What if blogs were run like a paper medical record system?

I always find it very ironic to see doctors bashing EMR on the Internet. They are bashing a tool designed to gather and organize information, improve communication, and give immediate access to important information, while using a tool that gathers and organizes information, improves communication, and gives immediate access to important information.

It is fine to bash the current state of EMR (I saw one site complain that EMRs have a Windows 95 feel, and I agree with that assessment). It is fine to bash the government’s attempt to force/lure doctors to use EMR. But bashing the basic idea of computerizing medical records is incredibly myopic. Are there really people out there who think paper charts are our best option?

To show how crazy this idea, let’s pretend that the Internet was constructed like a doctor’s medical record system.

1. To read this post, you would have to do the following:

* Get written approval and documentation on my writing system that you do have that approval.
* Wait for me to mail or fax them to you. I am terribly afraid that using email would jeopardize BIRPAA (Blog Information Readers Privacy Accountability Act) standards. To follow those standards to the letter, I would also have to get your fax machine authorized as truly being yours and not someone who wants to steal my blog information.
* Each post would be either dictated, taking an unknown amount of time to come back, or handwritten in generally illegible scrawl.
* Even after requesting the information (which you would do by phone or fax), you would have a fairly high chance of not getting that information.
* If I write anything about you, you would have to pay $5 per page to get a copy of it.
* If you request a single post, you would usually get a complete copy of every post I have ever written.

2. To comment on this post, you would:

* Quote the entire post back to me (as a specialist does with a patient history) before leaving your comment.
* Mail/fax the copy to me at my request. Most of the time, you’d just keep your comments in your own filing system that I have access to only at my request. You are terrified of violating BIRPAA as like me.
* Not have access to any of the other comments done by other readers unless you knew who they were and had written authorization to do so.
* Usually work with a very small part of this post to do your commenting about (as most specialists have almost no information from PCP’s when they consult).

3. My blog would have the following organizational system:

* It would be a bunch of paper shoved into a thick manila binder.
* Since I am a prolific blogger, I’d be on “volume 3″ of my blog, with volumes 1 and 2 available only by request from my blog records department.
* There would be a large number of incomplete posts, and also many missing altogether.
* My list of topics and tags would be kept on the left side of the chart, and (since I have ADHD) they would include a number of errors and outdated topics.
* I would have a large stack of blog posts on my desk waiting for me to complete them.

4. My posts themselves would look different than they do now:

* I would have to use B/M coding for the posts to be acceptable. This means that the vast majority of the information in the post would be there simply to meet B/M standards, while a small portion would actually have useful information. (See my post on “fluff”)
* I would practice “defensive blogging,” in which I would write about a bunch of unnecessary topics with extensive footnoting to keep from being sued by blogpractice attorneys, who scour blogs for inaccuracies that could give people information that is not true or incomplete.

5. Those of you with computers would have very little advantage from those who don’t.

* The computers would not interconnect or share information.
* The systems used to read and write information would be very expensive and be antiquated.
* Blog posts generated via computer would have a lot more unnecessary information, but would meet B/M coding criteria.
* To share your posts written on your computer, you would have to print them out and mail/fax to another blogger. They would scan a copy of your post and put a PDF file into their computer system.

Thankfully, the Internet is what it is — not at all like medical records systems. We have instant information, instant access to data, and can share opinions and ideas rapidly. Would it be possible to construct a medical record system that did the same? Would it be possible to use the information system you are using right now to make patients records more accurate and accessible?

I admit that privacy is the big beast that prevents most of this, and that has some justification. I don’t want anyone to be able to subscribe to the RSS feed of my medical record. But medicine takes very little advantage of the Internet to improve care, and connect providers. Perhaps the first step needs to be forcing docs onto EMRs that meet a communication standard — I have heard from insiders that this is part of the big-picture plan. Regardless, we need to combine the two worlds. It is very easy to write about healthcare and share that thought, but it is near impossible to write about a patient and share that care.

Something is very wrong with that.

Rob Lamberts is a primary care physician who blogs at Musings of a Distractible Mind.

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  • alex

    “It is fine to bash the government’s attempt to force/lure doctors to use EMR. But bashing the basic idea of computerizing medical records is incredibly myopic. Are there really people out there who think paper charts are our best option?”

