Thursday, October 12, 2006

Electronic records rant

It's no secret that I'm a news junkie. You can plainly see this from my blog. In addition to my patient rounds, I do my blog rounds and news rounds. I became really upset when I read this article from the Washington Post called, "Doctors Slow to Adopt E-Records for Patients."
About one in four doctors use some form of electronic health records, suggesting that a technology frequently billed as a way to improve the quality and efficiency of care has yet to win widespread acceptance, according to a study released yesterday.
As these type of articles in the media go, the following paragraphs build the case why an electronic record is a good idea -- it "collects patient information, displays test results, helps doctors make treatment decisions and allows health-care providers to document prescriptions and medical orders electronically." In addition, they "improve patient care, reduce errors, curb unnecessary tests and cut paperwork."

Yes, I get it. Even though I am one of the 75% of docs who do not use electronic health records (yet), I agree with everything that has been said above. I think all docs agree that going electronic is the future of medicine.

So, what's the hold up? Why isn't everyone using it now? There are two main hangups, in my opinion. The first one is covered later in the Post article, and it is who will have access to this electronic infomation? Also along these lines is who owns the information inside the computer?
"The big problem is that the vast majority of electronic medical-record systems do not give patients the right to decide who has access to the records," said Deborah C. Peel, a psychiatrist and founder of Patient Privacy Rights, an Austin-based nonprofit that wants greater safeguards. "They do not give patients the right to segment sensitive portions. . . . The electronic medical records in use now have been designed primarily for the convenience of physicians."
For example, if I'm talking with a patient and entering information into a laptop, and this information is stored on the hospital server three streets away from my office, who has access to this information - besides me? How comfortable would you be if I told you your medical data is on a hospital server and possibly backed up on an offsite server, while now, your information is in my paper chart under lock and key in my office? Just something to think about.

The BIG reason docs have not jumped on board is plain and simple -- COST! This is something that is never talked about in the lay press. The federal government has made a goal of most Americans on an electronic health record by 2014. Like a lot of other things from the federal government, this is an unfunded mandate.

Even for a small office like ours, the cost can be between 50-100 thousand dollars. But, hey docs can afford that, right, because I see them driving their expensive cars and have their expensive houses?

Medicare is a govenment program which is health insurance for people over 65 years old. As you all know, the number of Medicare patients is rising very day, because as a nation, we're growing older. Many physician offices depend on Medicare for a good portion of their income. In 2007, Medicare is slated to be cut by 5% unless Congress intervenes by the end of the year.

This cut will hugely effect docs across the country. Just as an example, here's an article from the Concord Monitor.
The New Hampshire Medical Society estimates that the cut will cost the typical family practice $20,000 next year, which could force some doctors to stop accepting new Medicare patients.

The association and its counterparts across the country have until December to persuade Congress to stop the cut. Lawmakers have, in years past, heeded similar requests, but local doctors remain worried.

"Primary-care doctors are really mom-and-pop shops," said Dr. Gerard Hevern of Suncook Family Health Center. "Most of us do it because we love it . . . but we do it on a shoestring. When you begin to erode that margin, it really impacts in ways that are profound."
So, bottom line, I totally agree that the electronic health record is the wave of te future, and all docs will eventually get on board. What the press neglects to cover is the real story of why this is not happening now. I know I'll continue to read articles like the one today in the Post, and I'll continue to get upset. But, here is the real story of why so few use electronic records now.

Addendum: Dinah from Shrink Rap has some additional thoughts and some great comments in her post entitled "For The Record." Check it out! Also, thanks to all of you reading via Grand Rounds this week. I invite you to check out the rest of my blog.


Wrkinprogress said...

OK, no one throw anything, but I agree with Doctor A. In my experience as an office manager for medical practices and in doing training/support for an internationally-known/used medical office software package (which includes electronic medical records), physicians in Family Practice do not even come close to making enough $$$ to make conversion to a state-of-the-art electronic medical records system. Hell, some of them barely get paid enough to support their families, and no, I'm not exaggerating. If a doc is heavily loaded toward Medicare/Medicaid patients, they get paid mere pennies on the dollar for their services and supplies, yet, generally speaking, this population requires the most care.

