Obama’s EMR-Land of Make-Believe: Another Alert Reader email on Obama’s $19B push for electronic-medical-records–opening up a whole new category of unintended consequences: [Emphasis added]
I’m an MD who makes a living reviewing medical records for attorneys. Before I switched to this work I was an internist for a large HMO, entering my notes into an EMR. My wife is an internist who works for a company that keeps records on an EMR.
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> # 1. EMRs encourage doctors and nurses to cheat and lie. EMRs have made medical records inaccurate and unreliable. When I read medical records nowadays, I often can’t tell what the hell happened.
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> As your Alert Readers note, EMR data entry is very time consuming. One workaround is for EMR software to include pre-programmed template notes. When a doctor sees someone with a cough, we no longer write or dictate what we actually did and saw. Instead we find the Upper Respiratory Infection template, which has a standard note for what would be seen and done in an average URI visit. We may or may not type a few words at the bottom. We click OK. The EMR records the note. The nuances that make this URI different from the average one are lost. In an EMR, every URI is an average URI.
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> When the medical condition is just a cold, losing the details is not a big deal. But every heart attack is not like ever other heart attack— complex medical problems can’t be captured by pre-programmed templates. Templates are used anyway. Data entry just takes too long.
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> I once reviewed a hospital record from a large national medical center that I can’t name, but [you’ve] heard of. The patient had a major operation. The operative note was incredibly good. Page after page it recorded in exquisite detail exactly where the surgeon cut, exactly what he retracted, exactly what he saw, exactly what detailed care he took to avoid injury to this organ and that one. I was impressed. I remember thinking, “Wow. No wonder this place has a national reputation.” This was the best documented operation I had ever seen.
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> In spite of this operation, the patient got worse. Four days later she went back for a repeat of the same operation. And the second operative note was the exactly the same as the first. Identical. Page after page, word for word, exactly the same. Leave aside the impossibility of having two multi-hour operations go exactly the same way, it is not possible to dictate or write two multi-page op notes that are word for word identical. The op notes were frauds. They were templates, worked out with the hospital risk management department to describe what should happen, and entered in the EMR with one click of a mouse. What actually happened? No one can tell.
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> Please understand, this is not an exception. This is how things are done these days.
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> Another reasons EMRs lie, is that they are subject to “template bloat.” When you write a template (I’ve done this myself), you don’t just cover what usually happens, you cover important things that might happen. The diagnosis is a cold. But it might be a stroke—so the URI template records the doctor doing a detailed neurologic exam. It might be a heart attack—better put in a complete cardiac exam. And so on. EMR records for colds record pages of stuff that never happened.
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> #2 Laymen seem not to realize that the federal government’s real purpose in forcing doctors to use EMRs is control. The central planners want to control —are now controlling—what doctors do.
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> Understand, EMRs are not files of free-text. They are databases. Each doctor-patient encounter is a database record, with individual fields for each detailed element of the visit. Blood pressure has its own field. Pulse has its own field. Did the doctor ask about mammograms, surgical history, race. Each one has its own field. “Do You Have Guns in Your Home?” has its own government-mandated field. (The proliferation of fields is why entering a visit into an EMR takes so long. Each data-field must be found, and clicked on, and entered individually.)
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> The central planners use the database to track “quality” scores—% of women who’ve had mammograms, % of diabetics with blood sugar testing, etc. The central planners pay doctors according to whether they meet the planners’ performance goals. “Quality” means doing whatever testing and treatments the guy with the checkbook says you must do.
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> While we’re on the subject of central planners picking treatments, did I mention that there’s a new term of art in medicine, one we didn’t use when I was seeing patients in the 1980s and 1990s? The jargon is “compassionate extubation.” It means, “remove the breathing tube, and let them die…because we are compassionate, don’t you know.” ….
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More to come …
Update: From another reader:
I work for a major HMO that has utilized EMRs for years. Your reader’s email makes some good points, but he fails to mention the drawbacks of handwritten charts. Many “charts” were huge, and the notes were illegible and sparse on important details. There are docs who write crappy templates notes in EMRs, there are great notes in EMRs. I think it has more to do the quality of the doctor. You can definitely say that EMRs improve care coordination between specialists and reduces duplicate services.
EMRs aren’t a panacea, but they are definitely a step in the right direction compared to the paper charts of yore.
Yes, but could the bad docs so easily write false (“crappy templates”) notes before? …