Wednesday, July 11, 2012

Is the Electronic Medical Record Full of Lies?

In a provocative piece in the Journal of the American Medical Association (JAMA), Elizabeth Toll, MD pens a powerful portrait of what the Electronic Medical Record have brought to the doctor-patient relationship, describing both its benefits and its limitations (be sure to see the 7 year-old's precient drawing as well).  Perhaps most disturbing was this passage in her essay:

There is a certain irony to all this. For years, we’ve been hearing that focusing on our patients as people, improving communication, admitting mistakes, and creating patient- and family-centered care will make us better physicians, gratify patients, and prevent lawsuits. In fact, professionalism and communication are core components of the residency training curriculum. Medical schools have begun to insist that applicants demonstrate proficiency in the humanities and social sciences, as well as the traditional hard sciences. So, to watch these directives shift with the mandate of the EMR seems a sad reversal of progress and common sense.

All this is not lost on our patients. In addition to the young artist, whose drawing speaks volumes, wherever I go in or out of the medical world these days, I hear patients' observations: “My doctor hasn't made eye contact with me since he got on that computer—he's not a very good typist.” “Our visits are rushed. My doctor used to have time to listen to my concerns, but now she spends a lot of time complaining about how hard her workday is.” Physician colleagues pour out similar comments: “In the past I would see a patient, write a note, close the chart, and spend a moment reflecting on the visit. Now my time goes to fighting with the computer and chasing down my colleagues to get them to lock their notes, so we can submit bills.” “I feel pulled in so many directions, like my brain is scattered. I went into medicine to work with people, but now I’m in front of a computer screen all day, managing systems. I still love my patients, but I hate how I’m spending my time.”

This essay has not been lost on the Electronic Medical Record industry.  They are feeling the pushback of doctors who are insisting not just more information, but better information and better efficiencies.  In a phone interview, Dr. Toll took some of these concerns further:

The EMR was designed to demonstrate the pieces of the record that you have to attend to in order to bill at a certain level. If you just enter a few questions and you only enter part of the exam, and you only add medicines and you only do this or that, you can only be reimbursed a certain amount. But if you asked about, for instance, the family history, the surgical history and the social history, then you have all the elements to charge more. So there’s an incredible temptation to just push, push, push and bring forward everything from the previous notes without re-asking the questions.

This creates a huge problem: The records are full of lies. They’re full of things that [physicians] have said they’ve done but truly haven’t. The patient has been in eighth grade for three years. The patients are divorced, but in the record they’re still married. The patient used to work as a nurse and now works as a librarian, but it hasn’t been changed in the record because people are giving quick, push-button answers to save time, and they don’t update the info. You can see this as you go through small things in the social history but also in [clinical histories]. Yesterday, someone sent me a letter about an amputee patient he sent to a podiatrist. He got a report back on both the patient’s feet. This patient only has one foot.

Cut and paste has its efficiencies and its downfalls. When audits happen to justify billing and innacurate copied paragraphs are found to fill the doctors' note, how will hospital systems respond?



Diane said...

We no longer forward records. We request ours and provide what is medically relevant and accurate.

17 years of medical records from specialists around the country and only 1 specialist even got close to accurate

As far as the social history? Sometimes I have wondered if they are more interested in the parents then the child patient. Hilarious how depending on the Dr. I am either mousey or pushy- too loud and ignorant to well educated. So either my entire family and I have a multiple personality disorder or Drs. really need to figure out what they should be recording.

Electronic records are only going to make malpractice rates skyrocket! Specialists ALWAYS depend on the previous records from their peers more then what the patient shares-

Anonymous said...

The EMRs we have are the completely inevitable, completely perfect result of our ICD/CPT/CMS medical system.

Anonymous said...

I have been doing anesthesia for 24 years now it seem I am occasionally abandoning my patient to either enter data in the computer or trouble shooting a data error. I feel that I get a pat on the back for proper computer entry not patient outcome

Anonymous said...