Oh, and the safety thing....remember when all of those electronic records were stolen from credit card issuers? My bet is that their computer systems are far more secure and possibly more sophisticated than those of healthcare facilities.

::stepping down from soapbox::

Peace, all y'all!

Anonymous said...

Well, many of the records are already electronic. Do you have any idea how much your banker actually knows about you? Docs write about viagra and tell funny stories. Um, even the banker has "viagra" stories, and it's all stored electronically without being questioned. Your financial records speak about more than your money . . .

Anonymous said...

Dr A:

We have been on EMR for 10 years. We first started when we had only 2 doctors and now are up to 6. We could never be profitable without our EMR. Done right, EMR has a huge ROI. Done poorly, it can put you out of business. We have one of the more expensive systems (GE) and are yet expanding it. Soon our patients will be able to fill out office visit information on the web before coming in to the office and so be brought right to the back when they walk in. We have a high enough percent of patients with internet that we should have no problem getting them to use it.

Our patients absolutely love it, because we never have to search for anything. Our quality is better as well - we are just about to get our NCQA certification in diabetes (DCRP) which will qualify us for Bridges to Excellence (which in GA could net us an extra $20K/provider/year).

The lesson? It is possible to make it work in a small office. I know we are the exception to the rule, but if done right, it can be wonderful. I actually have several friends in the Concord, NH area doing quite well on EMR.



Anonymous said...

Dr. A... I think EMR is a bad idea. I have been thinking it for some time now. Most of my doc's do use EMRs. And, most ALL of them have their office staff, when they show you into the exam room, sit down and pull you up on the computer. So, right there is someone who is not a Doctor having access to my entire medical records..

But, she is only the first in a series of people, who I feel have access to it.

If I have to go to the ER, the nurse comes in and tells me she just seen in the computer that I have went to Dr. so and so, that I have had this surgery or that surgery. Again, not a doctor but other people having access that maybe I would have only discussed with the ER doc. him/herself..

It is absolutely an invasion of privacy. And what about people that you may know who work in these places? Nothing or noone would convince me that if they have access they aren't looking... Of course they are looking. It's dangerous I think.

As for cost...I don't understand how doctors can afford to upgrade to this. It's also not just people over 65 who are on medicare, but all the people who are disabled,at any age, are on medicare. Those are the exact peole who use the majority of healthcare. I'm not proud that I fall into that slot..I know my medical expenses have been horrible, especially recently. It is only going to get more expensive. It isn't fair, not to doctors, and it also isn't fair for healthcare cost to be so high that NOONE can possibly afford it on their own.

I have my supplemental thropugh AARP now since I am over 50. It is VERY expensive and even with both coverages, I still have to pay alot out of pocket..

How do we fix this Dr. A.?

Anonymous said...

You hit that one right into my lap, Dr. Anon. This week and next, I'm cleaning up a report on one medical group's change from paper to digital records ... it will be the assignment which makes or breaks my grade for this particular class.

One of our mutual blogging friends was kind enough to give me a 1/2 hour telephone interview during which I pumped him for info to within an inch of his life ... :o)

The media is not hearing the full story, I think. I know that in my HIT course, I'm certainly not hearing the full story. There's barely a mention of any downside to EMR's, with the exception of cost. Those who graduate with me are going to pop right out of that course into the field expecting to find physicians lined up and begging for their services ... we both know that's not what they're going to encounter ... ;o)

From what I've gathered so far, I don't blame physicians for not being too thrilled about changing over to EMR's. Even the places in which the ERM's are working well, there are downsides, and the acceptance is less than stellar.

If you do Google searches on EMR's, you'll find that they're touted as one of the best things which has ever happened to medicine ... and that the only thing holding us back in the medical stone age is stubborn doctors who just don't want to be bothered to try something new. It's the same theme, over and over.

Personally, I think we have a lot to gain from using them, but we have a lot lose, too. They will change the way medicine is practiced ... some things will improve, and some won't.

