Thursday, May 25, 2006

Electronic Medical Record (Oh Doctor...)

This week's issue of JAMA has a commentary essay about the new Electronic Medical Record system. I'd have to say that it's right on the money for how inconvinient sifting through any chart is these days. The essay is available here for free and is written in a format that really drives the point home! (highly recommended)

EMR (Electronic Medical Records) is the new standard in medical technology. Basically, hospitals are hoping to have the entire medical record of patients available on the computer system, including all notes written for that patient. You can see the potential benefits, however, the idea has run into a few obstacles:
While EMR is highly efficient in producing notes, virtually all of its notes are longer, recombinant versions of previous notes. Even notes of different authors are morphed by EMR into clones of one another. As physicians have become more adept with the time-saving features of EMR, their notes have been rendered incapable of conveying usable information by their bloated and obfuscated nature.
For one, the notes never change. The longest note I've seen thus far here was seven pages long. SEVEN pages for a daily progress note. By a Doctor!
Moreover, EMR encourages everyone to copy-and-paste the notes of everyone else so that notes become the same from author to author as well as from day to day. Even consultants are assimilated into the oneness of the EMR Borg. A cardiology consultant recently copied-and-pasted the intern's note into his own, even including "consult cardiology in AM" in his recommendations. Perhaps he meant consult a more thoughtful cardiologist.

I'm all for making the intern's job a little easier (actually, no I'm not!) but this is really starting to get ridiculous, not to mention, downright dangerous.

For example, I am aware of a case where a patient expired due to what the team thought was a Deep Vein Thrombosis that traveled to the lungs. The team was aware of the DVT and were treating it appropriately, however, the intern's notes make no mention of the possible DVT. They were continually copied and pasted. The doctors who are now being sued have very little evidence to back them with no documentation.
It should be pointed out that EMR has some laudable aspects. Notes can be created quickly with minimal cognitive effort, and their impressive length implies diligence and attention to detail.

"Minimal cognitive Effort" is the correct term here.


Blogger Echomouse said...

My family doctor is part of a group practice here in Canada. About 2 years ago, they converted their entire office to a computer system. Our prescriptions come out of the printer now. And as we talk to him, he types away on the computer recording the visit. Every exam room has a computer with a flat screen monitor.

My only concern was about all my records prior to the conversion. I have yet to ask him if somebody input all the previous info. My mother, who is 70, was very upset about the new system. But she's getting better about it.

All in all, it seems okay, in our case.

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Blogger Dr. Rob said...

The fact that a technology can be used wrong does not make that technology a bad thing. Yes, you can cheat at EMR, but you also have a chance at documenting much better as well. There will always be the lazy ones ("minimal cognitive effort" as you put it) who will find ways to minimize burning of ATP. If, however, the payment for medical care is not directly linked to documentation (as it now is), then your documentation becomes a tool to acheive better quality (to do your job better and easier). Hopefully the linkage of EMR with payment reform will cause this kind of scenerio to not happen as often as it would in today's payment structure. I have heard it said "if you automate a bad process, you end up with a system which does bad much faster." Automation is not the end, it is a means to the end.

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Anonymous Anonymous said...

>agree with 'technology used wrong does not make that technology a bad thing'
>the good use of copying and pasting? 1. allows for extensive documentation that would likely meet the bullets required for documentation reimbursement [how many ways can you cite the bullets for findings in a normal exam for a system] 2. whomever is reading and relying on those notes better be paying attention to detail of what is different [especially true for daily notes on acute care patients - you cannot force every organ system, even the ones keeping the patient admitted, to change on a daily basis, so why waste your time repeating yourself for the same findings of yesterday and the days before; 'unchanged' does not cut that either, because nobody knows what it was 'unchanged' from
Bottomline: the writer and the reader both need to expend effort and understand what they are writing and reading!

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Blogger Internal Medicine Doctor said...

I agree with the both of you about your original point. I do not however agree that the reader needs to read through so much old information to find what's new. it's unnecessarily tedius.

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Anonymous Anonymous said...

Your post is thoughtful and dead on.

Billing and volume drive bad behaviour.

Even where billing is absent we recapitulate much of what is in the chart.

At our institution we rely on the "problem list" i.e. meds, allergies, PMH, PSH, Family and Social Histories being up to date as that data is automatically imported into notes.

Our house officers have been caught copying notes verbatim.

My HPI, and assessment and plan are always my own, and the "problem list" part of the H&P is pretty carefully verified by the patient prior to leaving my mark in the computerized medical record where everyone can see it.

What surprises me is folks are not embarrased that their documentation (poor documentation) is available for everyone to see. It can't be buried in volume 3 of the paper chart anymore.

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Blogger QCOMDRJ said...

I noticed that at the VA medical center especially, notes are copied and pasted routinely. Residents often copy the student's notes, and sometimes don't even delete the signatures.
For me, I think it is ridiculous. For one, if it is already in the note, you don't need to copy it. Someone can find it pretty easily. I really get annoyed when they want me to copy lab values. How lazy are you to not look on the next page? Secondly, you it isn't that hard to type new values. We had to write that stuff over every day with handwritten soap notes. Plus, stuff often changes every day. I have seen discharged patients with "r/o MI" on their problem list.

I think all it would take is removing the ability to copy and paste.

8:02 PM  
Anonymous Anonymous said...

Ha! As a third year medical student at the VA here, I had a GI consultant cut and paste my note verbatim as the consult note, thus removing any possible benefit from getting a GI consult. Although, maybe it means that my evaluation was as well made as his was...
Anyway, it does save time with things like medication lists and past medical type things.

9:10 PM  
Anonymous Anonymous said...

I can tell you that as a surgeon practicing for years in a large clinic that recently went to EMR, I found the change very welcome: it means that when a patient is referred to me within the clinic, all the notes are instantly available, including the one written most recently by the referring doc. No more records "lost" in limbo. No more patients showing up not knowing why, and with the referring doc out, and the chart who-knows-where. Xrays, now recorded into the record digitally, are there, too. And the hospital has a link to our system, so when I see someone at 2 am, I can get all the info I need. The "cut and paste" issue mentioned in the other comments, is foreign to me. But heck, if someone were to like my writing well enough to steal it, who am I to complain.

12:20 PM  
Anonymous Anonymous said...

Our hospital uses a kind of electronic medical records, most of us hate it. It's much easier to read old case notes on paper by the bedside than squinting at the puter screen. One old lady asked me why are all the doctors spending all day playing computer games? All hell breaks loose when there's a system bug so you can't get any notes at all until the IT guys fix it. We end up spending hours hassling the path lab for verbal results. At the moment we have a choice of writing the notes manually and the hospital hires some poor buggers to scan them overnight, or you can type your notes electronically first time round. Most people choose to write, except for operative reports or discharge summaries, which must be typed. We all curse the system when it first came out, but now we're all getting used to it.

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Anonymous Anonymous said...

As a pt with many health issues, I've decided I don't like this new fangled deal!
It's not unusual for me to sit in the internist's office for 20 minutes just waiting as he reads the computer screen!

I much prefer the old fashioned way, where he's asking questions, doing a hands on exam, instead of reading a question off the computer!
That's just me though and I'm now a dinasoar as I just turned the big 60....
He's a good internist though, almost as great as his former co-worker.

Why DO doctors have to move away?? Ahhhh well.
Maybe it's for the best we have computers helping...?

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