The Electronic Medical Record
Our multispecialty clinic is in the process of converting our standard paper charts to computerized files by adopting an electronic medical record (EMR) system. To say the least, this conversion has been the source of many gray hairs and stomach ulcers for nearly all personnel involved and raises the hackles of our doctors more than almost any other topic. My cardiology group made this transition about 7 months ago and it’s taken me this long for my strong sentiments to simmer to a level where I can produce a somewhat dispassionate discussion (never mind the fact that 6 months ago I would’ve had to type with only one hand, the other being occupied pulling out my hair).
First, a little history about medical records. Doctors have been making notes about the care of their patients for centuries for lots of really good reasons: as a form of communication to other caregivers; out of intellectual curiosity or for research purposes; or mostly because they, like I, have trouble remembering every detail about every patient they treat. Paper has been the universal format for this documentation ever since papyrus and parchment went out of style. Until recently, all doctors maintained a thick, variably organized chart on each patient into which new notes and test results were filed and from which, like socks in a dryer, others occasionally disappeared.
Now we have computers. In 2009, logically bundled into the American Recovery and Reinvestment Act (the “stimulus bill”), we received a mandate to transition all hospital and clinic records to some type of computerized, digital format. As health-care providers, our income will be rewarded or penalized based on our compliance by the deadline of 2015.
When we were initially introduced to EMR we were told (by the makers of the program) that we would become more efficient, safe, and thorough once we adopted their product. I can now say, without a doubt, that these claims were wildly overstated. However, unlike many other doctors who rant against EMR in hallways, doctors’ lounges, and blogs, I am favorably inclined toward this new technology while at the same time fully cognizant of its shortcomings.
So, here’s my simple critique of the realistic advantages and disadvantages of EMR:
Advantages of EMR
- For me the most valuable aspect of EMR is my ability to access it from virtually anywhere. I can pull up a patient’s chart from an emergency room or from my home computer and someday will likely be able to access all information from a portable device. No longer do I have to wait until the office opens on Monday to get a hold of the chart.
- Doctors’ handwriting is the stuff of legend. I was half tempted to scan a snippet of medical hieroglyphics and display it for the benefit of those of you who’ve never seen it, but I decided against it—not out of privacy concerns, but rather because I don’t want to be responsible for triggering PTSD among my readers who are nurses.
- Our notes are considerably more thorough with EMR. The computer system forces us to address oft-skipped issues such as family history, unhealthy habits, long-forgotten procedures, and drug intolerances. This information carries forward with each note and is always available.
- Our accounting people tell us that our billing is more streamlined with EMR. I know this sounds like a trivial issue but the fact remains that we, too, must make money or we go out of business. Our reimbursement is based solely on documentation, and the more thorough we can be in our notes, the more Medicare or your insurance will pay us appropriately for the work we are already doing.
- Our particular EMR (I believe most others do this as well) allows us to provide prescription refills rapidly and nearly error-free. We can send medication orders directly to your pharmacy so that your drugs are ready when you arrive. This simple function can save us an immense amount of time.
- I have heard from several primary care doctors how much they appreciate how rapidly we can provide documentation of the services we provide their patients. This is thanks to the ability to electronically transmit a copy of our note within minutes after the patient’s visit.
Disadvantages of EMR:
- Since the portal to the EMR is the computer terminal instead of the pen, the patient experience suffers when doctors attempt to put together notes in the exam room while talking to the patient. This is the complaint I hear more than any other when it comes to patients’ experiences with our new system: “My doctor spent the whole visit staring at the computer screen.” The method that works best for me is to build my note before and after I see the patient and to never access the computer in the exam room, an approach that allows me to devote my entire attention to the patient during their visit.
- The language found in most EMR-produced notes is stilted, mechanical, and sometimes difficult to interpret. Years ago doctors prided themselves on the fluidity and descriptive quality of their documentation and went to great lengths to impart the nuances of their patient interactions. This is all lost in a chart where most of the information comes from pick-lists and check-boxes. Read this recent article from the New York Times to get a sense of one doctor’s frustration with this type of system.