What I believe I'll miss the most is the human interaction ... and I'm sure that my physician - who'll be focused on the computer screen instead of me - will miss quite a bit too, at least in the way of body language.

We have a ways to go before this technology advances enough to fit itself around medicine - rather than the other way around.

Jules said...

Thanks for posting about relevant and interesting topics such as this that lay(wo)men like me need to know about. Keep them coming.

ipanema said...

I think we'll read a lot more on to EMR or not. I totally agree with the comments above and in addition, what strikes me as a patient are two things:

1. Patients records are supposedly confidential but with the example Cathy has given, it certainly isn't anymore. And it's something patients don't like knowing that other people besides their doctor have access to these.

2. I've experienced going to a doctor's clinic in my country and he was more focused on the computer than me. I felt strange perhaps it will take time for me to adjust. But I miss the 'personal touch' where doctors are intently listening to you face to face rather than all eyes on the computer and an occasional glance until he finishes typing his diagnosis.

Sad. Is this what technology will bring about? We better have robots key-ing in our complaints and printing diagnosis.

By the way, consultation fee was up compared to previous visits before EMR.

Anonymous said...


The physican you visited with the EMR was probably new on the system. The truth is, we spend more time face-to-face with our patients because the other administrative tasks are minimized (such as writing prescriptions, getting consults, looking for labs, and looking for consults). I look into the eye of my patient when I type my history and take their statements verbatim. I could never do this in paper or with dictation. I would spend a lot of time looking for things in the paper chart and writing with my eyes away from the patient while I wrote.

Most doctors who have an EMR are not using them well (that is what the study showed). The main thing EMR's offer is not documentation, it is the chance to re-engineer workflow in the office. Very few people (even in EMR companies) understand this. They tend to emphasize the exam room.

We have been in the process of adopting EMR for the past 10 years. We continue to improve our workflow and our convenience for our patients.

It really is a win-win for our patients and us.

Anonymous said...

There are some interesting Open Source packages available.

Fat Doctor said...

We converted to EMR over two years ago. Now, we're told that in another year or two we are going to be converting again to use the same system our hospital is going to be using. I just barely got this one program figured out, and we are still fixing kinks on a daily basis. Progress? I dunno. I miss the lousy (but faster) charting I did on paper.

It's me, T.J. said...

I have been using EMR in veterinary medicine for 10 years now. I can't imagine not using it.

We've also switched to digital radiography. All I can say about that is **n i c e**...

But what I think is the most amazing thing about this conversation is that I make 1/3 of what a person doing the same thing I do in human medicine makes. And so do most of the doctors in veterinary medicine.

Veterinary medicine has always had to be innovative and invent new ways to accomplish their goals...

Mainly because there wasn't anything available for us to use.

Things are changing a lot now for us, and it's all for the better.

Still waiting on that pay increase though.


Dr. A said...

Something interesting that I've found is that there is no middle ground on this issue. I'm not judging, it's just an interesting discussion.

There's the pro-EMR camp where it's just go-go-go and do it now because it's the best thing since sliced bread.

The other side is like, I don't think so. There are still too many questions out there right now.

From my colleagues who have one, it's super-duper good for specialists, because in general, it's the same questions being asked over and over again and a "template" of questions can be written into the program. If you have a wireless tablet, you can just point-and-click your history and physical, and you're done.

But, for primary care docs, it's a little more challenging. Patients can present with just about any medical problem. There is no way to "template" every possible primary care visit, so you end up literally typing in the entire visit. And, for those docs not technologically inclined, they long for their tape recorder to dictate office visits.

EMR/EHR implementation is the second biggest hurdle that docs are afraid of (after cost). Soon as you say, "It will effect your productivity at the start," this scares docs off. Yes, it will increase efficiency down the road, but how long down the road? 6 months? 12 months? What do you in the mean time when your productivity goes down temporarily and medicare may decrease by 5%? Not pay your staff? Not pay your bills? It's a hard question.

Sorry for the mini follow-up rant.

Anonymous said...

sounds really expensive and difficult a process.. the press always understates or leaves something out..

