The electronic medical record (EMR) is here to stay. Its adoption was initially slow, but over the past decade those hospitals that do not already have it are making plans for implementing it. On the whole this is a good thing because the EMR has the ability greatly to improve patient care. Physicians, as well as all other caregivers, no longer have to puzzle over too often barely legible handwritten notes or flip through pages and pages of a patient’s paper chart to find important things. With the EMR, it is easy to see what medications a patient is taking, when they were started, and when they were stopped. Physicians can easily find key vital signs – temperature, pulse, respirations, and blood pressure – plotted over any time frame they wish. All the past laboratory data are displayed succinctly. But it is not all gravy.
I use the EMR every day, and I am old enough to have trained and practiced when everything was on paper. The EMR is overall a good thing. Yet there is a problem with the EMR: it is trying to serve too many masters. The needs of these various masters are different, and their needs are sometimes incompatible, even hostile to one another. These masters include other caregivers, the agencies paying for the care, and those interested in medico-legal aspects of care. What can happen, and I have seen it many times, is that the needs of the caregivers take a back seat to the needs of the payers and the lawyers. The EMR is supposed to improve patient care, but sometimes it makes it worse. Physician progress notes are an important example of how this can happen.
Progress notes are the lifeblood of the medical record. They tell, from day to day, what physicians did to a patient and why. They are a narrative of the patient’s care. Three decades ago we sat down, pulled out a pen, and wrote out our daily progress notes. There were standard ways of doing this, but physicians were free to organize their notes however they liked. That was both a blessing and a curse. It was a blessing because not all patients fit the standard way of note writing, so you could modify how you recorded things; it was a curse because every physician was different, and some wrote very sketchy notes indeed, notes from which it was very difficult to figure out what happened. I once did a research project for which I was reading physician notes from the nineteen twenties, thirties and forties. I recall one patient in particular who was clearly desperately ill. He had critically abnormal vital signs (which I could tell from the nurses’ graphic chart), needed several blood transfusions, and even stopped breathing once. His progress note for the day, written by a very famous and distinguished physician, was one line: “Mustard plaster didn’t work.”
Physician notes have evolved a great deal since 1930. Certainly in my medical career, which began in 1974, physicians were expected to make some reference to what they were thinking, why they did or did not do what they did. Sometimes the notes were cryptic jottings that made it very hard to follow what was happening. But most of the time you could understand what your colleagues were thinking. But if this worked reasonably well for physicians, other users of the medical record complained loudly. Payers, such as insurance companies and Medicare, based their payment upon those notes. They were unwilling to pay for anything that was not clearly documented. They also increasingly based their payment structure on the complexity of the medical decision making; if physicians wanted to be paid at a higher rate for managing a complex and difficult patient they needed to show in their note just why that patient was complicated. They needed to show what they were thinking, and what information, such as laboratory data and the physical examination, they used to make their decisions. Finally, for the lawyers, the operative phrase was “if it’s not documented, it didn’t happen.” In theory, the goals of all three users – caregivers, payers, and lawyers – should be in alignment. But with the EMR the needs of the caregivers, which should be paramount, are losing ground.
The EMR, since it is on a computer, can be manipulated in all the ways a computer allows. Hospitals are laying out millions to implement the EMR, and to ensure maximum payment they want to make sure it is easy for the payers to find in the EMR all the things the payers want there. This is accomplished, among other things, through the use of templates and “smart text” for progress notes. For example, a physician writing a progress note in Epic, a popular EMR system, can open a template that has many components of the evaluation already filled in. The program can bring into the note all the previous laboratory values. It has all the categories of the physical examination sitting on the screen for the physician to fill in. It is easy to “drag and drop” information from previous notes with simple keystrokes. There’s nothing intrinsically wrong with all this. It can make producing a complete progress note quick and easy. But it also can destroy the original purpose of the progress note – to give a narrative of the patient’s progress. It can stifle the conversation between physicians embodied in traditional progress notes.
