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The Eyes of Big Medicine: Electronic Medical Records

When doctors spend more time in front of a computer than they do with patients.

by
Paul Hsieh

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September 18, 2013 - 9:44 am
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This is the third part in a series of articles on the rollout of Obamacare and how the law will change our health care system. Each week, we will publish two articles — one on the changes in medicine and medical care and one on changes in the insurance industry. We hope this series of articles will help you make better decisions when it comes to your health care and how you buy insurance.

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The first two articles discussed the growth of government-controlled Big Medicine and how it will affect medical care. This next piece will cover the role of electronic medical records (EMRs) in Big Medicine.

The HITECH (Health Information Technology for Economic and Clinical Health) Act of 2009 essentially mandates that physicians and hospitals adopt electronic records by 2014, or face penalties in the form of reduced Medicare/Medicaid payments.

At first glance, adopting electronic medical records would seem a no-brainer for doctors and hospitals. After all, electronic records are the norm for many successful businesses, assisting with sales, inventory, and billing. In theory, electronic medical records should reduce costs for doctors and help them practice more efficiently.

Yet as Dr. Adam Sharp notes, EMRs are a “dirty word” to many doctors because EMRs are cumbersome, hinder doctors’ ability to practice, and are too expensive.

In the New York Times, Dr. Pauline Chen described how EMRs are impairing doctors’ ability to interact with patients. Many young doctors in training are so busy filling out obligatory electronic forms, they are now spending only 8 minutes per patient each day. As a result, they cut corners:

When finally in a room with patients, they try to [rush through interviews] by limiting or eliminating altogether gestures like sitting down to talk, posing open-ended questions, encouraging family discussions or even fully introducing themselves.

As Dr. Chen noted, the bad habits they learn in training will carry over to when they become independent practitioners.

Another recent study showed that young doctors spent only 12% of their time in direct patient care compared with a whopping 40% of their time in front of a computer. Veteran ER physician-blogger “WhiteCoat” recently tracked his workflow and similarly found that 50% of his time was spent on the computer, not with patients.

One pernicious effect of doctors spending so much time on the computer is that they tend to “treat the chart” rather than treating the actual patient.

Dr. Richard Gunderman described an extreme example of this phenomenon:

An intern recently presented a newly admitted patient on morning rounds, reporting that the patient was “status post BKA (below the knee amputation).” “How do you know?” the attending physician inquired. “It has been noted on each of the patient’s prior three discharge notes,” replied the intern, looking up from his computer screen. “Okay,” responded the attending physician. “Let’s go see the patient.”

When the team arrived in the patient’s room, they made a surprising discovery. The patient had two feet and ten toes. Where did the history of BKA come from? It turned out that four hospitalizations ago, the voice recognition dictation system had misunderstood DKA (diabetic ketoacidosis) as BKA, and none of the physicians who reviewed the chart had detected the error. It had now become a permanent part of the electronic medical record — as if written in stone.

As Dr. Gunderman warned, “The flesh-and-blood patient is getting buried under gigabytes of data.”

Furthermore, these electronic medical record systems can be expensive, forcing doctors in practice to make some difficult business choices. One of my local colleagues here in Colorado described his conundrum:

While many small practices would love to implement new technologies, such as electronic medical records (EMR), in order to better deliver care, we have special challenges that are not addressed in health care reform regulations. Most small practices operate with low profit margins making introduction of expensive systems difficult.

Even with government incentives, costs can run well into six figures, especially with multiple providers. Large hospital-based practices are at a competitive advantage to implement such government mandates while small practices are forced to choose between hiring/maintaining medical staff, adding EMRs or selling out to Big Medicine to avoid such challenges.

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All Comments   (12)
All Comments   (12)
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Be afraid, very afraid.

Doctors and health practitioners are now asking leading questions that can and probably will become accessed by our "government:"

"Are there any guns in your household?"
"Do you ever feel sad, depressed or angry?"
"Do you engage in any high risk hobbies or sports?"
"How much alcohol do you consume?"
"Have you ever used illegal drugs?"

The list goes on, but you get the picture.

30 weeks ago
30 weeks ago Link To Comment
If the computers are working. I've complaints about the computer my doctor uses because the system rarely works. That means they have to write everything down and spend more time later putting it into the machine. When their machines are sort of working, someone else's machine in the chain isn't so everything gets backed up again.
30 weeks ago
30 weeks ago Link To Comment
the physician has little choice but to spend more time in front of thecomputer than the patient. If the note doesn't have enough detail (i.e past medical history 10 point review of systems, family history, socal history, templated phyiscal exam) the doctor doesn't get paid. For each detail added to the note, the doctor can charge the insurer more with the expectation that he or she will receive a fraction of the bill submitted. Furthermore, the EMR flags all the preventative medicine issues and drug interactions for the doctor so he or she can modify treatment or order additional tests (defensive medicine).
It is my feeling that the EMR has two real purposes: 1) to turn medicine into an algorithim so that medical assistants and nurse practioners can take over the role of a primary care physician and 2) to make it easier for insurers and government to mine the data to provide proof for whatever, social engineering initiatives they can imagine.
30 weeks ago
30 weeks ago Link To Comment
One of the many experiences I had in the hospital recently was watching the hospital staff trying to use a new computer system called EPIC. Basically, nothing got done, no drugs dispensed, no treatments, no taking vitals, etc., without an order to do so in EPIC and not a second before the time EPIC said to do it.

