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?

   

   

   

   

   

   

   

   

Electronic Medical Records

There have been many articles published about the benefits of electronic medical records. The US gov't has appropriated millions of dollars to aid in their development and adoption. The claim is that the adoption of such systems will save money by reducing the number of duplicated tests and also reduce patient mortality and morbidity because fewer errors will be made.

I will leave aside the question of the possible (unproven as yet) benefits of computer-generated hospital records and notes. I will note,however, that computerized hospital notes and orders use up more of a doctor's time, and that is the one dimension we already have too little of. It used to take me 5 minutes to admit a patient with pen and paper. Now it takes at least 25 minutes on a computer, in part because of "mission creep". By mission creep I allude for instance to the U.S. Census, which is mandated by the U.S. Constitution to do a head count every 10 years to re-apportion U.S. Congressional districts among the states, but now also requires you to tell the government how many bathrooms, bedrooms, and telephones you have, among other details. And when the computer crashes, all the residents are helpless.

I admit to two hospitals. In one of them, I cannot even admit a patient unless I answer the question: should the patient I am admitting have a flu and pneumonia vaccine at discharge (and there is no place to indicate that the patient refuses). In the other hospital (and only God knows why) they ask for the birth date of the admitting doctor. This information can't possibly help the patient, but someone wants the information. They even set up the answer matrix so that 00-00-0000 does not work.So now most of the doctors were born on 11-11-1911, because that is the easiest number to write that the computer will accept.

I am also concerned because not once in the past 5 years has a nurse called me from the ward to ask if my drug order was correct. The order goes by the computer to the pharmacy dept., who delivers it pre-labeled to the floor. The nurses seem to think that a computer-generated label must be correct, and besides, the pharmacy filled it. Of course the pharmacologist does not know the patient nearly as well as the nurse does, but it is efficient! I don't even want to discuss my reaction when I ask an intern for a patient's Hct. , and I am told that it isn't in the computer yet. It never occurs to them that the number is generated by the hematology laboratory, and you can call them up for the result.

Now let's look at electronic medical records, and their benefit for the patient. When I started practice, I used to give all my patients a photo-reduced copy of their EKG to keep with them , because when a patient hits the ER with chest pain, the doctor certainly wants to know what the previous EKG looked like. I found that fewer than 10% of patients carried the copy with them, so I stopped this practice.

Now a doctor's medical record system is supposed to be compliant with and interactive with the hospital system. This requires you to be HIPAA compliant which means the changing of your hospital password every 90 days, or else you cannot log on to the hospital computer. How in the world can two hospital computers exchange data? I can't imagine changing your password every 90 days for every hospital in the US, and the SmartCard still requires a password.

I also know that every doctor wants to review Xrays and MRI results personally before surgery, etc. So even if I have a transmitted electronic report about the result of an MRI, I would want to repeat it if the patient's treatment depended on it. This also holds true for cardiac echoes, stress tests, cardiac angiograms,etc. If you were a patient, wouldn't you want your doctor to personally review a study before operating? You also would not trust the result of a technically difficult lab test (e.g. N-terminal parathyroid hormone) unless you had total faith in the lab, and therefore you would probably repeat the test. And if different labs with different techniques have different normal ranges, this complicates matters still further. Similarly, where cancer is concerned, the pathologist and oncologist will want to review the biopsy slides personally, rather than rely on a written report.

All the above can be summarized by saying that no doctor would depend on a written report alone, but would want to see the actual data. If details are needed in the ER about a patient, then the ER doctor will probably communicate with the family doctor for information that is not in the computer system (e.g. the patient uses cocaine, is bisexual, etc.) because no computer system is totally secure. There is always critical data about a patient that is known very well by the family doctor but never makes it into the chart because of its sensitive nature. I would never write down in an office chart that a patient hates his wife or is having an affair if I know the wife has legal access to the chart, or vice versa. I am not being paranoid about the non-security of data in the hospital system, because in the last 2 years I have received communications from 3 Veteran's Hospitals that their information systems have been hacked.

I yield to no one in agreeing that computers are terrific for transferring information. What concerns me is the uncritical acceptance of information on a computer, and where the paper backup is when the system crashes. When patient lives are at stake, there must be accessible backup. As I recall, a few months ago LAX had to divert planes for 3 hours because of a malfunction in the computer program that linked their radar systems. There have also been recent articles on radiation overdoses received by patients because the technicians did not understand the intricacies of computer-operated radiation beams. And with a typical automobile having 30 computers with thousands of lines of code, it's a miracle that there aren't more recalls.

Let me close with the following anecdote (and I repeat that I am not a Luddite, and was an early fan of Wylbur): "Ladies and Gentlemen, welcome to the first fully automatic transcontinental airplane ride that is fully operated by onboard computers. We have 3 computers, and therefore double redundancy for safety. This system has been tested thousands of times. Relax as we take off, and be assured that absolutely nothing can go wrong, go wrong, go wrong, go wrong, go wrong,....."