Tuesday, March 18, 2014

Enduring Problems Of The Electronic Health Record

I think the national debate is coming back to the more reasonable position that the heavily hyped electronic health records (EHR) will not save up hundreds of billions of dollars due to "efficiency."  But then again again any physicians not working as an administrator hyping the EHR could have told you this based on their experience over the past 10 years.   If I had to think of a reason, I would imagine it is the companies trying to build a moat around their businesses.  Software engineering can't possibly be this bad.  Wall Street jargon considers moats or barriers to direct competition with a company to be a good thing.  Let me illustrate with a real world example.

Let's suppose you are working in a clinic that is not online with the largest managed care (MCO) company in your area.  The only way you can get electronic access is to pay a huge licensing fee, but in many cases the software company will not even accept that licensing fee.  It will just conclude that that you are not big enough to do business with them.  At any rate, you need electrocardiogram information on a patient from that MCO because you are looking at a new abnormal ECG on that patient.  You need to know if the pattern on that ECG is new or it has always been there.  You request the records from the MCO.  They fax you 50 pages containing the lowest possible amount of information per page.  There are two one line references in that 50 pages to an electrocardiogram.  One says: "Prolonged QTc" and the other says "Normal".  There is no graphic information (the tracing) and no numerical information (the intervals with the associated times in milliseconds, the machine read out).  So after the work put in by you and your staff to request this data, you have just read through 50 pages and found absolutely nothing useful.  A review of all of the pages shows scant information on each page.  As an example, one entire page contains a chest x-ray report, when it could easily be printed on an area 1/20th that size.  Some entire sheets contain 1 or 2 lab values of 3 to 5 digit numbers.

I am convinced that the multimillion dollar licensed legacy wide EHRs are designed this way.  There is really no other explanation for providing such an abundance of low to no information records.    Their intention is obvious.  Make sure everyone is using their system and at some point make sure that the government is forcing people to use somebody's system.  All physicians should be using electronic prescribing right?  It is only a matter of time before politicians mandate access and an extremely expensive portal will be required.

There was a time when the medical record was coherent.  Maybe I was spoiled by reading what sounded like fine literature by comparison.  There was one Cardiologist in particular who wrote incredible notes for consults.  Reading those notes gave you all of the medical information you needed and it also left the impression that you had just read something written by a highly intelligent person.  Somebody you probably wanted to have a conversation with.  Somebody you could learn from.

What has happened to the medical record leaves a bad taste in my mouth.  It reminds me of when an EHR consultant was showing me their latest time saving way to create a choppy, incoherent progress note, and sign off on a billing document at the same time.  She assured me that the "compliance people" would find it completely acceptable for billing purposes.  When she asked me what of thought of their system she seemed taken aback by my response.

"I would be ashamed to sign my name on that note."

That was about ten years ago and the electronic health record has not changed much since.  It will still kick out a phone book sized print out containing minimal to no useful information.

George Dawson, MD, DFAPA

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