Electronic Medical Records

The topic of electronic medical records has been big in the news. Our governor is pushing for it in all state health care facilities. It might even be required. Supposedly, nationally, "EMR" will save a lot of money and make medical care more coordinated, thereby making it "better." All these things remain to be seen.

I like computers and I do think that, ideally, EMR would be an improvement, but like all things in life, it can be a mixed blessing. I've had several personal encounters with EMR that show the downside and pitfalls, but the previous system, all in all, was probably worse.

A couple of years ago, my son went to a clinic, had a cursory check up and test, and got a prescription. We got the bill, insurance EOB, etc, and paid our portion of the bill. Our son had to go for a few monthly rechecks, so there were more bills, but the next statements were for much higher amounts. We questioned the higher fees by asking him what exactly was done at each visit, and we also wrote to the clinic. The clinic manager replied that the fees were justified by what the doctor had done at the visits, based on the charts. Our son OK'd release of the records, which showed a complete history and physical at each visit, which my son said was not done. We had the records reviewed by a physician, who agreed that the doctor could not possibly have done what he said was done within the time frame that was electronically recorded on the records, plus the time frame on the records agreed with my son's recollections. And the supposed H&Ps were not justified. When confronted, the clinic and doctor agreed that the doctor had used the EMR incorrectly, that is, he just checked off that he had reviewed every bodily system completely. They refunded the charges and corrected the records, and stated that they were going to review all the charts from that doctor.

I have been a patient at the same clinic for many years. My paper record files are quite large, so that looking up any thing old is inefficient. Ideally, a physician will keep a record on the front cover or front page of the current medications and problems. Not all physicians are that organized. My clinic converted to EMR a year ago. My yearly visit was on the first day of the new system, so they hoped I would be patient, which I was, but it was easy to see the pitfalls. First, somebody had put some of the old records into the system. Imagine how expensive it must be to input lots of old files. I had to fill out a paper form with a list of my medications, over the counter meds, as well as past surgeries, etc. It was like just like the paperwork one fills out when going to a new clinic. This was then entered into the computer by a clerk. Obviously there is a great chance for error or omission in my memory. There is even a chance for deliberate omission. The good side of my clinic's system is that the computer sent me a letter after the visit listing the results of my blood tests as well as the meanings of the values. I also got a note from my doctor, so I knew that a real person had reviewed the tests.

Recently, I went to a certified nurse practitioner at another clinic. Before I saw her, I had to fill out papers, just like I mentioned above. Then nurse entered all the lists of medications, previous surgeries, etc. into the computer. Then the CNP did a very thorough history and checkup. She entered a number of things into her computer, which printed out a paper for me. It told what we talked about, what was recommended that I try, what tests were ordered, plus my list of medications, and notations about past immunizations, etc. I was impressed with this printout. For one thing, I can't remember the medical jargon or the names of tests I don't understand, but now I have them listed in writing. Secondly, it let me see that there might have been a couple of misunderstandings in my communication with the CNP. But since this isn't my primary clinic, there were gaps in my record. It looks like, for example, that I've way out of date on immunizations and certain types of normal yearly checkups.

The CNP is talking about a specific test that I may have, but it involves some medications. I believe I've had these medications in the past, but, of course, I don't know specific names, amounts, etc, but I know I've had some very uncomfortable reactions. I decided to write a request for past records so that I can be sure about what meds I'd rather not have. I received a packet in the mail for a company whose business is going through old medical records.(??) This contained photo copies of exactly what I asked for, so I expected it to be helpful. Well, the suspect medications were clearly listed. But there were no amounts given listed. On all the pages but one, the notations were in various handwritings, some quite messy, or barely legible. I really don't think this will be helpful.

The next point has to be handwriting vs. typing. Typed notes are clearly better for future use by other people. In the past, some doctors just wrote, or scribbled, notes into their charts. Some doctors dictated their notes, which were then transcribed by somebody else, and, if the doctor was compulsive, the notes were read and countersigned by him/her. Medical transcription is a dying art, not taught in schools as in the past. These days, the doctor has to type his own notes. The plus side is that they should be readable and they should be correct since he/she can see them as he/she types. [Yes, some doctors do use a program such as Dragon Speak to avoid the typing.] The down side is that we are paying doctor's salaries to the typist. EMRs do contain a number of features that can streamline the charting process if the doctor knows how to use them. Some EMR programs necessitate that the doctor must finish the record before signing off, which would mean that the doctor could be late for the next patient or, OTOH, that a particular doctor still uses old note taking methods and goes to the computer later in the day or week to finish the records, which, of course, undermines the value of the EMR system.

Lastly, to be at their best, either all clinics and hospitals have to use the same EMR system or the systems have to be compatible. When I was going to see the consultant/specialist, my basic records should go with me, but they didn't. I had to tell them about my history and my doctor had to include a few photocopied pages of tests with his introduction letter. Obviously, this is still very inefficient.

In the long run, if EMR is used by all clinics, hospitals, and doctors to the fullest extent, records should be more complete, efficient, and useable. Doctors should be able to look at charts showing trends of testing, for example, rather than just looking at a number of screens showing various values of test results. At this point, much of EMR is just using the computer instead of paper, the computer being a glorified typewriter. There are doctors still resisting using the computer for their recordkeeping. There are the usual computer hassles we all have run into that does make us suspicious of keeping important documentation in the never-land of digital information. EMR is far from an ideal system, but the thick stack of papers, possibly disorganized, in a tradtional medical chart, with many notes handwritten, seems to have even more drawbacks.