Monday, October 17, 2011

Electronic Medical Record: American College of Physicians Speaks

Reading provider notes has never been a terribly enjoyable, but even the worst of notes were informative in some way. Problem lists, medication lists and allergies are always the must read section of any note. Histories, presenting symptoms, background information was always at the top and worth a glance before an initial visit. With a bit of experience one could even predict who the sub specialist provider was based on sentence structure and word use and if not from that the dictated physical exam was a give away. The cadence and rhythm of a person comes out as you drone on into a telephone receiver. I hated dictating as an intern/resident, now I hate to see it give it up, but like all things it is becoming something of the past. Not everyone is happy.

As with any system, an EHR produces the outcome for which it was designed. The most widely used EHRs are designed for auditing, compliance and billing. They are not designed for more efficient patient care in the office, better communication among providers, or the collection of group data for quality improvement efforts. As yet, there is no evidence that the use of an EHR provides less expensive care and/or better outcomes.

Medical record templates do not lend themselves to either recording or reporting meaningful clinical information. Details of a patient's story can be lost in a format that boxes individuals into disease categories, making it hard, for example, to distinguish one person with diabetes from another. Judicious use of cut-and-paste can save time and provide continuity with previous encounters. Poor use of it can perpetuate errors, and such files are often so poorly edited that two contiguous sentences can contradict each other.

Rather than being easier to read and navigate, encounter documents are longer, filled with extraneous information, and often lack the key elements of the physician's thoughts behind the assessment and plan. “Where are those informative notes we used to receive following our patient's visit to subspecialty clinic?” asked one of the community physicians who was swamped by the size and redundancy of the office notes he now receives and must file from consultants. Sadly, this problem affects us all.

After several months, I can now negotiate the system, but it still takes more time, effort, concentration and emotional energy than it should. The satisfaction of the examining-room encounter with my patients is compromised more than I could have possibly imagined. Furthermore, our high-priced EHR cannot import laboratory values from other organizations, is not configured to provide us with group data about blood pressure control and cannot electronically send our records to doctors outside our system with whom we share patient care.

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