The Truth About Electronic Medical Records

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May 31, 2015

Patients are either grateful or mildly amused when they see me writing in paper charts. Prompted by a few articles I read this weekend, I decided to share my thoughts with you about electronic health records or medical records (EHRs or EMRs).

The idea behind computerized records was that multiple doctors taking care of a patient could share notes, get test reports and avoid duplication of studies. In a rush to get medical practices on board, the government provided significant incentives for doctors to install an EMR system and then submit data proving “meaningful use”. Hundreds of different companies developed software for this purpose. The only ones that we looked at that could actually share data with other offices would charge us a large sum for each physician practice that we’d choose to exchange data with in the cloud. So essentially, as it stands now, none of the systems ‘talk’ to each other.

Some of the earlier software companies disappeared, causing many early adopters to have to change systems as soon as they became familiar with the first one. One practice we receive consult notes from has been taken over by a well-respected university hospital. They are on their 3rd EMR system and can’t always access their own notes from a few years ago. On several occasions, I have faxed their notes back to them (which were conveniently located in my dinosaur paper chart), so they could catch up on our mutual patients.

Many of my colleagues have cut back patient visits about 25% so they have the time to enter the info from the appointments into their computerized records. Some take home 2 hours of ‘data entry’ every night. Others have hired scribes, which is an expense that most internal medicine practices can’t afford. Many of my patients mention the impersonal effect of having a physician typing on a laptop while talking to them. It interferes with the flow of the conversation. Having a scribe in the room would interfere with the confidentiality of personal conversations I have with patients about their medical problems and home situations.

Patients have mentioned to me how important our chats and eye contact are to them. I’m an excellent typist, having worked my way through summers as a teen doing temp work, but there’s something about having a machine between us that would impair the doctor-patient interaction. A patient reported an initial visit with a psychiatrist who never looked up from his computer – how can that be?!

To make matters worse, I receive 4 and 5 page notes from consultants and have to search for the basic info I need – why did the patient see them, what was found on their exam, what is the diagnosis, how did they treat the patient and when will they see them again? The majority of the notes I receive are created by ‘cut and paste’ from prior notes, so errors can be repeated for years. Past medical notes cannot be altered, for good reason, although an addendum could be added. Current notes could be edited to correct the misinformation, but often aren’t. Patients bring in their copy of the notes – provided to them to fulfill the “meaningful use” requirement (see below) – and point out the errors – in medications, in history…

What’s more, I feel obligated to read these very long notes – what if there’s a line buried in there that says ‘there’s a thyroid nodule’ or ‘patient complained of chest pain on exertion’ and I’ve simply initialed and filed it? Not to mention that as an environmentalist, I’m disturbed at the reams and reams of paper, ink and toner that we use printing the notes as they come over the fax machine so we can add them to our paper charts. Consult notes were usually one or two pages before they were computer-generated.

In the past few years, physicians who implemented an EMR and were able to check certain boxes as complete (e.g., for personal patient info, BMI, meds … ) would qualify to receive a “bonus” for achieving “meaningful use”. If a practice couldn’t afford to transition to an EMR system, not only did they not receive a bonus the past few years, but in 2016, their Medicare payments will be decreased by 1% and by several more percent over the following years.

Physicians in different specialties might have different experiences with the EMR implementation. As internists, we need a system to be flexible and user-friendly to accommodate the details about the many organ systems we address, and the consult letters we receive. The use of EMR has been particularly costly and impractical for small internal medicine practices like mine. Given the shortage of primary care doctors prior to EMR adoption, this only accentuates the problem. Docs with decades of experience are retiring earlier than they intended, for multiple reasons, not the least of which is the debacle of the EMR implementation and other changes in the health care profession.

In my opinion, the use of EMRs could have improved overall health management, had we waited for a universal system to be developed that would have been used by all doctors. But as implemented, the use of EMRs has nothing to do with quality of care, and instead has wasted billions of dollars incentivizing doctors to use systems that cost them valuable time and money. Just my opinion – what’s yours??

See also The Washington Post article 5/29/15 by Charles Krauthammer titled Why Doctors Quit