I am both an informed and proactive patient (no doubt due to having worked my entire career in the medical industry) as well as a software engineer for a medical software vendor -- and am in fact the software engineer responsible for interacting with our customers for anything related to Meaningful Use.

I live in a community whose medical practices made the switch to electronic records quite early, and as such are relatively sophisticated users of this technology. In the clinics I've been to, each exam room has a small (2' square or thereabouts) shelf attached to the back wall at desk height, with the provider's stool on one side and the patient chair on the other. Providers and MAs bring their laptops in with them, and the laptop is on the table between the patient and provider. This setup allows the medical staff to review notes, enter information, &c. without having to turn away from the patient. The minor loss of eye contact is more than made up for by the ability of the provider to find information -- both patient-specific as well as more general -- without having to leave the exam room.

I'm not a typical patient, since I'm much more used to interacting with people and keyboards at the same time and don't find it inconvenient or distracting when others do so. However, I am amazed at how a simple shelf and two chairs in the right place can make the provider / patient interactions much more pleasant -- and how often it seems this sort of change wasn't considered when installing an EHR system.

Pluripotent said...

Forcing physicians to adopt EMRs was a mistake. People bemoaned how the world has advanced, but physicians are still writing paper charts. The fact is that EMRs were not yet ready for prime time, and still aren't. They're too expensive and not user friendly enough, and most of the wonderful things they're supposed to be doing for us aren't yet implemented, which is why they needed to be forced at this early date. EMRs are inevitable...they would eventually have become the record of choice, anyway. But now they have been adopted in a premature state and there is no reason to improve them, their customers are mandated to purchase them. This will only further delay the time when EMRs are finally worth using.

Anonymous said...

As nothing but a regular patient who has requested and read his own medical records, mine are full of lies.

I was not pleased to find symptoms and tests that never existed (another record mixed with mine).

Reading on, I found a number of complaints I never made. (ie. Patient complains of ....). Were they recorded to justify tests? to please insurance? as pure error? I have no idea.

More importantly, the pure volume of useless information was overwhelming. I had a hard time finding the important stuff, and I knew what I was looking for. No way a provider could find what he/she needs to know in that mess.

and..I'm a pretty healthy thirty something. I can't imagine what a complicated file looks like.

Anonymous said...

I am a medical transcriptionist. Yes, we are still out here, still "translating" many doctors' awful, garbled, yawned-through, chewed-through, belched-through reports for those that dictate instead of type. We get paid the grand sum of 4 CENTS a line to decipher information that a lot of doctors seem like they would rather not say, or say well. I often wonder if they talk to their patients the way they slur through their reports. To me, it's very disrespectful of the people who are counting on him. Do you care enough to clearly say 15 or 50 mg of a medication dosage? To make sure it's the right or left foot you operated on (many reports have both for a surgery on one limb). I could go on. I'm sure that most doctors really care about their patients and want to see them get better and maybe even not really need them anymore, but it's hard to tell sometimes. All the MTs I know care deeply about making sure the information we provide is correct. But it has to be given to us in some kind of coherent form. If you dictate or have colleages who dictate, I urge, no I BEG you to please encourage them to slow down and speak just a wee bit slower or clearer. It's all in the interest of the patient who should be number one. Right? Thanks for letting me vent.


Anonymous said...

Nobody is talking about power outages and EMR!
I was in an office today when the power went off and they were paralized. All work had to stop until it came back on again.
Have the whiz kids thought up how to cope in these situations?

Unknown said...

lets be very clear about one thing and one thing only, the ONLY reason doctors are now complaining about all they are doing is because of money/greed. Doctors were told they could save money in the long run with EHR/EMR by not using/paying transcriptionists and are now documenting in their charts by themselves. Doctors - if it's difficult to do your job of seeing/treating patients AND typing, cough up and pay a transcriptiontist to do the job correctly!!!!!!!and stop complaining cheapskates. there are still some doctors who value face-to-face time with patients, hats off to ya!