Let’s begin the discussion about whether or not medical technology is truly advancing the efficient and safe delivery of patient care with the topic of electronic medical records (EMR’s). Much has already been written on this subject; however, a recap of some of the arguments being made – pro and con – for EMR’s will set the stage for what I believe is the major problem with this technological advance.
If you have ever had to review old-fashioned hand-written records relating to a patient’s care, which I’ve been doing now for almost four decades, you were thrilled – at least initially - when you heard about the advent of this new, eye-strain-saving project. Not only was I counting on cutting down the number of times I would have to increase the strength of my prescription eyeglasses, I figured I might now be able to actually read what the healthcare provider learned by history, found on examination, thought was the more likely diagnoses causing the patient’s presenting complaint and what the doctor’s plans were to address the medical problem confronting that healthcare provider. What a bonus! No more guessing! Too good to be true?
Now with EMR’s, when you request medical records from a healthcare provider, you could expect to receive – presumably with the push of a “print” button, not papyrus-like records filled with hieroglyphics, but a formatted, easily readable comprehensive rendition of what happened in the course of patient care. Well, not so fast, I quickly learned.
With the arrival of EMR’s, I became mired in a world of radio buttons, drop down menus, cryptic narratives that didn’t really match the fill-in-the-blanks charting, and a world of metadata to find out the story-behind-the-story (like who accessed the EMR, what they were looking at and when they saw it).
Now let’s be real – I sincerely doubt that the medical profession and the computer and software vendors had lawyers in mind when they created and rolled-out this new marvel. As the medical profession is so quick to point out to us lawyers, lawyers are not the ones in the trenches trying to make people better and save lives. We’re the bottom feeders (oh yeah – that’s their description so many times), who do nothing but second guess for our personal monetary gain the medical community’s valiant efforts. That discussion is for another day!
Turns out, however, that it is not only my kind screaming about how this modern medical technology has flaw upon flaw associated with it; the medical profession has serious, second thoughts about just how wonderful EMR’s are.
The Concepts Behind EMR’s
Just do a search in your favorite search engine on the topic of EMR’s – add the word “controversy” or get really ingenious and pose the question: “What are the pro’s and con’s of EMR’s?” While you’re combing through page after page of search results, take note of who is writing about why EMR’s are not the next best thing to sliced bread. I’ll save you the task; it’s the medical profession. That’s right, the very people who hailed the advent of EMR’s and extolled the many intended virtues of this technology.
The Pro’s of EMR’s:
Here are some of intended benefits of EMR’s:
- improve the quality of patient healthcare through instant, universal access to patient data (at the click of a mouse or push of a button)
- avoid, if not eradicate, the “unreadability” (interpretation: I can’t read your handwriting; what are you telling me?) of hand-written chart entries.
- improve patient safety through better detection of adverse events. The intended goal is premised on EMR’s having a central database of patient information, decision-making, outcomes (including adverse events) and other key epidemiological data available and accessible for analysis.
- enhanced quality of care through immediate access of all pertinent patient information (e.g. testing, radiological studies, medications, vital signs, laboratory studies, etc.) so that caregivers can make better, faster and more informed decisions about continuing plans of care.
- making healthcare more cost efficient by reducing unnecessary redundancy of testing (due to inability to locate prior paper-based information), digital access to key points of patient data rather than the waste incurred through manual search of past records from various healthcare provider sources, copying, faxing, etc.
- keeping records safe: with proper digital storage measures, there can be avoidance of destruction, misplacement and the like.
- overcoming inaccurate past medical history (PMH) information since care providers would have access to a patient’s “true and accurate” medical history by accessing stored medical data. Healthcare providers would no longer be relying on ofttimes faulty patient memory of PMH.
- improved coordination and information exchange between healthcare providers. Studies have shown that the communication and transfer of information between primary care physicians and hospital-based physicians has been less than optimal.
- improved, accessible and faster surveillance capabilities for wide scale events such as epidemics, catastrophic natural disasters (e.g. Katrina) and even bioterrorism.
I have absolutely no doubt that there are a host of other EMR pro’s. Yet even though the concept of EMR’s has apparently been the topic of discussion for about forty years and there are so many potential benefits inherent in their use, one must wonder – why did it take so long to implement EMR’s and why are they not being fervently embraced throughout the medical profession?
As with many great modern marvels, once the allure of the new toy wears-off and implementation begins, some of the flaws begin to surface. ERM’s clearly have their share of warts.
- privacy concerns – do EMR’s have the ability to turn the sacrosanct confidential communications between physician and patient on their ear? Some scream a resounding “yes.” Some have expressed deep-seated concerns that such accessible data will be used against a patient when they apply for jobs, health insurance, or – I’ve seen said – even a college scholarship. The potential inclusion of genetic data in EMR’s and the accessibility by researchers or others who don’t fit the need-to-know category also has privacy advocates screaming “foul.”
- loss of the benefit of provider narratives (which were the norm in hand-written charts) so as to better appreciate the subtleties and thought processes of medical care. It is often said that medicine is an art, not a science. The ability to appreciate the art of medicine, some fear, has been lost when all that you can glean is pre-formatted information from drop-down menus and radio buttons. There’s no longer an ability to appreciate the true thinking process of the caregiver. Some refer to these problems as blind and meaningless use of short-cuts, templates and pre-fills, which don’t allow subsequent caregivers relying on EMR charts to get a true and accurate picture of a prior caregiver’s true thoughts. Apparently, quicker and easier input does not always translate into better or more accurate information.
