How the physician replaced the medical secretary

How the physician replaced the medical secretary

I recently sat in a small room, in the bowels of a local hospital, training for the impending implementation of CPOE. For those not familiar with current health care acronyms, this stand for Computerized Physician Order Entry.

Nearing the end of my medical career, I could not help but admire the timing of this phenomenon. “They’ve finally done it,” I mused silently. They have replaced the medical secretary with none other than the physician. I supposed this was inevitable. After all, for years now I have been stuffing my own charts with order sheets and progress notes, applying patient labels to same, retrieving my own lab and radiology reports, etc. This was just the logical conclusion

But for one who has been an EMR advocate, the irony did not escape me. For almost ten years now my cardiology group practice has had an EMR, and although it took me a good 6 months to become comfortable with it, I now couldn’t imagine going back to a paper chart. So why is the hospital equivalent so painful for myself and many other older doctors?

Lack of compatibility and conformity is one big reason. I am on staff at six local hospitals, which have three separate electronic health records. That means learning the ins and outs of three completely different means of accessing and inputting data. There are three different sets of user id’s and passwords, which change at different times and all with variable character requirements. If I read EKG’s or diagnostic studies, it is probable that I must use a different application with other unique id’s and passwords as means of navigation.

How bad is it? Well, because of this, and other personal applications that I access, I succumbed to a password keeper application. In less than six months, I now have about 75 different apps, or programs, passwords, which are now kept quite nicely on my iPhone, iPad, home computer, and in the “cloud.” For those of you technologically challenged, the “cloud” is a mysterious data storage area kept in a baffling location, holding onto a humungous number of bits, (or is it bytes?), of information all over the world. You can dump, and retrieve, data into and out of it with the touch of a keystroke. (Provided of course that you remember the correct use ID and password.)

IT, or information technology, is a wonderful thing. Yet, because of the ease, and wealth of information that can be handled, there is a tendency to abuse it. How much better is my life after reading, (or deleting), 100 or more emails a day? Do I really need a weekly e-mail update from the medical staff secretary about which drugs are now unavailable due to a “national shortage?” If I order it, and the pharmacy doesn’t have it, they will let me know, and I will order something else.

It is easy to loose site of the fact that IT is just a tool, and like any tool, can be used to improve our lives, entertain us, or to do evil, as in identity theft.  My gripe is that is the push for a nationalized electronic health record has come without any true means of having seamless integration of the multitude of programs. Few records, like hospital and physician offices, “speak to each other” electronically, and therefore create as many problems as they solve. Physicians’ efficient use of preciously limited time has become another victim.

We were sold a false bill of goods. Optimistic predictions by a RAND study in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place. (And oh by the way, RAND’s 2005 report was paid for by a group of companies, including General Electric Co. and Cerner Corp., that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, from $1 billion to a projected $3 billion in 2013.) But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services. Whoops.

The US health system is so large and heterogeneous that it is virtually impossible to integrate it in a seamless fashion. Imagine if we could carry around a microchip that stores all of our medical history and testing so any health care provider could access it instantly. So if you just had a coronary stent a few years ago in Miami, and while vacationing in Seattle you have chest pain, a local ER doctor can instantly read your old EKG and cath reports. Now that would be progress and provide potentially billions in savings. Of course there are privacy issues to overcome, but don’t tell me that the technology is not there to accomplish this.

We must standardize more. A decade or more ago as diagnostic studies became increasingly computerized, the cardiology and radiology fields faced a similar crisis. Ultimately, a universal display format called DICOM, was adopted, so viewing studies anywhere on any computer was feasible.

This is the only way for medicine and IT to become maximally useful and make doctors more efficient. Hopefully someone will spearhead this effort, but I will likely be retired and out fishing on my boat by then.

David Mokotoff is a cardiologist who blogs at Cardio Author Doc.  He is the author of The Moose’s Children: A Memoir of Betrayal, Death, and Survival.

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  • Doctor K Says

    I agree with the standardization BUT— We need more of a focus on the EMR being able to transmit what the treatment plan is. Ho many times have you read an EMR note that reports on every finding only to be left standing with no comprehensive written opinion and treatment plan moving forward? Docs are writing results and findings- we need doctor opinions and assimilation of the results.

  • betsynicoletti

    EMR: Let’s find the person in the building with the highest education, and ask them to do some typing. How does this make sense?

    • southerndoc1

      As Dr. Wes Fisher says in his blog, we’ve created the world’s most expensive steno pool.

  • Joel Sherman MD

    EMR is a huge time waster. I know docs who have stopped coming to the
    hospitals because of it. Others complain they can see fewer patients in
    the office because of it.
    It doesn’t have to be that way. France
    has a nationwide system of medical ID cards that holds all the info a
    patient needs and can be updated at any encounter. (The system was
    developed by an American company.) Unfortunately to work well, you need
    a national health system. But we couldn’t even pass a public option.
    Our one nationwide system, the VA, does have a system that works.
    As long as we stick to a private enterprise for profit system, it will never change.

    • kjindal

      its not just about private enterprise & profit. It’s more about the lobbyists (eg. allscripts) in bed with the current administration.

      • Joel Sherman MD

        Lobbyists have been in bed with every administration. The push to EMR was not started by Obama, but long before. Private money drives everything in government.

  • Guest

    I think with “meaningful use” being a requirement for reimbursement and the ARRA of 2009 this rapid change has taken effect. I work for a facility in NC that uses the EPIC vendor and most of the hospitals in NC has adapted this vendor which contributes to uniformity and less confusion for physicians with multiple privileges at multiple hospitals.

