President’s Letter – February 2012

Pitfalls of EMR

My practice began implementation of an office based electronic medical record (EMR) about six months ago. It has been a slow and sometimes frustrating process. Perhaps I am being shortsighted, but I do not consider myself a dinosaur. I have yet to experience the upside of the endeavor. I am not certain that we will meet the requirements for a government subsidy for achieving the “meaningful use” criteria as defined by lawmakers (Center for Medicare and Medicaid Services, December 2009).

Implementation of EMR is expensive. There is the up-front cost for computers, software and scanners, as well as the cost of lost revenue that results from seeing fewer patients per session. It takes time for staff and physicians to enter patient data and exam findings into the computer record. We had to hire additional staff to scan the paper charts, shred them and facilitate storage of some charts in an offsite facility.

The assumption by many is that the long term benefits of EMR will pay off. The reasons often cited include a reduction in overall costs, an increase in efficiency and improvements in patient safety. While small studies show a benefit from EMR, there have been no large, long-term studies conducted which support this claim. Often systems do not talk to each other, which results in tests and services being duplicated. Charting now demands more attention than the patient’s story. Multiple reviews of systems can be introduced into templates, resulting in practitioner error. Positive symptoms in a review of systems can be hard to find or are not listed in an array of negatives.

I have not been impressed with the quality of the EMR records brought to me by new patients from outside institutions. I am handed reams of paper filled with superfluous data through which I must forage in order to find data pertinent to the patient’s history and clinical situation.

My patients’ perceptions of EMR have not been entirely positive. My elderly patients complain that the new way of practicing medicine is problematic. They blame the computer for creating a wall between their doctor and them. One of my patients indicated that her internist had her eyes fixed on the computer screen throughout an entire encounter. She stated that the doctor never touched her. When patients feel that we are focusing more attention on the computer than on them, we must ask ourselves if we are treating the whole patient. We must not lose sight of the value of human touch as we embark upon embracing and adapting to new technology.

Last week our computer system was down for over an hour. Patients were kept waiting and my schedule fell by the wayside. We were at the mercy of our tech support. I also forgot to click the “save and sign” button after I had completed a new patient’s record. By the time I discovered the problem the following week, the information entered could not be retrieved. I was embarrassed when I had to call the patient and explain what happened.

Another very real problem with EMR is relying on information technology (IT) professionals who are unable to improve the efficiency of a system so that it works well for the practitioners. The reality is that technical support and physicians do not speak the same language.

The concept of electronic medical records sounds terrific. Well-intentioned legislators view EMR as a great improvement for healthcare delivery, BUT how safe is a system that uses EMR? How can an electronic medical record which can be accessed by any savvy IT technician be safer than a paper chart which is locked in a medical record room? We have begun to read about breaches in digital patient data.

Recently the non-profit known as the Massachusetts eHealth Collaborative was in the news when an employee’s laptop was stolen. The laptop contained unencrypted records for 13,687 patients. Each record contained some combination of the patients’ social security numbers, birthdates and insurance information – a veritable identity theft goldmine. Mishaps such as this one underscore the fact that transitioning from paper to EMR is serious business. Concerns about security are hardly groundless. In fact hundreds of breaches that have threatened patient privacy have been documented in a government website known as “Wall of Shame”.

Nearly forty percent of American primary care physicians and twenty-five percent of hospitals use electronic medical records. Thousands more are expected to adopt EMR this year in order to qualify for financial assistance under the 2009 stimulus package.

My advice to those of you who are embarking on the conversion from paper charts to EMR is to proceed slowly. Do not go paperless from day one. Make sure that the system you choose works for you and can interface with your hospital’s system. Become comfortable with your software, electronic prescribing, and the concept of computer order entry. Tailor your templates to your needs and encrypt all information. Focus on getting it right and doing it safely. Remember the system must work your patients AND for you.