Attack of the clones: “What I see constantly when I receive EMR records from other practices (where the patient was first treated elsewhere and the treatments were not successful so they are now coming to me) is that the patients look identical. That is – I can see histories populated from checklists and quick electronic choices . . . The diseases all look the same. There is never any detail on the nuances and subtle aspects of that individual’s condition.”
Related posts:
- EMRs and EHRs
- EMRs: Not ready for prime time?
- EMRs and malpractice insurance?
- EMRs and your life
- "If government wants a national EMR system so badly, perhaps it should pay for universal EMRs"
- Data entry in EMRs, and why doctors are slow to adopt information technology
- Looking outside of health care
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I agree.
Old timey records were made to summarize the doctor’s thinking at the time of a visit and a note of the plan.
Then medicolegal necessity required longer and more complete documentation, something that would stand up in a courtroom as a demonstration of a rational and reasonably complete clinical assessment and treatment paln.
Now we are in the age of the EMR and the driving force behind the grotesquely overwording is the CPT guideline for Evaluation and Management coding. EMRs aren’t about making records that make sense for some other doctor, or about establishing useful databases for remote access or to create a comprehensive patient record to avoid unnecessary over-testing or drug interactions. They are made to create records that will pass Medicare audits.
All you have to do is follow the money.
That can’t be! All the politicians, and venders, tell us that EMR are going to improve documentation and save medical care!
If you are right, then they don’t know what they are doing–and if they don’t what they are doing, who is going to save us!
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