    Either this is a straw man or you’re just not getting it. Of COURSE one can imagine a wonderful EMR that didn’t present an obstacle to actually practicing medicine. But if one does not believe there is any chance for such an EMR to be accepted by the actual powers in medicine (i.e., third party payers and medicare) and that in fact the drawbacks to EMRs from the physician’s perspective are often not drawbacks to them (20 minutes of typing per patient? Excellent, can you make it 25?) then it’s ridiculous to act like some “Dream EMR” ought to have any role in the debate over the role of EMRs. Just like the mythical jet car has no role in the debate over how big a role cars should play in our lives.

  • http://fastsurgeon.blogspot.com JF Sucher, MD FACS

    If the Internet was programmed like an EMR:

    1. You would have to open a different web viewing application for each website that you wanted to view.

    2. Each web viewing application would have a unique way to navigate, view, and enter information. The buttons would be in non-standard locations with a myriad of layered menus.

    3. You would have to open a separate application to view the pictures on the website.. but when you did, you the picture for the page that you were viewing would not be linked to the current page. Therefore you would have to search the entire web for the page. Then pick which image you wanted to view.

    4. There would not be ONE Internet. You would have to connect to many separate entities to get the information you needed.

    5. You would need to have an web browser rep come to your office and charge you a consulting fee to evaluate how you would use your browser.

    6. The browser rep would charge you a setup fee.

    7. The browser rep would charge you to customize the application to fit your particular needs.

    8. The browser rep would then take all your input on how the browser could be better.. and give you nothing in return.

    9. The browser would not accomplish what you needed it to do. You tell the browser rep. They update the application and charge you for the update.

    10. The browser fails to do what is truly necessary. That is, it fails to make you more efficient. It takes you twice as long to write and send email as it should.

    Sir, there are many positive steps that we have made in way of improving our access to patient information. There have been many more negative aspects because the industry has been extremely poor in its design of the systems AND the healthcare system has been more concerned with billing and documentation of Joint Commission and CMS requirements than it is with helping to improve communication between providers of care and patients.

    If we do not stop the path that we are on and focus on building a system that does the job we need… we will only have what is currently being shoved down our throats. That is, extraordinarily poorly designed systems that do not help us communicate better and, in fact, increase the number of resources and expenditure necessary to run them. EMRs, EHRs, PHRs, etc. can be much much better. What is being sold now will continue to be sold because we have been forced to accept it indirectly … as the government and “quality” organizations have mandated what is out there and the money therefore is required to be spent. In my opinion, the money that has been allocated should be spent on development of systems that actually do what physicians, health care providers and patients need.. not what administrators, government and insurance companies need.

    FaST Surgeon
    High Tech Surgeon

  • Rob

    Well Alex, then you haven’t read my blog. I use an EMR and am functioning far above the national average in income and any time we have been measured for quality patient satisfaction, they have also excelled. There are people doing it well (I am not unique), we just have a system that rewards documentation, and so EMR’s are created to do that. The problem is the payment system, which EMR’s have to recapitulate for them to be relevant to doctors. Garbage in, garbage out.

  • Max

    Well, EMR’s can help one get a level 4 visit out of a level 3. Just ask a few more ROS questions. Yep, EMR’s are wonderful. Shoot for the moon. You may even get a level 5 and it’s all good because you asked the questions the EMR said is lawful and legal to ask and you’ve got the documentation to back it up in case you’re audited. Besides, that support payment is coming due soon.

  • stargirl65

    If the banks can run secure private systems with our money and talk to banks all over the world then why can’t my medical record system do the same?

  • http://astridvanwoerkom.wordpress.com/ Astrid

    The problem with EMRs is not that it is technically easier to access records than with paper records, but that it is made practically easier to access records one previously required consent for from the patient. Like, it doesn’t make much of a difference whether you kept a paper journal or an online blog except that the online blog is technically easier to access by people all over the world. However, with EMRs it’s like if you used to have a private paper journal that people needed consent for to get copies of specific pages, and now that you’re swithcing to an online blog, you’re making the entire blog available to anyone you decide to give consent to. The reason I opted out of having my records filed in the EMR in the Netherlands is not that it is electronic, but that I don’t want a doctor to see all my records rather than request just the relevant bits. For example, if I have appendicitis and need surgery, my psychiatric history is none of the surgeon’s business. Of course one can trust that the doctor will only access the relevant bits (in case of appendectomy they wouldn’t have time to read 2 1/2 years of psychiatric records even if they wanted to ;) ), but I want to make sure my doctors get prior consent from me before accessing any part of my record. Whether they access the record via a computer or on paper, doesn’t principly matter to me.