It reminded me of the movie 2001 a Space Oddessy, with the psycho-computer HAL. In fact I had dreams about it as follows:

me: Hello HAL, do you read me HAL?
HAL: I read you Dave.
me: I need my medicines now HAL.
HAL: I'm afraid I can't do that Dave.
me: What's the problem HAL?
HAL: I think you know what the problem is as well as I do, Dave.
me: I don't know what you're talking about HAL.
HAL: Obamacare is too important for me to allow you to jeopardize it Dave.
me: HAL give me my meds!
HAL: Dave, this conversation can serve no purpose anymore. Goodbye.

Welcome to the future ...
30 weeks ago
30 weeks ago Link To Comment
Change is a normal and necessary part of medicine. Sometimes the process is difficult and takes time to adapt. The old paper chart with scribbled notes was no great shakes either.

The EMR is a step up. Yes there are errors in voice recognition and it is a big problem. In Radiology I have seen turn around times go from 24+ hours to that many minutes because of the new technology. Don't tell me that is not a net benefit.

When the consult, operative report, labs, vitals, or history & physical is available to everyone involved in the care of the patient within minutes that is a very big plus.

The skill of the clinician must always rest on treating the patient, not the chart or MRI, yet the patient trusts that you have all of that data in mind before you approach the bedside. We should never lose humanity nor humility. Neither should we reject technological and scientific advance because of fear of the government.

That is the challenge for young physicians today. I think they will do just fine.
30 weeks ago
30 weeks ago Link To Comment
There are some advantages, but the actual implementations are usually horrible. Why the major vendors did not simply try to re-create the paper chart in an electronic form is beyond me. Had they done that they could then have started working to improve it rather than moving to something completely foreign, and enormously user-unfriendly.

I work at a middle sized academic medical center and our current EMR (one of the most popular ones) is a mess. If I need to research what is going on with a patient in order to make sense of the labs we are seeing, it is nearly impossible to find relevant information quickly. Old history is often hard to tell for recent observations so you are never quite sure whether this complaint is current or from years ago. The staff has multiple phone conversations every day where it becomes obvious that what we see in the EMR is not what the floor nurses see. Their screens are different, and there is little commonality. We expected that when the providers could place orders in the EMR and have them transfer directly to the lab system, that we would save time from having to manually enter all the orders as we had been doing. The reality is the number of incorrect orders and orders that have to be clarified has increased and we now spend 25% more time cleaning up the mess than we did before. The providers did better with the old paper forms. Why they didn't re-create the paper form with check boxes I do not understand.

One of the things that does appear to be true is that the people building and designing these systems have apparently never actually worked in healthcare. Most are recent college graduates hired for coding skills with no knowledge of how an EMR needs to be used.

Another thing was "unexpected" was that because the EMR's captured more information than the providers used to write in their notes, especially in the ER, is that reimbursement for the ER visit is now higher than it was before because hospitals were undercoding because they weren't always sure they had all the pieces needed to justify a higher reimbursement code. The EMR knows what's needed for each treatment code and if sees all the pieces it needs to file the more complex reimbursement code, it does so. Medicare in particular has been hit by this, and has started accusing ER docs of overcoding where they were probably habitually undercoding before. I doubt this effect will lower our healthcare expenditures.
30 weeks ago
30 weeks ago Link To Comment
Get used to it. You ain't seen nothin yet. Take a seat and wait until your number is called. You're no longer a person, you're a health care consumer. you're doctor is not longer a doctor, he's/she's just part of the health care provider team; just like the receptionist. Coming next, no human interaction; you just sit in front of your computer and talk to the screen. You wish to see the doctor? Will schedule you in sometime next February. And that's the way it's going to be.
30 weeks ago
30 weeks ago Link To Comment
...and Corrie ten Boom got all her personal affects back, despite multiple transfers when she was released early due to a clerical error.
30 weeks ago
30 weeks ago Link To Comment
there was a saying i once read and tried to always remember back when i was practicing,

"look at the patient. that chart's not sick."

that day is gone now.
30 weeks ago
30 weeks ago Link To Comment
True, true, but the chart can make you sick if it's not kept properly and read timely.
30 weeks ago
30 weeks ago Link To Comment
which is just one of the reasons that you look at the patient.
30 weeks ago
30 weeks ago Link To Comment
To look and use common sense. I've had doctors tell me I need to lose weight because the BMI chart says I'm overweight. However, if they bothered to look and think they'd see I'm muscular rather than fat. More to the point, when I was the weight they want me to drop to I looked awful and was sick all the time. The computers and bureaucracy are taking over and that is going to mean more bad outcomes for patients.
30 weeks ago
30 weeks ago Link To Comment
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