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Friday, December 26th 2008

The Time Has Long Come

I’m in my fourth year of medical school. In a matter of months I’m going to be a physician. Until October of 2008, thirty-seven months into my education as a medical student, I had never even seen a paper medical chart. My only rotations were at a county hospital with a strong commitment to EMR and at government sites. I rotated at both VA and DoD hospitals both with strong nationally connected electronic medical record systems. I had also never seen any numbers on the prevalence of electronic medical records and so I assumed that most major hospital systems, at the least ones with integrated physician practices such as in much of academia, must also have full fledged EMR systems.

But over two months, doing away rotations, I learned hard and fast the reality. I rotated at institutions which, like most of the country, still rely on paper charts for the majority of the patient’s record. Sure they often times have lab data on the computers and certainly, nowadays everyone has a PACS. But they’re missing out on so much more.

Over those two months I had to teach myself certain skills which really should no longer be a part of the delivery of health care in this country. I taught myself how to write quick, illegible and uninformative notes by hand. I taught myself how to fight off nurses and social workers for patient’s charts and then hoard them. I taught myself to just give up hope of trying to decipher the handwriting on a consult note and just page the service to hear their recommendations over the phone. I taught myself to memorize my resident’s provider numbers because I knew the nurses were going to be paging to confirm orders which they couldn’t read. I taught myself the most likely places for “missing” charts to be. I taught myself the most likely places for various documents to be filed in the chart.

Nowadays I’m on the interview trail. It is the long and arduous journey to find out where I’ll do residency. And I laugh a little bit inside when residents try to convince the interviewees that it is a good thing their primary teaching sites still use paper charts because it’s “faster and easier” to write notes by hand. That’s novice talk.

The Myth Physician Handwriting Is Worse Than The General Public’s Persists…

Virtually all computerized note writing systems allow templates or, at the least, click at you go note building forms. With three key strokes a resident in my home neurosurgery department can bring up a virtually completed consult note on a patient with any major, common neurosurgical issue. A few buttons on the keyboard to personalize the note for that specific patient and the note is done at least as quickly as if they had scribbled it on a piece of paper down in the emergency room. There is a learning curve and it represents one of the largest non-financial obstacles to the implementation of EMR systems. But I simply refuse to believe, that once the system is known to all and full implemented, that a electronic medical records system does not improve the efficiency of just about any practice environment. From the huge general hospital to the small rural primary care practice.

Beyond efficiency EMRs offer significant patient safety benefits. Poor handwriting or misinterpretation of orders are certainly a source of medical errors. No, electronic order systems, don’t eliminate these in full but they do reduce the risk. Handwriting becomes a non factor. Most major EMRs offer physicians advice on drug-drug interactions, limit physicians’ ability to order too much of a medication and/or check orders against a patients list of diagnoses and try to make sure the physician is ordering what he or she really wants to. Linked dispensary systems, like Pyxis, can limit the risk of nurses or others giving patients the wrong medication. And electronic patient identification (such as barcodes on patient arm bands) can significantly limit the delivery of medication or therapy to the wrong patient.

Obviously there are some major hurdles to the widespread implementation of electronic medical records. Included amongst these are technical issues and of course, in large part, the initial expense of implementation.

But these expenses are far offset by the benefits and most providers who are calculating it otherwise are fudging the benefits.

For hospitals the investment in well designed and implemented electronic medical records pays for itself in pretty fashionable time as some experiences have demonstrated. For private practices the initial overhead can be more daunting, admittedly. But private practitioners shouldn’t delude themselves that the benefits aren’t there. Yes, the patient safety issues for a largely ambulatory practice are less pressing than in the inpatient setting, if still present, but other benefits abound. Consider a new Annals of Internal Medicine study which may demonstrate that physicians who use EMRs may be less likely to pay malpractice claims.

I am a strong proponent of electronic medical records. However my point, in conclusion, is a nuanced one. For major medical centers, especially academic ones with integrated physician practices, to not have full fledged electronic medical records at the present time is inexcusable. For private practitioners, we should be working to bring electronic medical records as a reality. The lifting of Stark law restrictions was a good start, if the current economic conditions mean health systems are currently not as inclined to invest in EMR systems for their physicians as would be ideal. Hopefully federal subsidization will help the spread of electronic medical records into the private sector at an increased pace. Indeed P4P efforts should include the implementation of EMRs for increased reimbursement. Of course we all know how CMS’ P4P plans are doing. Still, I can dream

I’m serious about this issue. Ever residency interview I’m at I ask about the hospitals’ computer interface and what the physicians can and cannot do from the computers. A more substantial roll out of electronic medical records is long overdue.