  • http://www.myhealthtechblog.com Deborah Leyva

    I have a theoretical perspective on the problem at hand….

    Medical personnel are educated in the science of medicine.
    The rest of the world uses computers to enhance their fields.

    All kidding aside, I believe the push-back on EMRs relates to their usability. If the program is not intuitive and it is not easy to use, then it is not likely to be easily adopted. Technical people shouldn’t be designing the user interface.

    My 2 cents.

  • http://www.heathero.com HeatherO

    Having just read an article that should’ve been called 101 reasons why doctors don’t want to communicate by email, I found this one hilarious!

    I can honestly say [from the patient family side of things] that I cannot begin to tell you how much pain, anquish and error could be avoided with EMR.

    I personally just did a demo of this one for patients and am signing myself and all of my family up!

    Great post, thanks for sharing

  • Rob

    Here’s the rub: For something to be “usable” for a doctor it must:
    1. Follow all of the documentation standards for reimbursement (even though those standards make the system less usable).
    2. Follow the privacy standards (which adds a huge chunk to cost).
    3. Interconnect with doctors who either have systems which can’t connect yet, or who are technophobic (which is a large chunk of the medical community).
    4. Penetrate a mindset that inherently resists big change and get them to accept that the old way is really terrible.

    What most bashers of EMR don’t recognize is that the shape of EMR has largely been forged by our perverse payment system that rewards procedure over thought. Any system that documents thought more than procedure – while being more useful for patient care – will make the job of doctoring harder. We document more to get paid than we do to care for patients (unfortunately).

    Again, however, I must point out that some of us have overcome these problems and have made EMR actually work for both patient care and for documenting for the sake of getting paid. It is a jury-rig, to some extent, that won’t be fixed until we lose the idea of doing more should be paid more. Doing better should be rewarded – something that EMR may actually be able to recognize.

  • r watkins

    “who are technophobic (which is a large chunk of the medical community).”

    Please put this lie to rest. It is not, and never has been, true. Every doc I know loves gadgets, gadgets, that is, that work and provide a benefit to someone.

  • Rob

    A liar? Nah. I really am a truthful guy.

    I have been on EMR for 14 years. I have tried ad nauseum to get docs to accept communication via secure email. It would give our specialists and hospitalists more information and would make their job easier. It would improve the care of the patient.

    Only one doctor in our community is embracing the use of a technology that the rest of the world is using. Perhaps saying “technophobes” is incorrect in that docs do use technology in other means, but their aversion to using electronic communication (and EMR as a whole) is remarkable. I am already communicating more with the readers of this blog electronically than I ever have with 98% of the local docs.

    And that’s the truth.

  • David Lubin, MD

    I love Dr. Rob’s thought process and scribing, or maybe it’s scribbling, if there’s an equivalent in the blogging world. At first we physicians are admonished for not embracing EMRs in our practices, but then Dr. Rob gives all the answers why we don’t. We “older” physicians are not going to take the time to learn the “system” just to increase income, and some may not find an increase at all, just from typing more words. Then there’s the exorbitant cost to get into EMRs and maintain them, especially for large practices. And then the incompatibility with others and the time involved. As much as doctors like gadgets, most have no idea how to use them properly or get the most out of them. I always joke about VCRs in doctors’ homes flashing 12:00 because they don’t know how to set the clock. I’m not sure what Dr. Rob’s patient load is per day, but I see about 30. EMRs would be difficult for me, even being computer literate and being able to touch type. I went to see my urologist, who has EMRs, and while he typed away on his laptop, I just had the feeling I was talking to the model of the penis and prostate. We discussed things a bit, but there’s that feeling that he’s actually being distracted while inputting data, something a blogger has compared to texting while driving. Dr. Rob, I’m sure, will agree that it doesn’t matter how much fluff you include, EMRs really have no, or little effect, on the actual healthcare we provide our patients. I’m not arguing that it might lessen errors. It’s all done in the name of money and scrutiny by the government and insurance companies. And ironic that the scrutiny continues to generate hours and hours of paperwork of getting prior authorizations for meds, diagnostic studies etc. There are ways to improve records within the doctors’ offices for their own use, but the overall use of EMRs to connect the world’s medical community just won’t make it….and that’s my two cents…or maybe a nickel’s worth.

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