  • Dewey Jones

    EMR is great for data mining and a standard platform will be a huge step forward. However there are too many industries with too much to gain financially to expect a universal EMR anytime soon. And don’t forget there is still a patient who wants to see you face to face.

  • pharmguy

    Want to know how many patient safety issues have arisen due to illegible handwriting from written drug orders? Way too many. Want to know how many e-mails that I get as a hospital pharmacist and clinical manager of medication safety? Way too many. Want to know how many e-mails I have to send out due to the huge crisis that we are currently facing with today’s drug shortages? Way too many.
    Should I not inform the anesthesiologists that we are out of Propofol or Duramorph? Should I not inform the internists that we cannot get Methylprednisolone injection right now? How about 50% Dextrose pre-filled syringes, a mainstay of the hypoglycemia treatment in the sliding scale protocol and crash carts? We can’t get those right now either.
    At our hospital we ask our medical staff to be an active and dynamic part of what we do…we expect them to be able to receive this information and prescribe accordingly. A physician certainly has the right to delete the drug shortage e-mails because they are not considered important. But when a drug which is unavailable is ordered, it costs an RN and a pharmacist valuable time (which they do not have in excess) for no reason. We believe it is the responsible thing to do to inform the medical staff of the significant unavailable drugs that affect a physician’s care of their patients.
    Physicians (collectively) have a piece of the responsibility for CPOE coming into being. There have been far too many patient safety issues that have arisen from illegible orders. There have been far too many RN’s and pharmacists bullied and yelled at for far too many years for calling to verify those orders that we cannot read. Going to yell at me for calling you because I can’t read your handwriting? I think the answer to that is an obvious, “ok, then enter your own orders, here’s your computer”.
    EMR can be both a curse and a blessing. I understand the spirit of what the author is saying and agree with much of it. But the tone of the article appears that he feels that his time is more valuable than other health care professionals, which I respectfully object to.

    • azmd

      With all due respect, emailing large groups of people repeatedly about various drug shortages and expecting those people to remember the content of the emails and prescribe accordingly is quite unrealistic (and possibly passive-aggressive). Surely you are not suggesting that we are supposed to stop before we write an order and run back through all of our recent emails to check to see what’s available and what’s not? How on earth is that efficient?

      We have CPOE, why don’t we just program the system to advise a doc when he or she writes the order that the drug is not available, and suggest an alternative??? Isn’t that the way we are supposed to be using technology? In a way that streamlines our work and makes it more fail-safe?

      • pharmguy

        Thanks azmd, I appreciate your feedback. I print a list appx two times per month, it consists of about 12 drugs, 2 to 3 of which would affect a specific specialty group. Our actions are not passive-agressive, that’s an accusation that I did not expect. We simply believe that informing our staff is the right thing to do. There is no requirement that any physician memorize the list, if they write an order for a drug that we do not have, we simply call them to inform them and get a clarification. We often get yelled at in doing that activity, by the way.
        In addition, CPOE systems are not programmed in a manner that allows one to frequently change their content. They are not nearly as dynamic as one would think. Order sets are set by policy, P&T and MEC approval. And for our facility, taking a drug off the list and adding another one is done at our corporate office level, 3000 miles away. So, if we run out of a drug for 2 weeks…it is not that easy to make those changes.
        Again, we believe that asking physicians to be an active part of the process is reasonable. No punishment is levied if it is not remembered…and we clearly understand that medical staffs have privileges at multiple facilities, making it even more difficult for them. Our communication is done as a courtesy. If we never informed the medical staff of these shortages, how responsible would that be?

        • azmd

          Informing the staff is not the passive aggressive part. I don’t think anyone seriously objects to being informed although it is true that we are all suffering from being overloaded with information that we really can’t meaningfully use.
          The passive-aggressive part of the equation is where you make snarky remarks about the physician being an “active part of the process.” By definition, the physician is an active part of the process. It’s hard not to be when you’re the one who’s name is on the line if something goes wrong. Remembering the contents of emails that you get every two weeks and automatically making adjustments to your order-writing is not “being an active part of the process.” It’s functioning like a robot, or a computer.

          • southerndoc1

            If you haven’t done so, check out this week’s New York Times article looking at where the money went in the rush to EMRs. Almost 500 comments from doctors and patients, overwhelmingly negative about their EMR experience.

          • pharmguy

            The problem with words on a page is that it is difficult to decipher one’s intent. I had absolutely no intention of being ‘snarky’, and I apologize if I came across that way. In order to ensure medical staff engagement in these issues I attend medical staff meetings and discuss these critical issues with them. We talk about reasons for the shortages, alternative therapies, choices, expected ETA’s of specific drugs and other issues.
            I ask to be put on the agenda to discuss these problems to receive the physicians’ input. I can get my questions answered from them, and I can answer their questions. They may freely voice their concerns and be assured that the pharmacy department is doing everything possible to avoid these very difficult problems. That is what I meant by the medical staff being ‘an active part of the process’.
            In our facility, they are very appreciative of it. It’s a great opportunity for our two departments to work together and it is an effective process. We also expect our staff pharmacists to be active in these issues, because their names and licenses are also on the line for what they do.
            I believe that it is a better run facility if everyone is informed and more well armed with information that dramatically changes our patient care as this issue has done.
            Thank you for the good discussion.

  • Bystander_450

    How about requiring a physician to write legible charts that EVERYONE can understand, not just physicians themselves and those who helped translate?

    • pharmguy

      That was exactly my point in my reply to this article…physicians have no one to blame but themselves. Have you tried reading a progress note lately? In most cases, impossible to decipher.

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