EMR is here to stay, which will be good for doctors and patients

The electronic medical record, the EMR, is upon us.

For those of us who learned medicine entirely with paper charts, some have enthusiastically embraced the EMR and some have refused, to the extent they can, to deal with it at all. But most of us have plowed ahead into learning how to use it as best we can. It seems to me that the degree of enthusiasm physicians show for the EMR relates less to the particular version of it we have chosen (or, more commonly, was chosen for us) than it does to the kind of medicine we practice. The old paper records worked reasonably well for all of us; in contrast, the several versions of the EMR I’ve used work very well for some kinds of doctors, but less well for other kinds. I think a good part of this disparity is that the basic purpose of the medical record has changed over the past half-century or so, and some of these new roles can conflict with the old ones.

The oldest repository of continuous patient medical records is at the Mayo Clinic in Rochester, Minnesota. In a very real sense the modern medical record was invented there, in the first decade of the twentieth century, by Dr. Henry Plummer. As the first multi-specialty clinic, it made more sense for each patient to have a single record that traveled from doctor to doctor with the patient, rather than having each doctor keep his or her own record for each patient. The idea was to have a single packet of paper that contained everything that had happened to the patient. From that it’s only a short step to the notion that the record should travel with patients wherever they go, even if it is to physicians not associated with each other. This is a key promise of the EMR.

Medical records began as the possession of the doctor. This paradigm is changing. Very soon, although medical facilities will have copies, the records will essentially belong to the patient, with doctors only using them from time to time as need requires. Of course this could, in theory, happen with paper records, but it would be cumbersome. One of the things that first attracted me to pediatrics was the sheer size of the pile of paper that the medical records clerk would plop in front of the hapless medical student admitting an octogenarian to the hospital; in contrast, a toddler’s chart fits neatly in a small packet. The EMR allows these massive piles to be reduced to disks or microchips. It also allows the record to be organized into searchable form, so important things don’t get missed because they are buried in the disorganized mess of sequential folders.

Those are a couple of the brave promises of the EMR, but we all know we are a long way from realizing them. One huge barrier is that, as of yet, there is no standard platform for the EMR. Like many physicians, I’ve had to learn several because different facilities choose different vendors. In our pluralistic medical system (if one can indeed call it a system), it’s a free-for-all. And each of them has its own maddening quirks.

I think there is a broader problem here: over the ensuing years from Dr. Plummer’s era the medical record has taken on roles unheard of back then. For one thing, now the record is a legal document, a buttress against anyone who accuses us later of bad care. This process began long before the EMR, or course, which is one reason the charts I had to grapple with as a medical student ballooned so much. As a graduate student in history of medicine I had the chance to review many of the Mayo charts from earlier, simpler times. I recall one chart, from the nineteen-forties, describing the course of a very critically ill child. Overnight the child’s condition had markedly deteriorated; it was easy to see this from the recorded blood pressures and heart rates. The physician’s note for the following day analyzed these developments with only four words: “mustard plaster didn’t work.” Now the EMR offers the possibility of recording all we do easily and without getting writer’s cramp.

The medical record has also become something else it wasn’t back then: it is also now a commercial document, proof of what we did and why, used by payers to check up on us to make sure we should be paid for what we bill. Today’s payers want to know what the doctor did and why. They want to know, quite precisely, why that mustard plaster didn’t work and all that we did to make it work.

I think some of the problems with the promise of the EMR are that these legal and commercial roles can clash with the original purpose of the chart, which is taking care of the patient. The computer whizzes who design the software don’t always seem to me to have quite the same goals as we doctors who use it. The old paper charts were easy to adapt to new things, new procedures. All we needed was a different sheet to add to them and stuff in the folder. Upgrades and tweaks to the EMR are much more formidable things.

In spite of all these things I find the EMR to be a powerful addition to my practice. In fact, I think I’m a better doctor for using it. I think a key reason for that is because of what I practice – critical care medicine. In the ICU we love to measure and count things. We want minute-to-minute monitoring of variables, which in the old days resulted in huge paper flow sheets covered with dots and numbers. Rummaging through them to identify key moments in a patient’s care was often difficult. In the ICU, each patient gets a large number of tests each day, results which used to get stuck on clipboards with all the other paper. Important things got missed. Now I can sit at a computer screen and find it all with a mouse click, and the EMR makes it very hard not to notice anything important.