- It is slow. If ever a rep from any EMR company tries to convince you of the efficiency of EMR, please refer them to me and I’ll introduce them to some of my business associates from Nigeria. In the course of one uncomplicated office note I am required to click the mouse so many times you’d swear I was translating Moby Dick into Morse code. We have a relatively good voice recognition system, but in the best of hands (or tongues) it is fraught with errors. (If I enunciate the sentence “Dr. Satpathy would like to order Pradaxa on a patient undergoing aquapheresis” it comes out like this: Doctor’s the past he would like to order per DACs on a patient undergoing aqua for recess.) The current generation of EMR software is nowhere as quick as a Dictaphone.
- Having an extremely thorough medical record has a downside: information overload. When all medical information is distilled to a database we have difficulty sifting what is truly important from what is trivial. I saw a young woman last week who was sent from a doctor whose office uses EMR and I was able to review the doctor’s most recent note before seeing the patient. The list of diagnoses contained at least 20 items and I was surprised to walk into the exam room and meet a very healthy young lady who had few of the problems described. Why her note stated otherwise comes down to how patient complaints are documented. In order to bill for the visit the doctor has to select a diagnosis from a list of approved terms, rather than simply describing a symptom. Thus, simple aches and pains mentioned in passing become diagnoses that stick with the patient (a stiff knee becomes degenerative joint disease, a cough becomes bronchitis, constipation becomes irritable bowel syndrome). As I looked over the patient’s diagnosis list I realized that none of them represented real medical problems.
- Our EMR in particular puts a great deal of emphasis on using the computer as the intermediary in the course of clinical communication. Prior to our adoption of EMR, if a patient called with a question our nurse would take down the details and call me for a response. I could then call the patient with the answer or have the nurse handle the problem. Now the system is considerably different. The patient’s question gets sent to a “tasking in-box” where it will languish along with dozens of lab and x-ray results until I log on to a computer to address them. During a day of hospital rounding and procedures I can’t reliably address my in-box on a regular basis. Now instead of patients’ questions being answered immediately with a conversation with the nurse, the patient’s request may not be addressed for hours or days. To make matters worse, the system for communicating with our own nurses involves more steps than it took for the engineers with slide rules to land Apollo 13.
The final issues I’d like to discuss are patient safety and cost containment. These are the two features that were heavily advertised by the government when the EMR provision was added to the 2009 bill. Global adoption of EMR was supposed to decrease medical errors and thereby save the US healthcare system $80 billion. This particular argument for EMR was best refuted in a Wall Street Journal opinion authored by the chair of medicine at the Harvard Medical School. My personal opinion is that this is nothing more than wishful thinking as I have yet to come across a situation where my computer has saved me from committing an error in the course of patient care.
In the end I have to confess that I like EMR despite the fact that our particular system is cumbersome, poorly structured, unintuitive, inflexible, and clearly designed by someone who hates the carpal tunnels of all doctors. I like being able to provide my patient a note as they walk out the door; I appreciate having full access to their history when I see them in the ER in the middle of the night; I love having a list of all their prior procedures and surgeries at my fingertips; and, most of all, I value the legibility of Times New Roman over Doctor Scrawl Italic.
I have a different view of the EMR. Yes stimulus money was used to make these available in clinics across the nation. I think most people (not in the medical field) thought stimulus money was supposed to be to create jobs; quite the opposite. I was a medical transcriptionist and have lost my job due to the implementation of the EMR. Also, the dream was to be able to access your personal medical records anywhere in the nation; however, there are SO MANY different EMR systems and they are not all compatible, so that is still 'just a dream'. The EMR system at the clinic where I worked does not even have 'spell check', but apparently spelling words correctly is not important. No, I am not a fan of the EMR, and as a patient - "God help us all".
Eric Van De Graaff MD
Nemili, I'll look into this for you. I contacted my younger brother, a 4th year student at University of Utah School of Medicine, and he tells me that such a database is no longer in use. I've got a call into their medical informatics office to see if anyone there recalls what it was called and whatever happened to it. I agree with you, I see considerable value to such a vast collection of information. Thanks for keeping up on our blog. Dr. VDG
As a primary care physician who has now been on Alegent's EMR for nearly 6 months, I can relate to the author's struggles, but have a couple comments to add that have not been covered.