Think I’m making this one up? Here’s what one internist at Harvard Medical School had to say about EMR’s:
Harvard Medical School internist and entrepreneur Dr. Rushika Fernandopulle says that many EMRs are designed to improve coding and maximize reimbursements, often at the expense of clinician functionality. “When you’re trying to read the notes of your colleague [in an EMR], it’s almost impossible to figure out what happened to the patient,” Fernandopulle tells the Journal. “You have to read through two pages of all this junk that’s put in to increase billing.”
- Notwithstanding the claims of EMR advocates, many in healthcare and related fields firmly believe that EMR’s are not safe and secure. They point out that despite encryption and restricted access through log-in’s via usernames and passwords, there are numerous and disturbing instances of hackers gaining access to private patient information.
• November 26, 2007, Canada. Hackers accessed medical information on HIV and hepatitis from a Canadian health agency computer.
• September 22, 2008, UK. The National Health Service (NHS) reported the loss of 4 CDs in the mail containing information on 17,990 employees.
• September 30, 2008, US. The company Blue Cross and Blue Shield of Louisiana confirmed breach of personal data, including Social Security numbers, phone numbers and addresses of about 1,700 brokers. The data was accidentally attached to a general email.
(source: The HWN Team @ HealthWorldNet.com)
- computer-driven healthcare is potentially hazardous to one’s health. Rather than paraphrase, let me share one comment I found on a blog extolling the virtues of EMR’s:
Try telling that to a computer: I am on medication that I take every three days. So, a normal 30 day supply last[s] me 90 days. However, the computer at my pharmacy automatically renews the prescription and I get a phone call every month asking me to come pick it up. I now have a year’s worth of pills on hand and they’ll expire before I can take them (which means I should not take them as they may not be effective). So, I called on Friday to tell them that I wanted to opt out of the system. The nice person informed me that I had been removed from the system. 9:01 AM Today (Monday) I got a call, telling me that my prescription is ready to be picked up. This is what happens when people cede thinking and into the ‘computer said it so it must be true’ mindset that we’ve all experienced from time to time to maddening effect.
- way too much information, a lot of which is purely redundant and distracting. From my perspective as a lawyer, this is a major problem with EMR’s. A click of a radio button or a selection from a drop-down menu often generates duplicate entry data in a host of other fields across the system. As you try working your way through the jungle of screens or paper generated by EMR’s, you say to yourself, “Didn’t I just read that same thing somewhere else?” Now put yourself in the shoes of a healthcare provider. You have a number of patients to see, orders to give, reports on patients to share, calls from your pager to answer – and all you want to know when checking a patient’s EMR is some key information so you can do what needs to be done and move on. What do you find? More information than your ever wanted or needed and at times conflicting information. Frustration mounts and you yearn for the days of color-coded, hand-written charts.
- How fast can you type? Simple but real issue for apparently many in the medical profession. EMR’s are meant to save time – perhaps not!
- How fast do the records load? Some have become frustrated when using internet portals for records with very slow loading time of EMR’s when using over-utilized internet connections during peak usage hours.
- those developing the EMR software failed to consult with practitioners before rolling out their product leading to templates, care strategies and selection choices that have no practical use for actual caregivers.
Just as is the case with the pro’s, there are many more con’s being voiced throughout the internet by medical care providers. That being said, I am of the firm belief that one of the biggest flaws is the manner in which EMR’s were and continue to be implemented – rolled out for use – in our medical institutions and physician offices. This can range from lack of training, lack of quality control, lack of system-wide coordination – you name it. In the rush to purchase, upload and put in use EMR’s, too little thought seems to have been given too many times to such projects before implementation. After the implementation, many problems started to rear their ugly heads.
Here are but a few examples of poor implementation voiced by a nurse, Kaye, in a comment she posted to the first installment of this series. Make sure to take particular note of Kaye’s fourth point!
1. Facilities are not getting input from the potential users before purchasing. Cost and JC compliance is more important than usability. “Here is your new system. Make it work.”
2. Seasoned nurses and ancillary staff are not given the considerations derserving of the huge technological changes. It’s a whole other language. A COW (Computer On Wheels) stands in the field.
3. A culture clash has developed between nursing and the IT department who cannot appreciate the urgency of correcting problems.
4. At my facility, there are 3 different systems. They don’t ‘talk’ to each other. Whose idea was that?
I could go on; but you get the point.
In my next installment, I will share with you with more real-life examples of just how misleading, inaccurate and unsafe EMR’s can be. Just to give you a tease – how about the case of a woman who was paralyzed following an epidural for labor and post-childbirth pain relief. Hours after she was diagnosed by a neurologist as having suffered injury to her spinal cord leaving her with significant, devastating motor deficits and sensory loss, she was noted by a nurse in the EMR to be “ambulating [i.e. walking] x 2″? I wonder if that would have happened if the nurse had to hand-write that entry and not just click on a drop down menu choice. There will be plenty more examples of such just how effective and safe EMR’s have turned out to be. Stay tuned and tune in to Part III coming next week.