By Menachem M. Meller, MD, PhD
From note pads to I-pads—and back again
Mention electronic medical records (EMR) at a medical staff meeting and the responses range from a smug sense of accomplishment to apprehension. Computerizing medical documents is no different in principle than computerizing grocery items. Some might ask, in a system as complex as health care, what took so long?
The fact remains that EMR means different things in different institutions, which has spawned a new expert—the informaticist, a medical professional who has training in both computer data analysis and in evidence-based medicine and medical treatments. What an EMR system does depends on what it is being asked, designed, and licensed to do.
Taken at its basic elements, the EMR is the electronic equivalent of the paper record. It has, however, the additional potential advantages of automation, interface, and standardization; it is widely available, yet restricted. I have some concerns that my patients may not trust EMR confidentiality and may not be as forthcoming as they have been in the past.
A poll of my colleagues regarding the transition to the electronic chart raised concerns about tradition, cost, complexity, time, reluctance to be dictated to, fear of loss of records, and dependence on the computer. Some individuals expressed enough reluctance to make the transition that they might consider retirement an acceptable alternative.
Within a health system, there may be some awareness of these concerns, enough to ask how far and how fast? But at the system I belong to, not once did I hear the questions “Can you type?” and “Are you computer literate?” EMR systems are prohibitively expensive for individual practitioners, yet when enacted system-wide, they involve multiple compromises.
Our system has network connections throughout the East Coast and has invested more than $40 million in this effort. It is not clear whether this budget includes replacement and maintenance costs. My training involved a brief online class, two simulated classroom activities, and monitoring by trainers whose first day on the job was in my office. Any question I had was relayed by cell phone to the main office.
One major problem is that patients don’t have a single record. On a daily basis, I use the following programs: Invision for inpatients, Picis for emergency room records, PACS for radiographic studies, NextGen for outpatient records, and Bayscribe for electronically stored, dictated hospital notes. Each morning I must run an inpatient list, an outpatient list, check lab results and studies, and sign incomplete charts—all by cycling through a list of programs. Electronic messages arrive via e-mail and various task boxes. The other hospital where I see patients does share some of the programs but they are not linked. Although one can assign the same unique identifiers to records, separate access is required. Information technology with a unique patient identifier is not yet here.
Remote access has its own issues. My home computer has an i7chip (the latest from Intel) with Windows 7 software. I purchased it with the anticipation of keeping up with the latest software requirements. Attempting to access the metaframe server from my home computer soon revealed that I had three choices:
- Dumb down my Windows 7.
- Get a patch.
- Image (back-up) my work computer at home.
Apparently the program could not keep up with the latest worldwide Microsoft.
For the present, EMRs are reducing my practice costs. Voice transcription has been replaced by computer-generated, physician-driven input. But the need to electronically record general health information—including vital signs and health maintenance information—has necessitated adding a new staff person for data collections. The computer does crash and the screen does freeze on rare occasions. We have not lost any data, and we store records in duplicate in geographically separate servers. It does take about 50 percent longer to enter patient data in spite of every effort to maintain the pace. Unfortunately, we cannot go back; calling the lab tech to look up a hematocrit level is becoming a thing of the past.
The office EMR is my most immediate challenge and concern. Of the five major components, only one is physician entry. Once I finalize a report, it is done. No chance to cross out and initial; making a correction requires another electronic record.
My longtime staff have risen to the challenge and faced the task of mastering the new technology. They have been inspirational in learning new techniques and new shortcuts daily. But what about practices where everyone is not “on board”?
Perhaps what I most take exception to is the commodity approach to electronicizing the record. The templates have yes-and-no choices, quick exams are prepopulated, and unusual but conventional diagnoses are not listed. There are no check boxes for equivocal findings that I would like to ascertain and review on follow-up. Subtleties must be free texted, which makes the EMR a very expensive word processor. I find myself leaving electronic crumbs to review on the next visit to mimic the conventional practice paradigms.
We have come a long way, however, and the not-too-distant future may include seamless integration and cheap and ready accessibility. In the short term, we have a system that makes the progress note available to be e-mailed to the primary physician before the patient leaves the examining room.
I continue to advocate for improvement by keeping a log of daily challenges. Currently, I go through the motions of electronic scheduling, electronic ordering, and electronic communicating. Every few weeks I find a new function that works or someone who actually responds—electronically. But I still use my note pad to keep track of my programs and passwords, and my phone is still my best medical device.