Why electronic medical records are dangerous to older adults

A recent experience with my father-in-law reminded me of something that has concerned me for some time. While EMRs have some benefits for older adults, on balance I believe that they portend more dangers. There are multiple reasons, but the biggest is that health care providers tend to believe everything they read in an EMR. Even if what they read is wrong!

A wise computer programmer once told me that “computer’s are dumb as posts,” they are only as good as the information that human beings load into them. Human beings make mistakes, hence, inaccurate or false information will find it’s way into an EMR. The doctor who reviewed my father-in-law’s EMR prior to seeing him made the first cardinal sin, he believed everything that he read in the record.

The second error was in not directly getting the history from my father-in-law and myself as I sat at the bedside. The final mistake was in doing a cursory examination and forgetting the most important tool a physician has, his own eyes, nose and ears. I’ve often told my patients that the most important thing I ever do is to pay attention to how they look and act when I walk into the exam room. My experience and instincts will sound alarms that then lead me on my search to figure out what I need to do to help them.

It is well known that chess grandmasters think in terms of patterns. They look at the entire chess board and look for recognizable patterns. I believe that geriatricians are similar to grandmasters. If we get caught up focusing on our patient’s diabetes and hypertension, we may miss the more subtle changes that are occurring in their function and quality of life. EMRs have the distinct disadvantage that they are often singularly focused on specific diseases.

The answer is geriatric medicine. Geriatricians are trained to care for the frail elderly. We are trained to look at patterns and the big picture. Keeping a 90-year-old’s blood sugar or blood pressure too low might create problems rather than solve them. The focus on maximized function and quality of life may not mesh with achieving certain laboratory based numerical goals.

One of my favorite stories is about an 88-year-old patient of mine who had been diagnosed with prostate cancer. He was treated with expensive anti-hormonal injections that chemically castrated him. He was getting weaker and finally ended up hospitalized with pneumonia. The urologist was killing the prostate cancer and killing my patient. We stopped the injections and actually placed him on testosterone. The urologist was apoplectic! I asked him what level of PSA was associated with metastases to the bone. He responded, as I knew, that it was over 30. I then said, well, let’s watch his PSA, and if it goes above 20, we can consider treating him again. My patient is now 95-years-old, and still active and functional. His PSA has hovered around 15 for the past 3 years.

Policy makers continue to believe that EMRs will lower costs and improve care. In the realm of the frail older adult, I believe it will do neither, at least not until we develop artificial intelligence software that thinks like a geriatrician. Even then, we must grapple with the issue of human error when inputting data. Until that time, I will continue to take my personal responsibility to heart when I touch, look and listen to a patient.

Michael Wasserman is a geriatrician and can reached on WassDoc.

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  • Ron Smith

    I couldn’t agree more!

    “A wise computer programmer once told me that “computer’s are dumb as posts,” they are only as good as the information that human beings load into them. Human beings make mistakes, hence, inaccurate or false information will find it’s way into an EMR. The doctor who reviewed my father-in-law’s EMR prior to seeing him made the first cardinal sin, he believed everything that he read in the record.

    The second error was in not directly getting the history from my father-in-law and myself as I sat at the bedside. The final mistake was in doing a cursory examination and forgetting the most important tool a physician has, his own eyes, nose and ears.”

    I started programming my EMR several months before I deployed it in 2000. The one most clearcut detractor was that the speed with which you *could’ click buttons and choose from choice lists were diametrically opposed to ‘thinking before clicking.’

    I have been so embarrassed for other doctors when I get a transfer patient who brings the printout of their EMR records. As I’m reviewing them with the parent, they comment at particular commonly examined items like the throat or ears, that their previous doctor never examined that despite what it says.

    I just shake my head especially because these are seasoned professionals! What is wrong with us?

    We all need to be very careful that when we carry our digital media (to coin my grandsons’ phrase) into the exam room that we first engage our patients with EYEBALLS and not the back of our heads! We need to dig deep each and every time no matter how many times we’ve heard that same history. Then we need to follow a pattern.

    History highlights are first. Record a few important highlights HPI and ROS highlights and check the PMH to jog your memory, Look up into human eyes at convenient intervals! You aren’t getting paid to handle silicon, plastic, and aluminum.

    Then do the same boring, meticulous exam each and every time! Try to do things in the same order! Talk as you exam and keep them engaged, but remember you have to listen too! If a parent asks me at the end of the exam would I please check the ears when I have already done so, then I say ‘Sure, I didn’t see anything the first time, but I’ll be glad to look again.”

    Then discuss your conclusions, and then its time to move back to the EMR. Record the highlights only, generate prescriptions and a POA (plan of action) and record that in the disposition. Then after the patient is gone, flesh in the negatives on the exam. You’ll know what they are because you do that same (boring) exam over and over.

    Patients leave quicker, feel engaged and like they have had quality time with you. Your record then is as complete as your exam and your quality of care is high.

    This all takes effort, but remember the EMR is a tool and not a crutch! If you are doing good diagnostics then it will show in the record! Just using an EMR will NOT make you look good just because you are ‘high tech.’ It will make you look worse like the doctors of my new patients that I described above.

    Age is not an exemption either. I’m 55 and have been practicing for 30 years. I still strive to do a good job and I kick myself when I don’t feel like I have! We should be our own worst critic, not our patient.

    Ok, now I’m stepping off the soapbox! Thanks for that great post, Michael. I think we are in agreement, don’t you?

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • Michael Wasserman

      Ron, we are definitely in agreement. I always tell my patients that I’m using the EMR to help them. I intermittently make eye contact. I’m still thankful to my 7th grade typing teacher…I can type while making eye contact! Also, I agree with repeating the conclusions and instructions I write in the record. Patient’s are often “deers in the headlights”, and need the reinforcement. Glad to hear another doc getting the most out of an EHR, rather than the least:)

      • southerndoc1

        People who text while driving also claim they “intermittently make eye contact” with the road.

        • Michael Wasserman

          Even in the ” old days”, we had to look down to take noted:). Connecting with patient’s is one of the most important skills a physician can have

      • May Wright

        “I always tell my patients that I’m using the EMR to help them.”

        Do they believe you? Really?

        “I intermittently make eye contact.”

        Oh. Well /that’s/ all right then. And at least if it’s only an intermittent glance here and there, you probably won’t catch them rolling their eyes at you that way. Good all around.

        • Michael Wasserman

          I understand your cynicism, our profession often deserves it. Physicians must endeavor to connect with their patients …one of the reasons I’ve often run behind . Also, there are plenty of times I ‘ve sat back in my chair and ignored the EMR !

  • Guest

    A wise computer programmer once told me that “computer’s are dumb as posts,”

    ——————————

    Yes, their grammar check can’t even differentiate between plurals and possessives.

    /pedant

  • Suzi Q 38

    Sometimes, at certain advanced ages, they are better to be left alone.
    Bravo, Doctor.

  • May Wright

    Correct. A post could just as easily be written “Why Electronic Medical Records Are Dangerous To Patients”, full stop.

  • http://warmsocks.wordpress.com/ WarmSocks

    A switch to EHR at about the same time she went on Medicare changed my mother’s type1 diabetes to type2. Add to that a new PA instead of the MD who originally treated her, and her treatment has completely changed. Twice she’s been hospitalized for DKA. Now she’s losing her eyesight. It just shouldn’t be that hard to treat the patient instead of the EHR.

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