Anonymous said...

Make no mistake, it is hard to do it well. We have gone through a lot to get where we are. You are basically changing the foundation of your house while living in it. Yet that is the right thing to do if the foundation is crumbling. Is it the best thing ever? No - it is a tool to improve patient care, but I am not in it for the computers, I am in it for my patients. I do, however, think it is now necessary for survival in the big picture.

Have you considered DOQ-IT? They offer free consultation in choosing a system and implementing properly. It is a federally-funded program that is aimed at small primary care offices.

By the way, the comment just prior to this one is spam. You probably want to delete it.

Anonymous said...

As a caregiver and sometimes patient, I have spent a great deal of time in hospitals, clinics, etc. The biggest fear is privacy-everyone has access to everthing.

Rob-Your statement that, "I look into the eye of my patient when I type my history and take their statements verbatim." Do you really think that this is a GREAT thing? I mean really? Imagine you were on the flip side of that example, as a patient, trying to discuss a highly sensitive matter with your physician, and they were recording it "verbatim" as you say. Do you think that is healthcare? Do you think that is personal service? Do you really think patient's are going to feel all warm and fuzzy as you do this and think, yes, I can't wait to divulge more of my information? Can you?

Your image of looking a patient in the eye while doing your task is eerily similar to a physician visit I had where the physician dictated through the entire visit.

Earlier this year, I had a visit with a orthopedic surgeon who specialized primairly in spinal issues. The visit began when the office worker pulled up my information on the screen. The doc came in and chatted with me for a minute. Then he stopped and dictated. Then he asked me another question, then he dicatated. This went on and on. By the time I was able to ask a question, he had already deemed the visit as over. I never went back to him. Did I feel good about this visit? No. Why? This visit was all about him-him getting his work done and not about me.

Sometimes, and I see this a lot with younger physicians, is that they don't know how to practice real healthcare, yes, they might know what to do, but they don't know how to "treat" patients like human beings.

If you want to take electronic notes, then why not be a mortgage banker?

Anonymous said...

Interesting post. I agree with a lot of what you are saying. 50-100thou is a HUGE investment, especially for a small office. Yes docs make money, but the way insurances are now they don't make nearly what they used to make and what people still think they make.
About the privacy. I think that is a major issue. I work in a hospital (as you know) and all the of the records are mainly on the cpu. Everyone can physically access them, but we aren't supposed to. Supposedly there are some IT people who check - obviously I work in NICU... if I am checking out a MR for an adult I am not where I a supposed to be.
As for the physicians in my family (giving another reason)... they aren't technologically efficient. I tried to explain how to use my palm pilot (I have a lot of medical programs on there) and they were interested but still didn't full get it - they graduated med school in the 60's. How many doctors/older adults just aren't tech savy? That may be another obstacle.
If we did go strictly to emr-- what if the system went down ( I mean technology isn't foolproof)? If your system was out for the day and the pt was in to your office, would it be appropriate for you to say, "um, can you just refresh me of your history because I don't remember you and I am not sure where we left off." Exactly... there are still too many obstacles to go completely to emr.

Wrkinprogress said...

One last comment -- re: privacy. Again, based on my own experience (for what it's worth), the privacy concerns raised by Cathy and others regarding folks other than their physician being able to access the info in patient records are absolutely valid. Confidentiality is a figment of the imagination, again, in my opinion/experience. Office staff many times DO have access to the entire chart -- remember who calls you with test results, or perhaps calls in your prescription for the Doc after chatting with you about the reason for your phone call to the office? If someone has diagnosis/procedure coding experience, one look at your codes tells them what your visit was concerning. Your superbill probably has the diagnoses themselves actually spelled out. If the practice uses an offsite billing service, that billing staff has all of your pertinent info, in order to bill your insurance company. Oh, and these staff members are not at all bound by ANY kind of confidentiality requirements. None. Nada. There's nothing, other than suing, that can be done to punish a staff member who discloses confidential info.

