If every medical director or reviewing doctor walked off the job tomorrow, they would just go on with nurses, psychologists, social workers, chiropractor, pharmacists–whatever.

They would shut down tomorrow if all or even most treating physicians wouldn’t deal with them on their terms. On the government side, reviewers would disappear if the medical community would effectively self-police. I have had doctors ask me to shut down their quack fellow staff members–what ever happened to peer review at the hospital staff level? That is primarily the job of the medical staff.

I appreciate your candor, but feel you are doing the right thing for the wrong reasons, or maybe the wrong thing for the right reasons.

Your surveillance of other doctors is not for the greater good of the patients, or for the integrity of the medical profession, but simply to protect the pocketbook of the insurance companies.

Imagine what would happen if all of the physicians that lend credibility to insurance companies saw the light. No more medical directors. No more chart reviews. No more approval processes.

If you are not part of the solution then you are part of the problem.

A family practitioner

I am the prisoner referred to and actually agree with your implications 100%. It is shameful, but true. Shameful for all of us.

When the medical profession began taking the King’s shilling and capitulated to the world of socialized medicine, they became unfree. I say capitulated because the generation of docs first presented with it rejected it’s proposal but lost the argument. Then they accepted the money rather than stand and fight in the only meaningful way–non-participation. Current generations no longer even remember the love of independence and autonomy that made their fathers reject it. Rather most of our professional organizations clamor for more medical socialism, not less.

The fact of the matter is that some of the prisoners NEED policing. With the loss of freedom and autonomy that come with socialism come a trend towards surrendering personal moral responsibility as well. In short, being in prison tends to make one bad. Read Hayek.

Some have so forgotten the traditional virtues of Hiprocratic professionalism that they now see a medical license as just a business license that allows them to extract money from public coffers.
As is indicated by the comments above, some routinely submit falsified “invoices” in order to do so.

Actually the money isn’t much. Less than I could make in practice and many times less than I could pay pretending to practice while milking the medicaid/medicare cow. The special privileges are the opportunity to defend traditional standards a bit on the margins by reinforcing certain minimal standards of care and at least the appearance of professionalism–and uninterrupted sleep at night.

I would rather that the system were more rationally focused on finding the bad actors and monitoring them, and leaving the rest alone–but I didn’t write the rules of the prison–after all, I am only one of the prisoners. Of course if we were still a profession, then we would be self-policing, but that practically never happens.

Also, residents notes these days are essentially a copy of the prior days note and it is difficult to determine what changed in the patient from day to day because the same crap is denoted time and time again and is mostly useless.

In short, as a fellow on a consultative service…it is quite difficult reading the EMR to determine what happened during the course of a hospitalization.

Also, I find that I spend more time in front of a computer then I do spending time with patients…and if I am in clinic I look more at the computer screen then I do the patient. How absurb is that???? Medicine has become impersonable.

When I am an attending, it will be written in my contract that I may dictate ALL my notes and I will never type another note into an EMR unless I openly choose too….which I never will. Or they can provide me a mid-level provider to write all my notes (of course they will learn to write them MY WAY) that I will co-sign. That way I can do what I love, takeing care of patients instead of stareing at a computer screen all day. Of course, the only nice thing about EMRs is that labs are easier to look at.

Also, any hospital that employs the CERNER EMR…well lets just say that I will not be applying to that hospital for privildges. And that hopsital wasted a lot of money implemting that system…and if they want anything changes, Cerner will always say “Can’t be done.”

All that being said. Dictations and hand written notes leave a huge thing to be desired. That is… structured data. This is the problem that we face when trying to advance the science of medicine. We have so much information that is being lost because it is trapped in hand-written notes, and dictations (which, by the way suffer from mal-transcription. ie. what you dictate is missing or incorrectly transcribed.) Without investing in putting structure to our documentation, we decrease our ability to reap the reward that can help us advance medicine.

Finally to address one key point that you have brought up. To quote you.

“Is it relly (sic) that hard to dictate your own note (and have it placed in an EMR)?”

This is the opposite of EMR. This process is simply a transcription documentation system. It defeats what EMR is about. EMR is meant to house information in such a way as to provide decision support for healthcare. However, this is yet to be achieved on a wide scale. Places like Intermountain Healthcare and Regenstreif Institute would be the best examples.

Read this most recent article from the British Medical Journal.

BMJ 2009;338:b81 “Use of primary care electronic medical record database
in drug efficacy research on cardiovascular outcomes:
comparison of database and randomised controlled trial
findings”

Thank you,

JFS

1. I did not “grow up” with the EMR. I have ran for my own xrays. I have plated my own slides.

2. I have however created an EMR. I created it based on the belief that it is the best way to advance medicine and help our patients. This will become true as long as physicians guide its development. I originally began programming computers in 1979. Back then I had no idea how powerful computers were to become. I lacked vision. I won’t make the mistake ever again.

3. It is perfectly understandable to harbor ill feelings towards past and many current generation EMRs. However, the idea that somehow a paper record is better than an EMR is shortsighted. I will for the last time make this clear argument that the EMR is simply a tool. That tool, like any other, can be used improperly or properly. It is the professional that controls its use.

Quite possibly I have not made my argument appropriately. Many EMRs of past and current generations have failed to deliver benefits for many reasons (suboptimal user interface design, poor integration with workflow, complexity of medical care, etc.). This is well documented in the literature and through simple historical perspective.

What I am arguing is that holding on to the paper record is like holding on to using a candle to illuminate a room when you have available the first light bulb. Sure, the light is dim and it burns out quickly. But if you can’t see the immense potential that it holds to radically improve healthcare and society, then you might as well continue to work in the dark.

JFS

A family practitioner