Thursday, September 27, 2012

Electronic Medical Records: A Solution or a Problem?

     There have been many articles written lately about the use of electronic medical records (EMRs)  in the hospitals, in the emergency rooms, and in doctors' offices. These articles have appeared in newspapers, in medical journals, and in statements from the government, from medical societies, and most recently from the office of the Medicare Inspector General. As one who used to always  use pen and paper and now still uses them in my office but not in the hospital, I would like to offer my perspective, which is in addition to my previous blog on this subject.

     Firstly, we have the Scylla of insurance companies saying that if you didn't write it down you didn't do it and can't bill for it, or the Charybdis of the same companies saying that just because you wrote it down it doesn't mean that you actually did it. In either case, you cannot prove a negative, and lack of evidence is not equivalent to evidence of a lack, as any first-year logic student could tell you. Doctors used to be told that they should document what they did very carefully in the chart because (a) other doctors would depend upon their notes, and (b) careful documentation was the best defense against malpractice. Now the same doctors are told that if they do not document their actions carefully, they cannot bill for what they did, so the incentive has changed from good (for the patient) medical practice to good (for the doctor and hospital) financial practice.

     Not to be a complete Devil's advocate, but we doctors are pretty savvy, and we have been gaming the system for our patients' benefit  for years: If the insurance company will not pay for a PPI drug unless the patient has GERD and not just a stomach ulcer, then presto---all of our ulcer patients for whom we wish to prescribe a PPI have GERD. Similarly, if I think a patient is anemic, Medicare will not pay for a CBC blood test to look for anemia, because "rule out" or "I think that"  is not a disease, but Medicare will pay for a CBC if the patient has fatigue (code 780.79) and every patient has been tired at least once since birth, so I can code "fatigue" with complete honesty, since no time frame is asked for in the diagnostic box. I even know doctors (not me) who code 799.99, "unknown disease", telling themselves that every patient has at least one unknown disease, which is ultimately known only to the pathologist. You note that in each of the above cases, our experience tells us that a patient needs a certain drug or test, and we have to adjust our codes and words so that it is paid for. One might argue that it is the patient's responsibility to pay, but if a doctor knows that then the test will not be taken or the drug not obtained, I feel that we are morally obliged to act in the patient's best interest to ensure the best possible result, because our implied contract is with the patient to see that he/she gets the best care possible.

     So the medical record now has a dual purpose: to document what the doctor sees and thinks as well as to record the results of tests, and to provide evidence for the doctor's and hospital's bill. Usually these two requirements are not at cross-purposes, but they do act to increase the amount of time a doctor spends recording data. Trivially, a doctor cannot write "cardiac exam unchanged" if he wishes to get credit for examining the heart, but  he must repeat his examination and notation of the PMI, murmurs, gallops, splits, clicks, etc. Of course with the right computer template he can just cut and paste to achieve this result, but this does take time, and time is a doctor's least fungible resource. There even are computer systems where if the doctor clicks "normal lungs" the template spits out words like "clear to percussion and auscultation, no vocal fremitus, no egophony, no post-tussive rales, diaphragms move well and equally", etc. I want to emphasize that the doctor did perform the complete pulmonary exam, but the use of the automatic printout saves him time in writing it all out. And the doctor is no more likely to click on the link without doing the actual exam than he would be to write "normal lungs" without doing the exam.

     Now what are the putative and actual results of electronic medical records aka computer printouts? In theory, there should be fewer errors and patients' care should improve, but I know of no studies demonstrating a decrease in morbidity and mortality. And the Johns Hopkins pediatric hospital where pharmacy errors were noted pre-computer orders was shown to have an increase in medication errors after the introduction of computer-only orders. At my own institution, the system was down for 36 hours due to some glitch (gremlins anyone?) and the residents were quite helpless. I do know that the housestaff have become technocrats: When I asked one resident what a patient's hematocrit was, I was told that it wasn't in the computer yet, and when I suggested calling the hematology lab for the result, I was met with an incredulous stare, as if it never occurred to the resident that somewhere a human had to generate the test result before it was logged into the computer.

     Then we have the question of the security of medical records. We are always reading about CD's being left in taxicabs with thousands of patients' records, or a computer billing service accidentally releasing patients' information. I doubt that any of you would trust the security of a computer to keep secret the fact that you are an adulterous, bisexual,  cocaine-using, HIV-positive patient with a gambling and an  alcohol problem. All of us have patients that ask us not to write down certain embarrassing facts, but if the ER doctor thinks that the electronic record is complete, they will never call the family doctor to find out those key additional facts. My main responsibility is always to the patient, and I keep a problem list of embarrassing facts separate from the office chart, with the understanding that I will forward a complete problem list to any doctor to whom I refer the patient. I also should mention that when a patient comes to the ER, where one would think an accurate record would be of vital importance, his/her life is generally saved without reference to any written past medical history. The complete medical  history is of most value to the next office doctor, who needs the total story to be digested at leisure.

     One last concern: I know that I have trouble finding a place to view my VCR tapes, I've given up on my 8-track musical tapes, and my new car won't accept cassettes, but only plays CD's. What happens when an old computer record cannot be accessed by the new computer system? Yet I have pen and ink notes in the chart of 80 year old patients that are perfectly legible 50 years after they were written by my predecessor. Does anyone have a timeless electronic version of the Rosetta Stone?










  1. I look at EMR as more of a solution than a problem. Sure, it is raising some health care costs, but it is making the lives of doctor's and patient's SO much easier. My physical therapy billing software shows me what payments are due and my payment history. It also shows what types of therapy I have received. I find it very convenient and useful and that is why I consider it more of a solution, than a problem.

  2. In 2005 the RAND Corporation predicted that the adoption of EMR would save the health system $81 billion/year, without really specifying how these cost savings would accrue. By 2012, medical costs have increased by $800 million. The RAND Corporation has no valid explanation for the failure of their prediction, but they blame the doctors anyway.