There are some things that Electronic Medical Records do well and there are some things that Electronic Medical Records do poorly. To say that I need Electronic Medical Records to help me type is nothing short of ridiculous. Unfortunately, when engineers meet computer programmers and try to help health care professionals type in the health care record in the name of “safety,” the results can torment those they’re trying to help.
Take auto-spelling, for instance. I have the nasty habit of typing “Lungs: Claer to A&P” and marvel at the auto-correction feature automatically correcting my typing to “Lungs: Clear to A&P.” This is an example of the wonders of electronics.
But when I type “DC Cardioversion” and the computer won’t left me type “DC” because it wants to know if I mean “discharge” or “discontinue,” the computer becomes intrusive, obstructive, and performs a service that should be right up there with water-boarding. I mean, is someone really going to mistaken that I mean “Discontinue cardioversion” or “Discharge cardioversion” when I’m typing my operative report? I could see this being a problem in the order-entry portion of the software, but when I’m typing by progress note or operative note?
Please.
Even better are the wonderfully useful letters “MS.” These might mean “magnesium sulfate,” “mental status,” mitral stenosis, “MS Contin,” “multiple sclerosis,” “musculoskeletal,” “Ms.,” or maybe even “Mississipi.” So, instead of being able to type a logical sentence without interruption, the doctor finds that that a drop-down pick list prevents those magic letters from being typed. It seems the chance that a nurse will wonder if you’re prescribing a drug in a southern state trumps the ability to enter a simple sentence on the computer. This is, after all, how we’re preventing medical errors.
But I wonder if these computer engineering road blocks are doing something much more insidious and detrimental to our health care delivery of tomorrow: like devaluing independent thought, reason, permitting the subtleties of context, and common sense.
Does the “Art of Medicine” really exist, or perhaps more importantly, can it do so in the computer age?
Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.
Communication with your patient is the epitome of the Art of Medicine. It is vital that physician and patient understand each other. This includes not only what the patient says but what they mean. This takes time, a commodity which is in short supply in the age of EMR. One should always remember a basic caveat about computers, which is, “garbage in, garbage out.” If wrong information is fed into the computer, it doesn’t matter what algorithm that you use because you will be following a false trail.
Computerization of medicine will lead to great advances if it is implemented properly. However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship – time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”
The combination of the computer age along with the time to listen to the patient and to accurately define their problem will indeed lead to a new age in medical care, but to ignore one or the other is not to fulfill our obligation to our patients.
Paul Ravetz is a family physician.
*This blog post was originally published at KevinMD.com*
At Health 2.0, Ted Eytan, MD, and I talked for a bit about why Kaiser Permanente’s “virtual health care system” has had such great success. According to his bio, Ted is a family doc from DC with a background in “working with large medical groups, patients, and technologists to bring health care consumers useful information and decision-making health tools, to ensure that patients have an active role in their own health care.”
Ted is Permanente’s Medical Director for Delivery Systems Operations Improvement. Permanente’s online system strives to bring the doctor and patient together online via the electronic health record (EHR), decision making tools and communications tools such as email. It further empowers the patient to be an active participant in the health care system by having access to the EHR and being able to book appointments online, renew prescriptions, contact health providers, and see labs and tests. Eytan has a wonderful summary of the system and the demonstration they did at Health 2.0 on his blog here.
Here are the highlights of our chat:
Dr. Gwenn: What makes Kaiser work so well compared to other areas of the country, for example Massachusetts?
Dr. Eytan: The key difference between Kaiser and here (MA) is adoption.
Dr. Gwenn: Why is that?
Dr. Eytan: The important point to teach doctors is the customer service approach. We do things because the members want it. That should be the reason for all change in health care. If places focus on quality not customer service, the system won’t work well and nothing will change.
Dr. Gwenn: What has helped Kaiser be so successful?
Dr. Eytan: Three major points that have worked well in Kaiser’s system: accountability, physician leadership and valuing members.
1. At Kaiser we have 100% accountability over everything. We own up to mistakes when they occur and help physicians learn from them.
2. Kaiser encourages physician leadership to spark reform and help IT departments facilitate change: Physicians do have value and can create the clinical vision. They work with IT to facilitate the technological changes that need to occur to make the doctor-patient encounter work better and to make the physician’s work life more manageable.
3. Kaiser listens to members… members have advisory groups, teen groups: they are involved and their voices are heard at all levels and all ages.
Dr. Gwenn: How do you oversee the online world with patients?
Dr. Eytan: The patients are the customers and the EHR must be usable to them – that is the MO of the entire system. In addition, there is an online, full time medical director responsible for the patient interface. There is no other way to have a patient-involved online system without a dedicated staff overseeing that system lead by a physician.
Dr. Gwenn: What problems do you help the clinical staff anticipate with online care?
Dr. Eytan: With virtual care, patients will see lab results and parts of the EHR they are not used to seeing and that could prompt questions or concerns. There has to be commitment from everyone to be ready to answer those questions fro the system to work well for the patient. They provide a great deal of training and support so the clinical staff will be prepared for questions from patients they may not have had when patients were not so involved in their care and seeing so much of their EHR.
