The case against a national EMR

[swampfox]

I thought there may be some interest in this. The story is how the VA EMR went down and the havoc it caused. Imagine a national EMR as has been proposed by some (including Newt Gingrich) going down. The VA is put up as the example of how a national integrated EMR can work.

http://www.computerworld.com/action/article.do?command=viewArticleBasic&articleId=9047898&intsrc=hm_ts_head

[sweaner]

I think that for EMR to truly be useful, it does need to be national, or at least regional. However, this is going to be a problem when dealing with electronics. There would need to be a great deal of redundancy built into the system. Maybe the system could work like Napster (RIP) did. The data could be on thousands of individual servers.

I tell people that my system has never gone down, and only a fire could stop it. I am still using paper, which has clear advantages as well as disadvantages.

Scott

[Graham]

There's always gains and losses when adopting a new technology.

For instance, when the Egyptians made a move from clay tablets for medical records to papyrus, then they found that fire was able to damage the latter but not the former. But not having to create clay tablets made the move to papyrus an easy choice.

Likewise a few thousand years later, the move to electronic records has many advantages including regaining the invulnerability to fire due to the ability to replicate data off site. But the main advantages are readability and mobility. I do clinics out of town and carrying patient paper notes with me would be unthinkable. Instead I just dial home as it were to my server while I am out of town.

[swampfox]

My old paper charts had their problems, but they never crashed or got viruses. Open the chart and the data is there every time, even in a power failure. I still like my EMR.

[cdoc42]

We just had a small snow storm in the NE - 5 inches of heavy snow. Less than 1000 homes lost power for most of the day. But our computer access for billing purposes was out for most of the day, then was on and off for the remainder of that day and into the morning of the next day. If I had an EMR I would have had to convert to paper to see patients, then redo all that work, updating the records, once the system was up and running again. Computers are great for repetitive tasks, but when they CAUSE the repetition, it can ruin your day big time.

[abower]

Communicating online suggests some level of computer comfort. My billing system in the past communicated with the schedule and Quickbooks and could take dragon dictate notes.
Does anyone else fine that only with writing can I formuate ideas, diagnoses and treatment plans? With dictating I must concentrate on the form and substance. Typing I must plan ahead as well.

[Graham]

We just had a small snow storm in the NE - 5 inches of heavy snow. Less than 1000 homes lost power for most of the day. But our computer access for billing purposes was out for most of the day, then was on and off for the remainder of that day and into the morning of the next day. If I had an EMR I would have had to convert to paper to see patients, then redo all that work, updating the records, once the system was up and running again. Computers are great for repetitive tasks, but when they CAUSE the repetition, it can ruin your day big time.

If you need electricity to run mission critical applications, you do what everyone else does .. and run backup generators.

If you happen to live in such an area, running laptops is also better with lower electricity consumption.

BTW, what happens when you run out of paper due to lack of foresight in buying enough??

[dawso007]

I haven't seen it posted so far, but the real problem with a national EMR is that it turns your personal medical data over to government and business for whatever purposes that they want.

In my opinion, personal medical data should never be stored in a depository that anyone can theoretically access. The government and their friends in business have done and absolutely atrocious job with both financial data and Social Security Numbers. As far as I am concerned the government has actually facilitated identity theft and refused to do anything about it.

Allowing them to develop a national EMR is pure madness and the first step toward a Gattaca like society.

With USB drives there is no reason why everyone can't carry their data around with them and plug it into any system for updating.

GD

[DaffyDuck]

I always get a trickle of patients. Who tell me that their doctor is no longer around. They say they went to the office for their appoinment, and found the doors closed lights off and clinic empty. They say they have called every one and there is no news of the doctors where abouts. They have no access to their records. I say no problem, give the front office the name of your pharmacy, the lab that you use, the diagnostic center you have been to in the last year and and the name of the specialist you have been to, and your insurance carrier, Give us a few hours and we can regenerate your chart as good as knew.

