By Wayne Persky |
- My old written notes had only the meat, the pertinent data. They were mostly my thoughts. This was how we all communicated with each other. Our thoughts were what was important. We can't do that now. We can't be candid about our thoughts because our patients can see their charts. The open medical record is one of the worst decisions ever made.
- We used to be able to use abbreviations and blunt language in our notes to remind ourselves about a thought trail, to get a consult, to order tests. Now, we have to edit for our readership, and be evasive about sensitive issues. Often, this leads to the whole thought process being left out in service of time. So we have an issue of the forest for the trees, and all we have are junk trees.
2. Poor compatibility between various EMR systems
3. Excessive data entry requirements interferes with the ability to efficiently access the data
4. Correcting incorrect data is so difficult and time-consuming that it typically doesn't get done
5. The EMR system has reduced physician productivity by at least 20%
2. Despite the fact that the EMR was supposed to facilitate communication between physicians, Doctor Magnuson found that emergency room doctors weren't able to access her notes, and sometimes the hospital doctor couldn't access her clinic notes, even though they were in the same EMR system. And sometimes specialists with whom she was consulting had difficulty viewing her notes. And because some specialists used a different EMR system, she sometimes couldn't see the notes from a consultation until weeks later.
After the advent of EMR, when she was doing Skilled Nursing Home medicine, often, she didn't have a hospital discharge summary, and she never had the hospital record, when she received a new patient. Getting the needed information, was often difficult at best, and impossible, after hours, or on weekends. Needless to say, this is not just inconvenient — it can be dangerous in some situations. Prior to EMR, she always received a folder containing a written summary for every new patient, and it came with photocopies of important laboratory reports, and daily notes on important events that occurred during the hospitalization — it may not have been a perfect system, but it was dependable, and it worked.
3. As the American Medical Association (AMA) points out, the term "meaningful use" defines certain minimum U.S. government standards for EMR data entry. These standards outline how patient clinical data should be exchanged between healthcare providers, between providers and insurers, and between providers and patients.
Medicare imposes the requirement that physicians must use certified electronic health records technology, and demonstrate meaningful use of the system by completing an attestation process at the end of each meaningful use reporting period, or they will be penalized by reduced Medicare reimbursements. The use of diagnostic codes [International Classification of Diseases, Tenth Revision (ICD-10)] is required, and must be exactly correct. The ICD-10 code is normally printed next to, or under the "Diagnosis" (or "Dx") heading on a medical report, bill, or provider letter. All insurance claims are based on these codes.
To receive full Medicare reimbursement, physicians must document items (for the patient) such as a family history review, medication and allergy review, social history review, past medical and surgical history review, active medical problems, and various other details, and these must be documented for every patient encounter. Information not entered with each appointment (even though it is repetitive) may be lost from the system. The complexity of all the requirements requires a physician's full attention, lest something be overlooked.
4. Correcting problems that arise in the records can only be done by certain medical professionals. And errors in medical records are likely to be made, because for one thing, EMRs include a step that basically amounts to a Catch-22 situation.
Remember the movie, Catch 22? The movie focused on a U.S. World War II Army Air Force base located on an otherwise desolate, inhospitable island. Almost everyone who was stationed there soon tried to apply for a transfer to a more pleasant location. But according to military regulations for the base, the only justification for granting a transfer off the island was insanity. And obviously, anyone who wanted off the island was not insane.
Clinicians have to order certain medical tests in order to make accurate diagnoses of their patients' issues. But the EMRs essentially require that physicians must make a diagnosis before ordering any tests, due to the fact that they are required to enter a diagnostic code before the system will allow them to order the needed tests — a Catch 22 situation. Obviously, in the long run, this is bound to result in many incorrect guesses, and these, and other errors tend to accumulate in the records.
Doctor Magnuson also points out that specialists never clean up incorrect data. They always leave this for the primary care doctor to deal with. But because of excessive demands on virtually all primary care clinicians' time, no one ever removes most of these errors from the system.
5. Adoption of the EMR systems have resulted in at least a 20% reduction in all physician productivity, and the productivity loss has been significantly worse in primary care. More than 80% of physicians attest to at least some measure of burnout, and EMR is responsible for much of that. As Doctor Magnuson says:
We didn't train to be coders or secretarial staff. Doing EMR tasks is such a waste of our education and skills.