Electronic medical records should not be viewed as just a new way to create a record of our patient care or a way to make billing more streamlined--that just makes it an expensive "virtual" paper chart/system. What the health care team is doing with the EMR is creating a data base, and as we know, data for data's sake is not very helpful. Creating that data base and converting our existing records to the EMR is a tedious process and often frustrating. The real value of the EMR will lie in our ability in the near future to take that raw data and use the computer to do what it does best--sift and sort data to give us workable and valuable knowledge to manage our patients' care. The EMR's next step will enable us to create patient registries that will be used in improving a goal of "wellness" and following up on existing disease states/problems unique to individual patients' cases. With a touch of the button, Dr. Van De Graaff can see all of the patients who have received a certain type of stent and who are due/overdue for followup or medication changes that are recommended. Dr. Stearnes can find out which women have not had their mammogram, PAP, or returned for that often missed third gardisil injection. Dr. Klein can retrieve all of the patients who were on a certain medication that now has a new black box warning and notify patients as needed. I will be able to see which of my diabetics are coming up for routine checks. As we change our current mindset from treating disease episodes to one where we also work to promote wellness and management of our "patient population", the EMR then becomes invaluable.
Second, the computer terminal is just another way of "taking notes" and does not need to be a barrier to connecting with the patient. I still sit across from the patient, look them in the eye and communicate--the mode of recording is just different. My patients are used to me having my note completed and their treatment plan discussed before I leave the room. Getting used to the EMR has been a test to that, but I am nearing the point where my efficiency is close to the day when I recorded by writing. AND my record is legible, more complete, and accurate (we actually president Bush to blame for RAC, MIC, and other acronyms for those audits from the fraud divisions that are seeking out abuse). I loved it when I was able to access my partner's record on a complicated patient at 11:30 p.m. on a Saturday night when I was admitting him and he was unsure which 15 medications he was on for his BP, COPD, diabetes, renal failure. It is this new use of the EMR which will open new ways to use our medical records across the continuum of a patient's care that will decrease errors, length of hospital stay, and readmissions--all of which are goals we as physicians need to take the lead in as we work to curtail rising healthcare costs and improve the well-being of our patients.
Jeff Stearnes, MD
I agree with your article. An additional thought, that comes to me multiple times throughout the day, is this one... "If EMR could only be made by Apple, everyone would love converting to EMR." Those who have iPhones and iPads know exactly what I'm talking about. Apple has a way of making computers intuitively work and think for you, as opposed to you working and thinking and troubleshooting just to accomplish something with the computer. My only hope is that eventually EMRs will become an Apple product, or at least more Apple-like. It has to. I just wish it were in 5-10 months vs. 5-10 years. I also think vendors of the EMR products made a 1st draft, did not consult with any physicians, then sent it out. That is the only way I can explain why it has no flow, little logic in how items are laid out, and the HPI templates are essentially un-useable. Again, time can only improve this. Looking forward to future EMR updates and/or future EMR products. Apple.... please help us!
Many of these large systems have the best of intentions, but I am not sure the needs of users or actual user behavior is always taken into account during system design, in spite of what a sales rep will tell you. There is a tried-and true practice of having the authors of the code design the interfaces and help files. Bad idea. This is often true in an age where technical communication, including interface design, is set aside for financial reasons. Ease of access is only useful if the output of the activities is useful. We must remember that it is the quality of diagnoses and treatment that is important, and if end-users are not getting the results they need for this to be the case, they can and will find work-arounds.
Harry Klein MD
Having been a utilizer of an independent EMR system for 20 months I have to say that just about everything discussed above is true. The initial utilization of the EMR was one of the hardest things to which to get accustomed.Especially for the 50 year plus crowd. Hair pulling, nail biting and anxiety were rampant in our office. I was surprised that a computer terminal wasn't used as a weapon of mass destruction. Then, time went on and it became more tolerable (6 months) and now it is pretty much old hat. Yes, I have become an excellent typist which will serve me well if I need to seek an additional job if medicine doesn't work out. My notes are quite lengthy but that is what Mr. Obama obviously wants. More bureaucracy and paperwork to fill the coffers of the computersphere. Medicine cannot however be put into small check boxes and trying to take a history using such a system is absolutely inane. Who cares if the computer cannot calculate my E and M code. I would rather do a thorough job describing my patients' problems then have a robotic sounding diatribe that makes no grammatical or coherent sense. The same is true for the assessment and plan which is the most vital part of the physician note.It has to convey your thoughts and concerns which again cannot fit into a neat check box system. So as we adapt to the culture of EMR,which has some good points too (as I don 't want to come off as a naysayer) the system has to allow us to still practice the science of medicine while conveying our thoughts in a meaningful humanistic fashion. Putting the ganlion in my wrist and the carpal tunnel symptoms aside, I have embraced the EMR for better or worse such as to survive in the current atmosphere of change. As long as the system doesn't crash or lose my longwinded notes I will remain a happy camper.
