Electronic Medical Records: Last Year's Silver Bullet

I was skeptical in the extreme when President Obama and other PPACA supporters  claimed so much savings would come from electronic medical records.  While in theory good, portable records might prevent some accidents and streamline care in certain emergency situations where there might not be time to take a full history, my actual experience with these systems did not give me much confidence.  And it just sounded like yet another politician's silver bullet  (HMO's were another such bullet 20 years ago).

This was a pretty powerful article about medical records and patient care.

There is no point in trying to automate the diagnostic process with an expert system AND retain the 12-year-trained doctor in the room.  It strikes me as one or the other.  Perhaps these systems are close to working fine and doctors can see themselves getting automated out of a job and this type of job is their last-ditch attempt to stop them.  Or perhaps the systems really suck and add a lot of extra time and cost.  It will be interesting when this has a chance to be fully studied.


  1. Matthew Slyfield:

    "And it just sounded like yet another politician's silver bullet"

    If only there was a silver bullet for politicians.

  2. sch:

    A little over the top, but in my experience with a full bore EMR just before retiring, not very much. The programs insistence on checking
    every box does demand more time of the practitioner and can lead you away from the line of inquiry that is actually pertinent to the
    patients problem. My line was emergency medicine, so pertinence was a big thing, but the powers that be insist the record reflect
    past medical history, family and social histories and a moderately extensive inquiry into other potential problems whether pertinent or
    not. This was in addition to inquiries as to whether they felt safe at home, were cared for, threatened, did drugs (what and how often)
    exercised, had flu, pneumonia, tetanus, pertussis shots etc etc. Net result is a minimum of 20% extra time spent in the FP, IM, pediatric,
    GYN and EM scenarios (ie primary care) just to fill out and finish the record. The net result is a record that "justifies" a higher value
    billing because of all the bullet points hit. Ironically CMS has gotten huffy about the higher bills it has been receiving with the advent of
    meaningful use EMRs. Any of you that has seen a primary care MD in the past few years will have noted attention diverted to the
    computer that was in the past directed at the patient. It will likely get worse a lead to primary care being taken over by NPs, it is already
    happening with ~200k NP/PAs and 850K MD.

  3. DirtyJobsGuy:

    I watch my Docs work with the EMR and see how clumsy it makes them. You cannot blame lack of computer familiarity for this but its really the design of the system. The biggest problem seems to be that a system for allowing access to tests and records (which seems to work well) is being bundled with both an audit system (bad) and a poorly setup work order generation system. Perhaps the easiest way around this is to simply have the MD write notes on a pad as always then scan them in (using a pad or other photo scan). The information is then available as always to the writer. For the patient orders etc. simply give the traditional forms to an administrator to enter them all in as required. I find the printouts of standardized instructions both to be slow and unhelpful (I can recognize boiler plate when I see it).
    We were lead to believe that by making these electronic they could be shared between Physicians easily (yes for scans and tests), but the Medicare billing system is now running the show along with policy wonks requiring checklists for everything.
    Once again the state run part of the payment system is running the show.

  4. Mondak:

    I wrote this article on the "PMR" or paper medical record and resilience in the face of the EMR a few years ago. Still very relevant today.

    TLDR: Even when providers and clinics have implemented and actually USE an EMR system, there is little to no ability to share information from system to system. So the big benefit to an EMR - the ability to share the thing when needed - goes out the window if it ever is required to leave the four walls of the office where it originated. Instead, nearly 100% of the time it is printed or at best dropped to PDF. The PDF is nothing more than a picture of the medical record - all the smarts and electronic content is gone.


  5. eddie:

    It seems as if the doctor here is incompetent, in that he is doing the equivalent of filling out post-encounter paperwork instead of assessing the patient and identifying a course of treatment.

    If a filing clerk were standing between you and your patient, would you sit there talking to the clerk for an hour, or would you tell the clerk to wait until you were done treating your patient?

    In truth, I'm sure the doctor is not actually incompetent, and this particular scenario was dramatized for the benefit of his audience.

  6. eddie:

    Actually, it's not a dramatization. It's fiction.