Dr. Gwenn: How does virtual care help the system?
Dr. Eytan: There are a number of important ways virtual care helps the system on many levels:
1. It builds confidence in the doctor patient relationship by fostering conversation.
2. There’s a database to give patient’s article-based information (Permanente uses the “healthwise knowledge base”).
3. They use true medical terms with patients and in the EHR that patients will Google. This helps patients be more savvy in the health care system and know what terms to search for should they seek more information or have questions to ask of the clinical staff.
Dr. Gwenn: What are the benefits of virtual care for the patients and the physicians?
Dr. Eytan: There are three primary benefits:
1. Online care helps empower the patients to be part of their care and shapes use with guidance from the staff.
2. Patients become so involved they become invested in making sure the EHR is accurate and often point out mistakes they note, such as typos.
3. Doctors can be more efficient by using pre-visit emails to organize their time.
Dr. Gwenn: What’s your take on the Health 2.0 vs. Ix (Information Therapy) debate during this conference?
Dr. Eytan: Useful, accurate information is the goal. Give people what they want, when they want it. All systems need to use more health 2.0 tools member to member. Ultimately the goal is to connect to the doc.
Dr. Gwenn: How can docs be more health 2.0 savvy?
Dr. Eytan: All docs should ask patients if they use the internet. It’s the 6th vital sign.
Dr. Gwenn: Many patients don’t live in a virtual health care system like Kaiser, how can they get from their system what you offer at Kaiser?
Dr. Eytan: Ask and demand! Most electronic medical record systems have the tools in place, like email, and just have to start using them. Patients need to ask for what they want. Physicians want to do a great job and hate waste.
My final thoughts:
With such great models such as Permanente in many areas of our country, it’s frustrating we can’t get similar systems everywhere. Perhaps it is not just the patients who have to “ask and demand” for what they want in the health care system. Perhaps it’s time docs everywhere stood up and demanded a system where docs were compensated well, treated respectfully, and had a system that actually supported good care.
*This blog post was originally published at Dr. Gwenn Is In*
Bolstered by the stimulus, there’s no doubt that there’s a significant push for doctors and hospitals to adopt digital medical records.
I’ve written before how we’re essentially throwing money at Windows 95 technology, but now, as an article from BusinessWeek points out, there’s a real danger in moving too fast.
Somewhat under-publicized were the incompatibilities with older systems in the Geisinger Health System, which after spending $35 million on software, noticed a spike medication errors that required another $2 million to fix.
Or what happened at the University of Pennsylvania, which found medication errors stemming from software designed to prevent mistakes.
Worse, there is no national database tracking the errors that are caused from electronic medical records. Because most of the programs are not open-source, confidentiality agreements meant to protect proprietary technology also serve to hide mistakes.
Ideally, these issues need to be resolved before throwing more money into bad technology. But, because of the intuitive notion that technology automatically improves health care, no one seems to be advocating a more cautious route which may, in actuality, better serve patients.
***
Better Health Editor’s Note: Please read this post for more in-depth coverage of how difficult it is to transfer health records electronically.
Tim Cromwell’s mother-in-law is 86 years old. Her husband is a Korean War veteran who developed Alzheimer’s disease, and receives care from both the VA and private healthcare providers. Because she and her husband take so many medications, they actually replaced their dining room table centerpiece with a collection of orange and white pill bottles. Mrs. Spencer keeps a hard copy of all of her husband’s medical records in a large file box that she carries with her on a cart with wheels. She has no alternative for keeping all her husband’s providers up to date with his complex care, and lifting and transporting the records has become more difficult for her in her eighth decade.
If this story sounds all too familiar, then you’ll be glad to know that the government is facilitating electronic medical and pharmacy records portability. One day it may be possible for Americans to dispose of those hard copy files, knowing that any provider anywhere can access their records as requested.
Tim Cromwell is passionate about alleviating his mother-in-law’s need to carry medical records around, and believes the way to do this is through the US Department of Veterans Affairs’ participation in the Nationwide Health Information Network (NHIN). Working in compliance with NHIN standards, the Federal Health Architecture group recently oversaw the creation of software (called CONNECT) that creates a seamless, secure and private interface with hospitals, and over 20 federal agencies’ medical records systems (including the Social Security Administration, Department of Defense, Veterans Affairs, the Centers for Disease Control and Prevention, and the National Cancer Institute).
On April 6, 2009, NHIN released the CONNECT software necessary to make Electronic Medical Records systems interoperable. The software is “open-source” and free to all who’d like to incorporate it into their EMRs. Those who add the free software will be able to share data with NHIN’s member groups, which include early adopters like the Cleveland Clinic, Kaiser Permanente, Beth Israel Deaconness Medcial Center, and MedVirginia.
This means that if Mrs. Spencer and her husband receive their care from participating hospitals and federal programs, they’ll never have to tote paper records again. But it may take some nudging from patients and healthcare professionals like you to grow the network. If you’d like your hospital to participate in the NHIN network, encourage them to view the NHIN website here.
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