Just last week I visited a patient in a hospital in Indianapolis where EMR is used. Walking down the hall, I saw laptops affixed to the walls for the staff to use for charting. I thought at the time that it was pretty dangerous to do that, and, sure enough, on the way out of the facility, I passed by two different staff members in two different places in the hospital who had a patient's record pulled up on screen . I could see the names of the patients being charted for on the screen, with no effort made on the part of the staff member to hide the information. Had I been more nosey, I would have been able to read who knows what all about people I didn't even know, or maybe I did know them...either way, I shouldn't have been able to see their records.

This is a discussion well worth having. Input from as many angles as possible should be sought before making up one's mind about utilizing this technological opportunity. Normally I would be all for converting manual documentation to electronic/digital methods, but when it comes to something so personal, so private as the information one discusses with one's physician, I don't believe you can be too cautious.

Peace, y'all.

Anonymous said...

If you think that your info is only seen by your doc just because it's on a paper chart instead of in a computer, you're mistaken. As someone else already said in the comments, the office staff probably has access to the paper charts and your 'private' information is exchanged with insurance companies, outside labs, other healthcare providers, etc., as needed, to provide you healthcare or process payments. Not that they are perfect, but there are regulations intended to help ensure that your personal info is not shared for reasons other than this.

Dinah said...

I've posted about you!

Beastarzmom said...

Totally interesting entry + comments. I am an RN, working in IT and involved in a very large EHR implementation. My reservations are similar to those stated by others - lack of privacy. However, the ability to share information has GREAT benefit, both to patient and clinician. Duplication of efforts does go down. Ultimately documentation does decrease, a bit, because if done correctly, an observation should be documented by only ONE person, not several. (Chat with JCAHO and other government agencies if you want to document less... please!)

I know this sounds pessimistic, but it's true - information about all of us is available all the time, in so many ways. Might as well get some benefit from it! If I can avoid having blood drawn a 2nd or third time because the results of a recent test are available to my caregiver, I'm pleased. If a change in my mammogram is caught early because my baseline film was immediately available to the radilogist, I'm happy.

I totally agree with Rob, though, that it must be done correctly, and it involves serious changes in workflow in order to be successful. Wish me luck!

Masked RN said...

I'm just beginning my healthcare careeer as a student nurse... But, I can see the potential for the electronic records to be very helpful in reducing errors. One of the biggest challenges for me each time I prepare to go to clinical is "deciphering" the doctor's handwritting in the pt chart. I've scratched my head many times wondering, "What in the heck does that say?!?"

Anonymous said...

Thanks for the Link, Dr. A. Don't forget to take our poll.

PaedsRN said...

Cathy writes:
If I have to go to the ER, the nurse comes in and tells me she just seen in the computer that I have went to Dr. so and so, that I have had this surgery or that surgery. Again, not a doctor but other people having access that maybe I would have only discussed with the ER doc. him/herself..

It is absolutely an invasion of privacy. And what about people that you may know who work in these places? Nothing or noone would convince me that if they have access they aren't looking... Of course they are looking. It's dangerous I think.

What I'm reading in some of the comments thus far to my mind shows a lack of understanding about how traditional medical records work. There seems to be an assumption that they are in some way more private than the electronic kind.

Maybe in some isolated areas of practice they are all kept under lock and key and accessed only by physicians, but I have to say that in major institutions the opposite is usually the case.

The medical record, even in a GP's office, is already available to nurses. I wouldn't look after a patient if I didn't have access to their file, and neither would any responsible RN. In addition, office staff (receptionists etc.) generally have access to the medical record and could, in theory, read whatever they want to.

In a hospital the list of people with access to files expands out of all proportion. Various staff from physical therapists to pharmacists to social workers to medical students all read files.

Privacy is a valid concern when dealing with electronic information, but let's not operate under the misconception that the paper medical record is somehow sacrosanct. Paper does have some advantages, but privacy isn't one of them. At least with an electronic record, you can usually look back and find out who's read it.

I'm pro-EMR, with reservations. It has tremendous advantages but I don't feel the software has evolved far enough, and there is some shameful price gouging going on in the industry.