Frankly this data is all that is needed and should be the only thing that should be in the chart. But we instead have turn the whole charting chore into defending our selves from a law suit that may or may not never come. charting every issue regardless of clinical value " Like patient was directed to the er, patient was advised that symptoms can be life threatening, Patient refused to go, patient signed a AMA form after it was verbally explained to here, Patient put tea bags in the wound without direction, patient has terminated relationship with this clinic, patient is non compliant, on and on. Hell in some countries there is no charting

[BigDoc]

I always get a trickle of patients. Who tell me that their doctor is no longer around. They say they went to the office for their appoinment, and found the doors closed lights off and clinic empty. They say they have called every one and there is no news of the doctors where abouts. They have no access to their records. I say no problem, give the front office the name of your pharmacy, the lab that you use, the diagnostic center you have been to in the last year and and the name of the specialist you have been to, and your insurance carrier, Give us a few hours and we can regenerate your chart as good as knew.

Frankly this data is all that is needed and should be the only thing that should be in the chart. But we instead have turn the whole charting chore into defending our selves from a law suit that may or may not never come. charting every issue regardless of clinical value " Like patient was directed to the er, patient was advised that symptoms can be life threatening, Patient refused to go, patient signed a AMA form after it was verbally explained to here, Patient put tea bags in the wound without direction, patient has terminated relationship with this clinic, patient is non compliant, on and on. Hell in some countries there is no charting

In the UK (at least when I worked there) there was ONE chart, if you admit a patient who has had extensive treatment at another hospital, call, the ORIGINAL chart will be delivered by cab

[BigDoc]

We just had a small snow storm in the NE - 5 inches of heavy snow. Less than 1000 homes lost power for most of the day. But our computer access for billing purposes was out for most of the day, then was on and off for the remainder of that day and into the morning of the next day. If I had an EMR I would have had to convert to paper to see patients, then redo all that work, updating the records, once the system was up and running again. Computers are great for repetitive tasks, but when they CAUSE the repetition, it can ruin your day big time.

In a snowstorm without power, I'd be hard-pressed to open the office

[cdoc42]

Let me clarify. The office had electrical power. We were functioning in every way except for the computers being down. Comcast told us it was our modem. But the bank at the end of the block and the pharmacy next door had exactly the same problem as I did and we do not share the same modem, but we do all have Comcast. There was no reason for being closed to patient care.

Re: Graham's note: in 31 years I have never run out of paper. Even if you don't have any at all, you can always run to Staples-like stores and buy tablets of any kind of paper.

The real reason for pushing EMR is not for patient care. It's an extension of third party need to look over our shoulders for fiancial reasons. Can anyone honestly admit they have reviewed all of a colleague's progress notes when you receive a transferred record ? We're looking for adiagnosis list, med list and any ancillary studies connnected to the diagnoses.

[dawso007]

"Can anyone honestly admit they have reviewed all of a colleague's progress notes when you receive a transferred record ? We're looking for adiagnosis list, med list and any ancillary studies connnected to the diagnoses."

This is another unspoken problem of the EMR and documentation guidelines in general. They are basically set up to satisfy billing requirements rather than any clinical need and as such have mostly redundant and therefore useless information.

It seems that bureaucrats and politicians want a few kilobytes of useful information buried in gigabytes of useless information. Their most likely motivation to me seems to be to slow physicians down and make them less productive. Less productive physicians have less direct costs.

Their mantra has been: "If it isn't documented it didn't happen". Let's face it - any one of us can document everything that happened in a note that it much shorter than one containing all of the E & M bullets.

Until there is an EMR that actually rapidly sorts through all of the information and pulls all of the good stuff up for analysis - the current EMR is only slightly better than surfing amazon.com.

GD

[Graham]

The real reason for pushing EMR is not for patient care. It's an extension of third party need to look over our shoulders for fiancial reasons. Can anyone honestly admit they have reviewed all of a colleague's progress notes when you receive a transferred record ? We're looking for adiagnosis list, med list and any ancillary studies connnected to the diagnoses.

In NZ, we don't have anyone overlooking our shoulders to audit our records. Nevertheless I do not know of any FP who does not have an EMR.

[cdoc42]

Graham, I wonder how a comparison of the data your area EMrecords present would compare to ours. I've seen GYN routine exams, 2 pages long. Endocrine diabetic revisits, 3 pages. FP revisits as long as 5 pages. Automatic "blow-ins" that don't make sense like a patient who is no medication but an entry at the end states "Continue same meds." A patienmt visiting for routine seasonal allergy treatment but the history states "No known allergies."

