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Electronic medical records: are we there yet?

In a happy coincidence, my favorite blog fodder feeder sent me a link to an article about Kaiser Permanente’s electronic medical record woes a day prior to Dr. Feld’s latest post on the subject of EMRs. Dr. Feld’s thoughts on the matter will certainly help to round out this discussion.

I’ve always been fascinated by technologies that are ahead of the curve. I blame this on my parents (take note – parents can be blamed for good things). Growing up in rural Canada our family was ahead of the tech curve – we had a satellite dish before there was scrambling, we had the very first Apple computers at home, and we built our own yogurt factory complete with an advanced digitally automated temperature gauge system, before the rest of the industry had moved beyond millimeters of mercury.

In college I was the first kid with a laptop in class, and in med school I was one of the first with a PDA. I took a portable printer with me to Europe in the late 80’s to go along with my Wordstar word processing program. I thought I was pretty cool, I guess! Stirrup pants, granny boots, permed hair and pink lip gloss.  Those were the days.

Cliff Bassett recently asked me why I was working at a new company (Revolution Health) that was so cutting edge rather than remaining in clinical practice. I had never thought about why I did it before – but now I see that it was part of my pioneering pattern. There’s nothing more fun than being ahead of the curve… but it can be aggravating as well.

Technologies are awkward for their first adopters – they aren’t streamlined, they can actually take more time rather than saving it, and they can make communications with others (who don’t use it yet) more difficult. But a few of us do it anyway – we jump in head first, believing by faith that the enterprise itself is worthwhile and that once we get to version 3.0 we’ll be sitting pretty.

But what do we do when we’re at version 1.0? Normally, we just tear our hair out and send lots of “bug alert” messages to developers. But when the technology affects someone’s health, the bugs are a lot more sinister. The recent article about Kaiser Permanente’s digital growing pains is disturbing indeed:

Kaiser Permanente’s $4-billion effort to computerize the medical records of its 8.6 million members has encountered repeated technical problems, leading to potentially dangerous incidents such as patients listed in the wrong beds, according to Kaiser documents and current and former employees… Other problems have included malfunctioning bedside scanners meant to ensure that patients receive the correct medication, according to Kaiser staff.

Still, 90% of physicians use paper records, making it difficult to share information – and this is no doubt contributing to the IOM’s estimated 98,000 error related deaths/year. Dr. Feld explains the complexity of a fully functional electronic medical record:

However, a paperless chart is in reality worth little unless the information entered is usable in a relational data base format rather than word processing format. Only then, can patient care be enhanced…An effective Electronic Health Record must consist of five components

Electronic Medical Records
Personal health records (PHR)
Continuity of Care Record (CCR)
Electronic health record (EHR)
Financial Management Record (read more…)

So, the bottom line is that the EMR is in version 1.0 at Kaiser Permanente, and only a twinkle in our government’s eye. It is complicated to create, nearly impossible to coordinate, dangerous if implemented half-way, and yet utterly necessary for ultimate cost savings and patient safety.

What can we do between version 1.0 and 3.0? Prayer and vigilance come to mind… it will be up to the foot soldiers (the docs, nurses, and hospital staff) to keep patients safe while juggling paper and digital until digital can fly on its own.

How do you think we can minimize our digital growing pains?

This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.


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5 Responses to “Electronic medical records: are we there yet?”

  1. ValJonesMD says:

    Well good for you, Dr. Smith, for being a pioneer yourself! We are a long way from the EMR promised land, but companies like Revolution Health are walking the desert trek along with you! Making medicine electronic is the digital version of America’s Transcontinental Railroad. Right now we have a “fax your record” capability at RHG (so at least people can keep all their paper records in one place on the net), but this is only the first step…

  2. Dr Rob L says:

    You have a subject here that is dear to my heart. We have been on EMR for 10 years and have been awarded by HIMSS and NCQA for the quality of our care. We are operating at a much higher level of efficiency and at a much better quality than most practices (certainly the combination of efficiency and quality is extremely unusual). While Kaiser’s experience is poor, it is very possible to succeed with EMR. Our office is but one example. The only thing holding us back from even higher quality is the fact that we would have to lose money to do so. We did just get our first $5000 check for quality, however, and I suspect it will be easier to motivate physician change when they see more of that kind of thing. I always find it amusing when other’s say it cannot be done. It can, and it will be increasingly required by the government (I know that because I am involved with the government at various levels and they clearly see the need for EMR and changing incentives for physicians). Yes, there are a lot of bad stories like Kaiser (although there are plenty of physicians within Kaiser that would tell you a different story), but there are also success stories like Providence in Portland, or MeritCare in MN and ND.

  3. ValJonesMD says:

    Thanks for sharing, Dr. Rob! So you’ve had a peak at the promised land… Would love to hear more about what works and why. I spent the last 3 years at a hospital that had NO electronic records of any kind – eek. Our clinic patients would literally break down and cry some days when I had to tell them that we couldn’t find their chart and they’d have to explain everything from the beginning… again. It was so painful.

  4. Hashslingingslasher says:

    I made my choice of physician based in large part if they were using an EMR. The safety issue was and is paramount. I don’t believe that EMR’s make bad physicians into good physicians. An EMR will not substantially help.

    However, I do believe EMR’s make good physicians, better.

  5. lex72 says:

    We all have to take part in fixing the system, the first step any person can take is by creating a digital health record , this does two important things first it reduces medical errors and second reduces costs so that duplication of services are less likely. It also puts the patient/ consumer in more control of his information which is a powerful tool. A good example of this which is currently free to the public is http://www.medicalrecords247.com. It potentially could save millions of dollars if the public would just take responsibility for there own health, and it starts with the medical record.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

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Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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