Unhealthy pressure to implement electronic medical records

Pressure to implement electronic medical records has been driven by hype, without due regard for the unintended consequences. Many thought leaders in medicine have contributed. IHI president Donald Berwick, in a Time Magazine commentary on how to “fix” healthcare, made this incredibly simplistic observation about EMRs:

My pizza parlor is more thoroughly computerized than most of health care. It's high time to put the paper medical record where it belongs — in the Smithsonian, next to the typewriter.

In a Medscape Webcast Video Editorial Dr. Carolyn Clancy, head of AHRQ, asked, in effect, “What are we waiting for?”

Doctors hesitate for good reasons. In their April 17 NEJM Perspective piece Pamela Hartzband, M.D., and Jerome Groopman, M.D. (author of How Doctors Think) sounded a note of caution. Concerning EMRs, they wrote:

We worry, however, that they are being touted as a panacea for nearly all the ills of modern medicine. Before blindly embracing electronic records, we should consider their current limitations and potential downsides

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I made brief mention of the article the day it came out. I’ve since had the opportunity to parse it in greater detail and observe some blog reactions.

The authors noted that the illegibility of the old handwritten doctors’ notes has been replaced by a new form of electronic illegibility: template generated clutter. A few clicks of the mouse generate paragraphs of repetitious, boiler plate verbiage with a low signal to noise ratio leading to reader fatigue.

They also made this disturbing observation about how EMRs can undermine our professionalism:

As we have increasingly used electronic medical records in our hospital and received them from other institutions, we've noticed several serious problems with the way in which notes and letters are crafted. Many times, physicians have clearly cut and pasted large blocks of text, or even complete notes, from other physicians; we have seen portions of our own notes inserted verbatim into another doctor's note. This is, in essence, a form of clinical plagiarism with potentially deleterious consequences for the patient.

Yes, clinical plagiarism. In some EMR systems it’s not even necessary to go to the trouble to copy and paste. The text is imported automatically. It’s fine to incorporate information from previous records into your note. But in the paper days we had to read and think about the information first. (I previously noted another threat to professionalism: EMRs encourage doctors to over code). (original post by ER Murse).

The authors went on to say that electronic template generated notes discourage thought:

Writing in a personal and independent way forces us to think and formulate our ideas. Notes that are meant to be focused and selective have become voluminous and templated, distracting from the key cognitive work of providing care. Such charts may satisfy the demands of third-party payers, but they are the product of a word processor, not of physicians' thoughtful review and analysis. They may be "efficient" for the purpose of documentation but not for creative clinical thinking.

And this:

A colleague at a major cancer center that recently switched to electronic medical records said that chart review during rounds has become nearly worthless. He bemoaned the vain search through meaningless repetition in multiple notes for the single line that represented a new development. "It's like `Where's Waldo?'" he said bitterly. Ironically, he has started to handwrite a list of new developments on index cards so that he can refer to them at the bedside.

True, handwriting in charts is sometimes illegible and can lead to miscommunication. It might seem that the printed (or at least typed) word, which we are all conditioned to respect, would always be more definitive and have more impact than text written by hand. But we have observed the electronic medical record become a powerful vehicle for perpetuating erroneous information, leading to diagnostic errors that gain momentum when passed on electronically.

The electronic medical record, all too often a substitute for thought and critical analysis, will create new challenges in the teaching of students and residents. Excellent clinicians write notes that tell patients’ unique stories in narrative form and explain their clinical thought processes. Electronic template generated notes discourage the teaching of this skill.

The NEJM article is not entirely negative about EMRs, but it issues a plea for caution. It’s a must read if you’re involved in planning for an EMR.

Further reading: Health Care Renewal’s take on the NEJM piece.