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Electronic health records here to stay, unfortunately
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Record that which you have seen; make a note at the time; do not wait. — Sir William Osler, MD, founding professor, The Johns Hopkins Hospital
The increasing ability of physicians to disentangle specific disease entities … was an intellectual achievement of the first magnitude and not unrelated to the increasingly scientific and prestigious public image of the medical profession. Yet, we have seen a complex and inexorably bureaucratic reimbursement system grow up around these diagnostic entities; disease does not exist if it cannot be coded. — Charles E. Rosenberg, “The Care of Strangers,” 1987
By computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care. — George W. Bush (January 2004, State of the Union Address)
Why do we have a medical record? Ancient Egyptian, Greek and Arabic physicians clearly wrote about health and disease, accumulating philosophical, physiologic and practical medical reasoning and treatments — some even in narrative form. Written observational science likely can be traced to astrology, but medicine is a later developing profession and to appropriately apply the word science would take centuries. Patient lists, early accounting software, seem to date to the 16th century. Observational descriptions soon followed. But when and why did we as physicians begin to depend on a medical record to base our care? I suspect we would be surprised at the relative modernity of the notion.
William T. Gerson
The primacy of the written medical history was the bedrock of my training — so ingrained that it is difficult for me to separate my notes from my thoughts. This reliance on such a tradition probably explains my hesitation in adopting the electronic format. Not that it is digital, but that the electronic form in current use is so noxious. If only Apple had taken an interest in the medical record. Perhaps then it would more reflect the texture of the written record.
I must admit I dislike the uniform appearance of the electronic health record (EHR). Every note appears the same, and with cut and paste, it often is the same. Searching past notes is taxing, without any of the familiar textual clues available in the old patient chart. All notes are now long, regardless of the reason for the visit or hospitalization. The elaborate listing of family history, social history and medical history is not dictated by need nor accurate by necessity, but driven by documentation standards defined by the insurance industry to limit reimbursement. I wonder how we surrendered to forces not directly interested in the care and well-being of the patient. And remind me, please, why I need to reconcile admission medications and review an allergy list for a newborn in the regular nursery?
Sloppy thinking
No longer can we use the length and breadth of the clinical note to define the degree of difficulty of medical thought. Embedded templates and pull-down menus predominate and contribute to, rather than diminish, sloppy thinking and medical errors. Lost is the admitting intern struggling with a multi-volume chart; however, also abandoned is the discovery of an old admission note of a trusted mentor or now senior physician. Often lost also is the usefulness of the task.
Emphasis in any EHR should be placed on the logical flow of data to our chart in a format that complements our patient care requirements and supports our professional status. The problem-oriented medical record has allowed smart technology to be built into EHRs to eliminate duplicity, errors and potentially hazardous interactions, but requires detailed and updated problem lists; often a more complex task than currently understood by most nonclinical information technologists who develop the EHR software. Even more likely as the cause for such maddening complexity is the requirement, built into our EHRs, for linking each problem list diagnosis with an ICD code — preferably one that adequately captures the true degree of difficulty assignable to the patient to maximize billing opportunities. Such an exercise, validating the concept of the patient as an example of a disease, is professionally abhorrent.
Records with a purpose
Laboratory and testing data should populate our notes directly from the laboratory or service without the requirement of manual entry. Our input should highlight a critical medical history, physical examination and description of medical reasoning to include a presumed diagnosis and plan of action. Opportunity to describe an expected outcome upon re-evaluation and re-examination and the requirement for reformulation if the expected outcome is not achieved should be clear. A description of expectations of other physicians (or clinicians) involved in the care or follow-up of the patient should also be clear.
Until recently, I have been comfortable in stating that a good pediatrician may keep an adequate patient record on a 3 × 5 index card. While I believe that remains true, EHRs are here to stay. While I continue to postpone its introduction into my office practice, EHRs universally exist in hospital practice and in more and more private practices. Unfortunately, most have not lost their origins in billing software, remain awkward and cumbersome in medical practice, have little to add to critical thinking or research, and they decrease productivity, increase physician time and decrease physician satisfaction — all the while collecting conflicting data on both cost and health care outcome grounds. An unusual track record to say the least, EHRs remain only a promise as a transformational force in the provision of health care. They have, however, fully captured the imagination of our political leaders. Now I can sleep comfortably.