[Kursk]

I have seen hand written and dictated notes that have the exact same stupid things. EMR is just a tool. And like a chisel that is misused as a screwdriver, those lazy folks that don't believe in accurate documentation will misuse EMR to falsely upcode or do other nonsensical things that annoy you. Templated documentation occurred before the EMR (I know ENTs that dictate like this: "sinusitis, plan B"). Perhaps the silliness is more flagrant now. My advice to physicians is don't buy an EMR that does not allow you to document the way that you want to document and check everything for accuracy - since it is your legal medical record. Most EMRs today are flexible and allow for frequently used phrases to be automated, they can incorporate partial dictation and all have to allow for free text entry. Its entirely up to the physician to accurately record what was done. However, I would certainly agree that most physicians do not understand E/M coding and the payors are asking for too much detail that is unnecessary and counterproductive for knowledge exchange - but again that is not the fault of the EMR.

[Graham]

Graham, I wonder how a comparison of the data your area EMrecords present would compare to ours.

Usually they're so brief to be useless :eek:

Ie. the EMR note is just how they would have written in on a bit of card in the days when they used cards.

Of course when they send a referral to you, it's basically alll of these notes padded with their blood results. There is no long list of unrelated ROS, or examination of unrelated systems.

[ivaldes1]

The possibly misleading aspect of this VA failure is that the current VA Health IT leadership decided to centralize and consolidate what was heretofore a very distributed and very reliable system. It is very predictable that this would happen given such centralization and consolidation. FYI the current VA Health IT leadership appears to be making what many consider not one but several massive strategic blunders in what was and is a national treasure.

A public/privately owned national system based on the VA software that safeguards physician and patient ownership of data is being built now by organizations of all kinds. This is because the VA VistA software is available in the public domain and many are beginning to use it.

A introductory system administrator training event for this software is being held December 7-9th in Houston, Texas. More information here: http://hchic.org/events-1/intro-wvehr-sys-admin

-- Ignacio H. Valdes, MD, MS
-- Editor: Linux Medical News
-- http://www.linuxmednews.com

[DaffyDuck]

I had patients whom I referred to lets say the GI. I would recieve the notes by Mail 5-7 pages long typed on the finest paper available with a H&P that honestly would make most PCPs blush. Then I later would see the patient who reports to me that the GI walked in "question" them why they where there, then touch the abdomen "not exmine'' then walked out of the exam room. Patient would leave the clinic with no plan, treatment or follow up appoinment. But in the notes you read that patient has been sent for an extensive evaluation and will be seen back in 1 week. "What a Farse"

[cdoc42]

Who do you believe? Often patients don't listen to what is being said, then come home with, "I wasn't told anything." One of my pet peeves is being interrupted by the patient with a statement that has absolutely nothing to do with what I'm trying to teach them.

[DaffyDuck]

"Who do you believe? "

What do you think.
Look Occasionally my significant others need to go see a Doctor, because I don't treat family or friends. They tell me the same thing. In and out no exam.

[Ignatz49]

abower, yes, writing definatly (sp?) helps me think better including formulating differential dg and txs.

I agree that most EMR notes (including my own) are terribly bloated with junk but I see that more as a problem with CPT/E&M/lega issues. I dearly love getting old records on 8x5 cards (11/29/87 URI Amoxil #28) Total note for encounter. And all that was truly needed for such an encounter.

[Graham]

Hard drive space is so cheap you could video record the whole consultation and just go back to documenting on cards.

If they wanted to audit you they would have to sit down and watch all those videos.

[drsam]

Hard drive space is so cheap you could video record the whole consultation and just go back to documenting on cards.

If they wanted to audit you they would have to sit down and watch all those videos.

That's actually a pretty damn intriguing idea!

I wonder what the actual effect on cost, HIPPA laws, etc would be for something like that.

[DaffyDuck]

What happens if some one comes in for a rectal exam?
Then insist on a copy of the film.

I don't think so.
Call me old fashion.

[Graham]

One could always be a bit selective ....

Synapse allows one to dictate a consult and have that dictation embedded into the encounter permanently. I suggested to one user who wished to save $$ that he could dispense with having the dictation transcribed, and just make a couple of one line notes as reminders.

If audited, they could review his dictation.