In contrast, I have friends who hate the EMR. It causes them hours of pain in training time, pain for which they aren’t compensated, and is slower for them to use than paper records were. In their minds, it gives them little or no advantage over paper in caring for their patients. I’ve noticed that they practice specialties that are less concerned with number-crunching than mine. They also tend to be office-based, rather then hospital-based, and don’t have to deal with as many other physicians as I do each day in the ICU. Thus many of their notes are written for themselves, not for other members of a large clinical team. Yet now they are asked to conform to how others want their charts to be.

I don’t know how all of this will work out. The EMR is here to stay. On balance, I think this will ultimately be good for doctors and their patients. But we don’t really know yet just what it is and what it should look like. I worry it will end up like one of those military boondoggles – it gets loaded with so many bells and whistles because it is supposed to serve so many purposes that it ends up being an expensive monstrosity that doesn’t perform any of its missions well.

Still, I’m an optimist. I prefer to be excited by the possibilities, rather than discouraged by the obstacles. I think the EMR will be good for patients, and will make us better physicians. For a while though, things will continue to be more than a little messy.

Christopher Johnson is a pediatric intensive care physician and author of Your Critically Ill Child: Life and Death Choices Parents Must Face, How to Talk to Your Child’s Doctor: A Handbook for Parents, and How Your Child Heals: An Inside Look At Common Childhood Ailments.  He blogs at his self-titled site, Christopher Johnson, MD.

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  • Killroy71

    Thank you for pinpointing the very reason that doctors SHOULD appreciate EMRs — they can correlate the data that hold the key to improving outcomes across the board.
    Learning any new technology is hard and at first takes longer than the “old way,” whatever it was. But that improves.
    Paper records haven’t worked so well for me, partly because of human error to be sure, but I have virtually no record of medical treatment before age 40 because of all the different doctors and health plans I had. This means I have no idea of the treatment I had for hyperthyroid at 37, or the mammogram from age 32 when I felt a small lump. When I left the state I lived in for 20 years, I carefully wrote to 5 doctors/plans asking them to forward my records to the new doctor. Only one did, but I didn’t find that out for 8 years, too late to retrieve them. Obviously, I’m not a “frequent flyer.” But I look forward to the day when all my data is downloadable onto a thumb drive.

  • KP Internist

    Killroy, my patients can have the majority of their medical records placed on a thumbdrive for 5 dollars. They find it handy for when they are travelling. By the way, I work at NCAL KP. If anyone wants to see the beauty of a fully functioning EMR, pay a visit to your nearest KP facility. It is absolutely impossible for us to go back to paper.

    • Max

      Nice to extol the virtues of a system you don’t pay for. I’m sure KP is wonderfully electronic. Order the Rx, order the labs, etc etc. tap tap tap click click click. Then you go on to the next patient while the computer and the front desk and back office handle all the directions and paperwork. Now imagine a private practice. One physician. One MA/RN. One front desk. Tell us how that EMR is gonna work there? You have 10′s of helpers clicking and directing for you at KP.

  • PCP

    Pediatric ICU doc. Am sure you’ve worked miracles.

    Good thing as you said you work as an employee in a highly instrumented unit that runs on oceans of numbers … and you specialize on patients who as you said have no med history to speak of.

    You might feel different if you were a pediatrician in private practice.

  • Stephanie Trifoglio, MD

    The issue is that the EMR is not ready for complex, complicated patients with a tapestry of medical problems. My patients cannot be reduced to check boxes and drop down menus. It diminishes what I do, it does not enhance it. Meaningless data is reiterated over and over and thoughtful analysis is minimized. No IT person has ever asked for or welcomed my input. Geriatrics, complex internal medicine — patients who have been in my practice for well over twenty years do not go easily into any of the currently available EMR’s

  • David Hager, M.D.

    This all remains an optimistic leap of faith.

    As a lifetime geek, I was shocked to hear anti-EHR sentiment from the VP of a company for which I worked. He’d worked for years for a large hospital chain and enlightened me to the onerous costs and burdens of EHR technologies.

    This article further resonates that concern:
    http://www.modernhealthcare.com/article/20100430/NEWS/304309962

    And listen to patients who complain that their nurses are now stuck at terminals instead of the bedside.

    As a user of a bad EHR in a hospital system, I am not an enthusiastic EHR advocate. It slows me down and does little that’s clinically useful. The only people happy with this EHR are the administrators and auditors.