Recently I saw an example of the problems this can cause. A couple of weeks ago I heard I was getting a patient into the pediatric intensive care unit with multiple problems, most acutely a blood problem. One of these lesser issues was a heart problem that required surgery. Because of the other serious problems, though, the surgery had been postponed for the future. I read about all this in the patient’s EMR before she even arrived in the PICU, which is one of the great aspects of the EMR. We no longer have to wait for a clerk pushing a cart around the hospital to deliver the paper chart. The patient had been seen just that morning by her hematologist for the blood issue and the progress note in the EMR told me the plan for her heart problem was surgery sometime in the future when the child’s other problems had improved. It said so right there on the screen. In fact, all the notes had been saying that for over a year. So imagine my surprise when I went in to see the child and saw an obvious and well-healed surgical scar on her chest, clearly from cardiac surgery. She had had her heart fixed two months before at another institution. I gave her hematologist the benefit of the doubt and assumed her doctor knew the surgery had been done, and that what had happened (I hope) was that the doctor had used the beguiling convenience of drag and drop on the progress note template to do the note. This particular incident was innocuous, but I think you can see the potential for mischief with this sort of thing.
This is not an isolated event. I have seen many examples, so many that I now cast a suspicious eye on all those uniformly formatted progress notes. The ease with which mounds and mounds of verbiage and laboratory data can be stuffed into a progress note may give the payers what they want, but it often does not give me what I want, and that is some evidence that all this information was processed through a physician’s brain and led to a carefully considered decision about what to do. I want a human voice, and that is getting harder and harder to find in the EMR’s stereotypic and bloodless documentation.
Medicine is about stories – patients’ stories. I was taught forty years ago that most of the time the history gives us the diagnosis. Osler reputedly said: “Listen to the patient. He is telling you the diagnosis.” (That attribution has been questioned, but the spirit is definitely Osler’s.) Of course these days our wonderful scientific tools often give us the answer, and I certainly do not wish to toss all those things aside to go back to using only what Osler had. But medicine is not really a science. It is based on science, uses science, and is increasingly more scientific. But medicine also contains large measures of intuition, educated guessing, and blind luck. I do not think that aspect will ever go away completely. When I read (or wade) through a patient’s record, I look for the story. When I cannot find a coherent story, I cannot give the best care.
For myself, even though I of course use the EMR, I refuse to use all those handy smart text templates. It takes me longer, but I type out my progress notes, organized as I did when I used a pen and chart paper. It takes me a little longer, but it makes me think things through. No billing coder has ever complained. More than a few colleagues have told me, when seeing shared patients, that they search through the EMR to find one of my notes to understand what is happening with the patient. I recommend the practice.
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.
Working as a physician in a hospital means being buried with paper — lots of it. A patient’s medical record, the medical chart, is typically a fat three-ring binder that gets rapidly fatter by the day the longer the patient stays in the hospital. Children in the PICU may build up a medical record that weighs more than they do. Old medical records for patients — records that describe their previous hospital stays — are often delivered to the hospital floor from the medical records department in a very full shopping cart. Plowing through these old records can take hours. More importantly, one can miss important things, key nuggets buried deep in the largely unhelpful mass of paper. And, of course, if the patient has had medical experiences at another hospital, those are not even in the chart.
Many believe the answer is an electronic medical record (EMR), with everything stored on a computer. The record can be easily organized and searched for important information. Assuming that systems are standardized (a big if), the record can then be easily portable and travel with the patient on a disk or be sent over the internet.
The whole topic of EMR is a highly emotional one among physicians. Many like the idea, many absolutely hate it, even though the latter group recognizes the EMR is inevitable, really. For hospitals, the start-up costs of implementing the EMR can be huge. Thus far, few have done so. A recent survey in the New England Journal of Medicine found that only 1.5% had done so in a comprehensive way, although many had begun implementation of various portions of the EMR. The Obama administration has proposed federal funds for part of the costs, but inevitably each hospital will have to spend money upfront to initiate EMR systems.
For myself, I happen to work at one of the few hospitals with complete EMR. I like it a lot. For PICU practice, the ability to get important data quickly is key to giving good care to critically ill children. I’ve been doing this for 30 years, long before there were computers on every (or any) desk and the EMR allows me to do my job better. I look forward to seeing it implemented across the nation.