What’s the electronic medical record (EMR) really for, anyway?
This is a cross-post of an item I wrote for Maggie Mahar’s excellent heathcare blog, Healthbeat
The electronic medical record, the EMR, is upon us. For those of us who learned medicine entirely with paper charts, some have enthusiastically embraced the EMR and some have refused, to the extent they can, to deal with it at all. But most of us have plowed ahead into learning how to use it as best we can. It seems to me that the degree of enthusiasm physicians show for the EMR relates less to the particular version of it we have chosen (or, more commonly, was chosen for us) than it does to the kind of medicine we practice. The old paper records worked reasonably well for all of us; in contrast, the several versions of the EMR I’ve used work very well for some kinds of doctors, but less well for other kinds. I think a good part of this disparity is that the basic purpose of the medical record has changed over the past half-century or so, and some of these new roles can conflict with the old ones.
The oldest repository of continuous patient medical records is at the Mayo Clinic in Rochester, Minnesota. In a very real sense the modern medical record was invented there, in the first decade of the twentieth century, by Dr. Henry Plummer. As the first multi-specialty clinic, it made more sense for each patient to have a single record that traveled from doctor to doctor with the patient, rather than having each doctor keep his or her own record for each patient. The idea was to have a single packet of paper that contained everything that had happened to the patient. From that it’s only a short step to the notion that the record should travel with patients wherever they go, even if it is to physicians not associated with each other. This is a key promise of the EMR.
Medical records began as the possession of the doctor. This paradigm is changing. Very soon, although medical facilities will have copies, the records will essentially belong to the patient, with doctors only using them from time to time as need requires. Of course this could, in theory, happen with paper records, but it would be cumbersome. One of the things that first attracted me to pediatrics was the sheer size of the pile of paper that the medical records clerk would plop in front of the hapless medical student admitting an octogenarian to the hospital; in contrast, a toddler’s chart fits neatly in a small packet. The EMR allows these massive piles to be reduced to disks or microchips. It also allows the record to be organized into searchable form, so important things don’t get missed because they are buried in the disorganized mess of sequential folders.
Those are a couple of the brave promises of the EMR, but we all know we are a long way from realizing them. One huge barrier is that, as of yet, there is no standard platform for the EMR. Like many physicians, I’ve had to learn several because different facilities choose different vendors. In our pluralistic medical system (if one can indeed call it a system), it’s a free-for-all. And each of them has its own maddening quirks.
I think there is a broader problem here: over the ensuing years from Dr. Plummer’s era the medical record has taken on roles unheard of back then. For one thing, now the record is a legal document, a buttress against anyone who accuses us later of bad care. This process began long before the EMR, or course, which is one reason the charts I had to grapple with as a medical student ballooned so much. As a graduate student in history of medicine I had the chance to review many of the Mayo charts from earlier, simpler times. I recall one chart, from the nineteen-forties, describing the course of a very critically ill child. Overnight the child’s condition had markedly deteriorated; it was easy to see this from the recorded blood pressures and heart rates. The physician’s note for the following day analyzed these developments with only four words: “mustard plaster didn’t work.” Now the EMR offers the possibility of recording all we do easily and without getting writer’s cramp.
The medical record has also become something else it wasn’t back then: it is also now a commercial document, proof of what we did and why, used by payers to check up on us to make sure we should be paid for what we bill. Today’s payers want to know what the doctor did and why. They want to know, quite precisely, why that mustard plaster didn’t work and all that we did to make it work.
I think some of the problems with the promise of the EMR are that these legal and commercial roles can clash with the original purpose of the chart, which is taking care of the patient. The computer whizzes who design the software don’t always seem to me to have quite the same goals as we doctors who use it. The old paper charts were easy to adapt to new things, new procedures. All we needed was a different sheet to add to them and stuff in the folder. Upgrades and tweaks to the EMR are much more formidable things.
In spite of all these things I find the EMR to be a powerful addition to my practice. In fact, I think I’m a better doctor for using it. I think a key reason for that is because of what I practice – critical care medicine. In the ICU we love to measure and count things. We want minute-to-minute monitoring of variables, which in the old days resulted in huge paper flow sheets covered with dots and numbers. Rummaging through them to identify key moments in a patient’s care was often difficult. In the ICU, each patient gets a large number of tests each day, results which used to get stuck on clipboards with all the other paper. Important things got missed. Now I can sit at a computer screen and find it all with a mouse click, and the EMR makes it very hard not to notice anything important.
In contrast, I have friends who hate the EMR. It causes them hours of pain in training time, pain for which they aren’t compensated, and is slower for them to use than paper records were. In their minds, it gives them little or no advantage over paper in caring for their patients. I’ve noticed that they practice specialties that are less concerned with number-crunching than mine. They also tend to be office-based, rather then hospital-based, and don’t have to deal with as many other physicians as I do each day in the ICU. Thus many of their notes are written for themselves, not for other members of a large clinical team. Yet now they are asked to conform to how others want their charts to be.
I don’t know how all of this will work out. The EMR is here to stay. On balance, I think this will ultimately be good for doctors and their patients. But we don’t really know yet just what it is and what it should look like. I worry it will end up like one of those military boondoggles – it gets loaded with so many bells and whistles because it is supposed to serve so many purposes that it ends up being an expensive monstrosity that doesn’t perform any of its missions well.
Still, I’m an optimist. I prefer to be excited by the possibilities, rather than discouraged by the obstacles. I think the EMR will be good for patients, and will make us better physicians. For a while though, things will continue to be more than a little messy.