    In the comments, the author says "It is fiction. I tried to capture exactly what it feels like as an ER doc in this day and age trying to take care of patients while constantly being disrupted by computers. I wrote it after a shift where 99% of my time was spent clicking through screens, sitting at a desk, entering orders, acknowledging warnings that have no relevance at all to what I do."

    The parts that seem most outrageous to us layfolk are complete fiction. They didn't happen, and they don't happen. EMR systems are vastly better-designed than the author is portraying them to be, and EMR users - i.e. doctors - are vastly more capable of using them without allowing them to interfere with their actual practice of medicine and use of clinical good judgment than the author portrays his first-person protagonist of being.

    This is "what it feels like" to a doctor. This isn't what it actually is, though.

    Well-designed EMR systems save lives, because doctors make mistakes ALL THE TIME that kill people. EMR systems aren't perfect either, but when well-designed and well-managed and well-used (which certainly doesn't always happen, but happens often enough to matter) they are a tool that can help doctors do their jobs much, much better.

  7. ErikTheRed:

    According to a good friend of mine who is a highly-regarded specialist doctor, these these new electronic medical records systems are apocalyptically awful in a manner that is easiest described using complex-compound profanity. His biggest beef - from his personal perspective - is that the new systems no longer allow him to dictate notes on his patients, and that he must enter the data himself. This is not the prima-donna bullshit it sounds like. When he could dictate notes, he would elaborate at length into a recording device and hand that over to a highly-trained medical stenographer that would get all of his arcane and specialized terminology and references and create an accurate and highly-detailed analysis of what was going on with the patient; this was often several pages. But as a practicing doctor, he doesn't have time to type that up, and so his notes have shrunk from several pages to just a few terse paragraphs. Because of the complexity of the cases he deals with, this is potentially detrimental to The System's ability to handle his patients - especially those for whom he is the diagnostician and not the treating physician.

    As an IT security specialist, my take is that the question isn't whether or not this system will be hacked - it's how often and how appropriate analogies involving tentacle rape pr0n will be.

  8. bloke in france:

    A decision tree is an expert system! We could do without doctors and hire more ninth graders.

  9. James:

    My doctor used to look at me, ask questions, and interact including follow-up questions based on my answers. Now it seems like he's got his nose buried in the computer screen, reading off questions and checking boxes. Very little interaction. It has completely changed the experience, and I don't really like it. Maybe I should just enter a bunch of stuff into WebMD or something instead and bring it with me.

  10. aa:

    To emphasize the point by sch, the primary use of the systems is billing, not patient care. Since MD's are not usually involved with cost allocation and billing, they play little or no role in the design of the systems. Somehow we need to get back to patient care and make billing a secondary function, not the primary function.

  11. Scott Robinson:

    The traditional medical record was organized like a book where sections could be turned to and read. The EMR is basically a data base, primarily valuable to regulators and payers, while adding little functionality for physicians (nurses or PA's as well).
    The problem of alert fatigue is now coming to light as well.

  12. STW:

    Or a simple wooden stake.

  13. sch:

    Well that is the point Eddie, that there are damn few "well designed, functional EMR systems". They probably do capture billing information reasonably well, and when the chart is "completed" it certainly satisfies at least part of the CMS requirements for
    documentation, but in primary care or first encounters it increases MD time at least 20% to accomplish this. You cannot close or
    finish a chart until all the "Ts" are crossed and the i dotted. Typically in a reasonably busy ED this can be 3000 to 4000 mouse
    clicks per 12 hour shift. In the paper days I could fill out a chart in 5-10 minutes per patient and the billing people were happy with
    over 95% of the work product. The total chart size with MD & nursing notes, lab and xray reports, demographics and any consultant
    notes rarely exceeded 20 pages and most were around 10 pages. EMR when printed out are never under 40 pages and can go to 50+, judging by the charts sent in from other hospitals with ED to ED transfers. Trying to wade through the computer generated verbiage to
    figure out what happened is excruciating. EMR electronic transfers do not exist when different EMR systems are used so paper copies
    have to be printed. Note the comment in the NYT article about SF General spending $160M on their EMR that the chief of ED calls
    a nightmare. The article cited in the original post is actually quite typical of the MD experience, at least in the ED and many primary
    care settings.

  14. jdgalt:

    How hard is it for doctors to avoid the whole pile of crap by refusing tax funds? I'd jump to the first one that does this.