for us with their "clinically meaningful use" criteria. Those criteria are not really designed to let physicians and nurses practice their best medicine, but rather to keep tabs on "quality" and billing. If EMR as it now exists, was really such a great idea, you would not need incentives. No incentives were needed for physicians to adopt cell phones or electronic scheduling. Simply put, the present EMR's suck, and the promise of "instant access" to patient information (labs, etc) is poor at best.
ReplyDeleteThough I like EMR in general, you are right on about a problem in the lack of prose. Tell your office manager to f off. Going to a point and click assessment is no longer being a good doctor, and we're not willing to do that.
ReplyDeleteThanks for your suggestion, Nick. I may pass on your suggestion of a comment to my office manager, as we try to keep the office communications at a PG-13 rating.
ReplyDeleteDr. Kirsch,
ReplyDeleteI'm a "lurker" on your site, and a frequent reader of the HealthCare Renewal site. Though you might find this article of interest as you go forward with your adventure in electronic technology. http://hcrenewal.blogspot.com/2010/10/21st-century-emr-experiments-screwing.html#links
Melody
Melody, thanks for the link. No need to 'lurk'; step right out in front!
ReplyDeleteSee the new JAMIA article:
ReplyDeleteJ Am Med Inform Assoc. 2010 Nov 1;17(6):617-23.
Health information technology: fallacies and sober realities
Karsh BT, Weinger MB, Abbott PA, Wears RL.
Department of Industrial and Systems Engineering and Systems Engineering Initiative for Patient Safety, University of Wisconsin, Madison, Wisconsin, USA.
Abstract
Current research suggests that the rate of adoption of health information technology (HIT) is low, and that HIT may not have the touted beneficial effects on quality of care or costs. The twin issues of the failure of HIT adoption and of HIT efficacy stem primarily from a series of fallacies about HIT. [Not discussed are the origins and maintenance vectors of those fallacies, a topic for significant research itself - ed.] We discuss 12 HIT fallacies and their implications for design and implementation. These fallacies must be understood and addressed for HIT to yield better results. Foundational cognitive and human factors engineering research and development are essential to better inform HIT development, deployment, and use.
I have a brief post on it at http://hcrenewal.blogspot.com/2010/10/jamia-health-information-technology.html
Thanks, Scot, for your comment and the link to your fine blog.
ReplyDeleteAs a denial management specialist to hospitals to argue insurance denials, the EMR dilutes the recipe for accurate documentation - poignant, specific and detailed documentation that supports the status of the patient and substantiates why that patient is in the hospital. All too often professionals complete the pre-formulated checklists and one cannot tell Patient A from Patient B. It is not a substitute for narrative.
ReplyDeleteHospitals and professionals who engage in electronic charting need to also become environmentally conscious - the mounds of paper that are being wasted are incredulous. There seem to be a few companies that minimize wasting and also have a layout that is conducive to professional thought processes(i.i. tables of lab results rather than one day of lab results on each page). The EMR companies seem to be dictating the standards, while it should be the professsionals to minimize error etc.
Ela
"Patients will have their medical histories, EKGs, medical images, etc., recorded on flash drives, which will load into any EMR system. When this occurs, it will no longer be possible to be an EMR non-believer."
ReplyDeleteMichael, that's what the MedKaz™ is all about. Would love to have you participate in our forthcoming pilot study. At the very least, I'd like to talk with you. You can reach me at 802 484-0249, or I'll call you.
I am a perfect example of what can happen when hospitals rely on EMR (Electronic Medical
ReplyDeleteRecords).
I was brought to the Southwest Medical Center Emergency Room because I could not breath.
It was an episode caused by COPD.
I was brought by ambulance. I had a printed information sheet (given to the paramedics
by my granddaughter prior to leaving my home via ambulance). The information sheet showed
ALL of my current medications, allergies, name, date of birth, next of kin, blood type, etc.
While in the ER, no one bothered to review the sheet. Instead they relied on the records in
their computer system. OLD records that did not show current allergies.
I was given an antibiotic that I am highly allergic to. Because of my condition, I was in and
out of mental faculties. When the nurse brought in a bag of medicine to administer via the
IV, I asked her what it was and she said just an antibiotic.
Within five minutes, I could not breath even though I was hooked up to an oxygen unit
with a C-pap mask on. I felt my body getting hotter and hotter and my throat was closing
and my mouth was getting dryer and dryer. I was screaming for someone to come and help
me. A nurse came in and I told her I could not breath and she told me the oxygen unit was
fine. I begged her to remove the C-pap mask and she would not. Instead, she called
respiratory to come down. Respiratory said the oxygen unit was fine. I begged her to remove
it so I could breath in the room air because I felt like I was dying. I was screaming "you are killing
me." I looked down at my arms and they were BLOOD RED and on fire as was my entire body.
Finally, two nurses came in and I asked what was in the IV bag and they said Avelox and I said,
I am alergic to it. They told me, "well, it's almost done now." But the one nurse told the other
to disconnect it.
If they had taken the time to review the medical information sheet I brought with me and which
the paramedic gave them, they would have noted my allergy to Avelox.
So, Electronic Medical Records are useless and could be VERY DANGEROUS. They are NOT UP
TO DATE.
If you want to learn more. Just ask me. I am trying to find an attorney to help me get some
restitution for this incident.
Great post! I never knew that there is a Myth for Electronic Medical Records. Anyway, I enjoyed reading it and I learned some information about Electronic Medical Records. Thanks for the post.
ReplyDelete-krisha-
I guess it's not just me. See http://on.wsj.com/gJMG3g
ReplyDeleteAs a person who is about to add an EMR product to his ultrasound supplies business, this article was very informative. It's allowing me to see the constraints through your eyes. In fact, the backbone example that you mentioned (how an ER visit could be sent to your EMR) is something a friend and have discussed and currently working on it. I will definitely feed your blog posts into my twitter account b/c they are very informative.
ReplyDeleteThis is very interesting information. We have been doing research on EMR to see if it is a good fit for our company. So far what we've read has been so helpful. Thanks so much for sharing your article, it was very helpful for us as well.
ReplyDelete