    It has also been my experience thus far that active, busy clinicians at the sharp end of care have the least interest in changing to EHR technologies because these technologies haven’t yet achieved the ability to evoke an “OMG, I’ve got to have this!” reaction.

    When that happens, the feds won’t need to dangle carrots.

    If this doesn’t happen, no amount of carrot dangling and stick brandishing will be sufficient to engage clinicians durably into this technology.

  • Marc Gorayeb, MD

    What is this myth that EHR somehow helps to distill and make sense of the ‘numbers’ on a patient? Or that it will integrate all of a patient’s medical history ACCURATELY into one easily accessible location? This is pure fantasy for all but the most regimented and closed practice environments. (The term ‘cloud’ computing is particularly apt, isn’t it)?
    A patient’s chart should first and foremost record and express a physician’s thoughts and judgments about his or her patient. That is what I used to see in a physician’s office record, or a hospital progress note. That kernel of knowledge is slipping away, buried in a sea of irrelevant (and frequently inaccurate) data.

  • http://www.chrisjohnsonmd.com Chris Johnson

    I agree that too often an EMR-generated progress note is just a word and number salad of junk imported into the note from elsewhere in the record. For myself, I refuse to import anything — no lab values, not even vital signs. I force myself to type them in, so I know I’ve seen them and digested them.

    As Marc said above, what we want in the physician note is evidence of thought, of processing the events, lab results, and physical exam. One of the downsides of the EMR is that it makes it easy to write a poor note. Sure, it looks great to coders, because it has all the boxes checked, but it can be next to useless for actual patient care.

  • PCP

    Dr. Johnson … which is it?

    From your original piece:

    “We want minute-to-minute monitoring of variables, which in the old days resulted in huge paper flow sheets covered with dots and numbers. Rummaging through them to identify key moments in a patient’s care was often difficult. In the ICU, each patient gets a large number of tests each day, results which used to get stuck on clipboards with all the other paper. Important things got missed. Now I can sit at a computer screen and find it all with a mouse click, and the EMR makes it very hard not to notice anything important”.

    Or your reply immediately above:

    “I agree that too often an EMR-generated progress note is just a word and number salad of junk imported into the note from elsewhere in the record. For myself, I refuse to import anything — no lab values, not even vital signs. I force myself to type them in, so I know I’ve seen them and digested them.”

    First you are gleeful about how everything is right there “a mouse click away” … and then you say you import everything yourself.

    Perhaps for your practice the hospital’s ICU EMR works well with your limited patients you see in a day. Not sure how that translates to a PCP where each of the five of us see 30 to 40 patients a day including 40% Medicare who have been in our practice for 15 years or more.

    Your revenue stream in a ped ICU may support your diligence that your cases in life or death conditions require. Our revenue stream and the payback in delivered clinical value does not.

  • http://www.chrisjohnsonmd.com Chris Johnson

    PCP:

    It’s both, and neither. I’m a little ambivalent, which is what I wanted to convey in the post. On balance, like a decade from now, I think EMR will turn out to be a good thing. Right now, though, there are major problems. As an ICU doc, I find the EMR, on balance, to help me practice. But, as I wrote, I have many colleagues for whom the EMR is still mostly a pain.

    As I wrote, a good portion of the EMR seems geared toward billing and coding, not medical practice. That’s the tail wagging the dog. It’s not a knock on the EMR concept itself. And it should be fixable.

  • PCP

    @Dr. Johnson…

    You aren’t the only one who is ambivalent. And I agree that a properly designed EMR/EHR should provide clinicians a tool to better manage ongoing pt treatment plans and their outcomes. Unfortunately, as you noted it is being driven by those who would prefer to use the tool … networked to a national level … to audit the provision of care to Medicare pts initially … and to all pts ultimately in order to in the Administration’s opinion bureaucratically control the national cost of health care.

    An alternative solution developed and offered the primary care segment in the UK has been widely deployed by NHS-contracted PCPs. Whereas in the U.S. over 300 vendors are trying to penetrate the EHR market in the UK one entity … Egton Medical Information Systems http://www.emis-online.com/ has been one of a handful of developers who are successfully delivering the tool we are talking about to our Brit colleagues.

    If EMIS has been successful to volunarily take over 50% of the UK PCP market … without a national ARRA MU carrot and stick … what is ONC doing wrong?

  • Jim Tobin

    If EMR “belongs to the patients”, why does the physician have to pay the exorbitant fees for the software and hardware?
    Until there is a clear standard and lower cost I am holding off.

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