As a nurse in acute care I love the EMR. My mother is a nurse at Health Clinic transitioning from paper to EMR and she has a much different perspective (but realizes that the hard work she is doing will pay off for future healthcare workers). However the EMR is just the beginning. The technology that our smart phones and tabloids/ipads/skype have now is incredible and we are only seeing the beginning. GE is running great commercials involving advanced healthcare (not paying taxes = better commercials...I guess). Pocket ultrasound machines and MDs evaluating patients via camera phones en route to a hospital by ambulance are really just the tip of the iceberg. I believe that in the near future physicians will see just as many patients via electronic media as they do in person. There will be a loss of personal connection, however, we are already being enculturated with less and less human-to-human interaction. Healthcare is no different. Specialists are now in groups, hospitalists are becoming more common, less and less PCPs even visit the hospitals. Many people facebook/twitter/email far more frequently than make phone calls. Is it good? I don't know. Is it going to happen? Yes. I hope that you write a blog after your first skyped home visit.
Loan (Lowen) Eby
I read Bill Gates’ book "The Road Ahead" copyright 1995. Mr. Gates envisioned the internet to be a tool in which individuals would use in their daily activity. People would communicate, buy and sell goods and services. I recall the feedback was that Mr. Gates’ book was before his time and people would not use the internet to the extent he predicted. Fast forward to today, I think Mr. Gates knew what he was talking about. My profession is providing computer training for end users. I love your perspective because I hear the same feedback from the people I provide training to. My take away from your blog is that we will all gain the anticipated benefits of EMR, however, the technology should be such that it's used as a workflow tool and allow people to conduct their business as uninterrupted as possible. The process should be an evolution instead of a revolution. Mr. Gates published his book in 1995 and we evolved to what he predicted in 2011. 2015 will be here before we know it; I hope there’s not a revolt.
It was fascinating to read your responses to EMR. We in behavioral health are waiting in the wings. I agree, Apple's contributions would be most appreciated. I hope we get to the point where we have a mix of drop-downs and space to use Dragon Speak for dicatation using our own verbage. Thanks for your honest reactions.
As a customer I am looking forward to EMR. As I understand it I will no longer have to worry about retrieving my records from one doc when I go to the next one. There is always some pain in change, believe me I know. But as the younger docs (no offense to Dr Graaf) begin to practice the EMR will become an accepted way of doing things. Dr. Graaf's idea of taking notes rather than working on the computer is a great idea, he might consider taking it one step further by recording his appointments.
I am a medical informatics student at the University of Northwestern. Just read your article called: "The art of medicine and whether computers can replace doctors." As I'm in the midst of writing my thesis on better interfaces in EMRs, I was extremely curious about the program that the tech geeks built which enhanced medical student learning through signs/symptoms input. Is there a name for this computer application? Does it still exist? Is there any literature on it? The reason I ask is because I was dreaming something like this up as a way to improve quality of care for physicians. It's a long story, but if you have more information on this program or can point me to somebody that does, that would be most helpful! Thanks! *N*
I just had my first experience with EMR as a patient and it was great. My medical information had already been entered so I didn't have fill out any paper work, the nurse didn't have to write anything down, she just asked if I was still taking X, Y, Z and that was it. Then when my physician came in she pulled the screen right over me and stood right next to me as she normally would. We had a great visit and when it was time to order blood tests, etc. she had me looking at the options on the screen and discussing what we should do. I felt very involved in my healthcare and able to learn more instead of her always righting down secret notes and always wondering what she is saying on them! The best part was probably getting my prescriptions renewed, with one click of the button it was sent over to my pharmacy (which was already pre-loaded in the system) and now I don't have to deal with calling the pharmacy to see if the doc called in the prescription, etc. From a patient perspective, it just seems like such a smarter way to work and makes for a much better patient experience!