Controversy over electronic medical records

Does the medical profession deserve the Luddite label as DB suggests? The Dinosaur doesn’t think he does even though he is skeptical about the benefits of electronic medical records (EMRs). I’m not a Luddite—I’m a computerphile. I was one of the first kids on my block to go on line with medical searching, way back before the days of the World Wide Web. But I share much of Dinosaur’s skepticism. I place myself in the middle ground on this debate.

Let’s look at a couple of Dinosaur’s objections, which addressed some of the popular myths about EMRs. First, do they really improve legibility? That depends, of course, on the quality of the doctor’s handwriting, and whether or not the doctor dictates his/her notes. But Dinosaur makes an important point about readability problems inherent in EMRs which rings true in my own experience: computer template generated clinical notes have a very low signal to noise ratio. For the doctor the signal is clinical information. The noise consists of all the clinically useless clutter which serves no purpose but to keep the insurance coders happy. Template generated progress notes make it nigh unto impossible to communicate a doctor’s thinking or tell a patient’s story in a meaningful narrative form.

Do EMRs save time? There’s probably not an “evidence based” answer to this, but the overwhelming subjective experience seems to be that EMRs are a net consumer of time, at least for a year or two after implementation.

Do they improve reimbursement? Dinosaur addresses P4P and points out that any P4P rewards gained from EMRs are nominal. Do they improve E&M coding, thus improving reimbursement? The potential is certainly there. I’ve encountered software that prompts me to “add one more system to the review of systems and two more to the physical exam to code one level higher.” This ensures that the documentation will support the coding but is it ethical? If the patient has a cold does he/she need a complete system review? A great deal of template generated “documentation” appears gratuitous to me.

Do EMRs improve quality? Many studies report soft outcomes. An EMR may increase the rate of documentation of patients’ hemoglobin A1C levels from 75% to 83%, but what about error rates and clinical outcomes? Although EMRs may intercept certain types of errors they increase others. Data on hard clinical outcomes are sparse, but at least one study showed an increase in mortality related to computerized physician order entry.

How can this debate be resolved? The answer is “it depends”. In a MedGenMed Video Editorial last year opinion leader Robert Wachter, M.D. gave a sober assessment. He cautioned that Computer systems must be implemented carefully, with unforeseen consequences not only sought but anticipated. Systems should be launched on a pilot unit, and should be extensively vetted by user groups before going live. Staff must be educated, and swarms of real-time problem solvers should be immediately available after implementation. The computerization of healthcare will ultimately improve the quality, safety, and efficiency of care. But the road will be full of bumps and curves. It’s not a matter of “just doing it”.