The Perils and the Potential of EMR: The Good, The Bad and The Ugly

As medicine moves forward in its most technologically advanced era yet, we continue to struggle with basic concepts such as record keeping.  The medical record is vital to the care of the patient.  It tells the story of each patient’s journey through the medical system.  The idea of centralizing all pertinent medical information is, in theory, a step in the right direction.  In utopia, there would be one medical record for each and every patient that could be accessed by any healthcare provider on the planet at a moments notice.  However, in practice, this is a monumental task.  Earlier this week, the New York Times published as special section on The Digital Physician.  As part of the feature, the current state of the Electronic Medical Record (EMR) was examined.

The Federal government has mandated the implementation of EMR in order for providers to be paid at the highest allowable rates and receive certain incentive pay for complying with EMR. Terms such as “meaningful use” have been coined by legislators in Washington, DC.  Certainly, a great deal of money has been spent by both the US government as well as individual providers to develop EMR and implement electronic records by predetermined government deadlines.  EMR has the potential to provide increased patient safety and significant cost savings if developed properly.  However, current EMR systems are not really ready for “prime time”  There is no real data out there that has demonstrated improved outcomes with EMR use–it is interesting that Medicare refuses to reimburse for unproven therapies but the Federal government will mandate EMR implementation without long term outcomes data.  Only recently are studies emerging to give us some idea of the impact of EMR on patient outcomes.  I think that there is a great deal of work to be done in order for EMR to have the desired impacts on safety, communication and healthcare cost containment.

What are the biggest issues with EMR today?

1. Work Flow:  Many providers find EMR to decrease efficiency and decrease patient thru-put due to non user friendly interfaces and difficult navigation.  Many physicians find that the EMR actually adds significant hours to their work day.  From personal experience, it is often that I am in the office after hours completing EMR notes.  Sometimes I have to finish them at home on the weekends.  Proponents of EMR argue that electronic records streamline and  reduce physician time spent with documentation.  Nothing could be farther from the truth.  Many EMR systems are cumbersome and time consuming.

2. Errors in documentation:  Most EMRs are plagued by erroneous data.  As my wife ( a lifelong outcomes researcher) often says about databases in general–”garbage in equals garbage out”.  The point and click and drop-down menu capabilities of most EMR systems foster the propagation of erroneous data.  Unless a provider takes the time to audit the electronic record on each visit, inaccurate information can be placed in a record and continued forward.  In addition, auto-populate and recall functions can lead to documentation of things that were never done (such as particular physical exam components).

3. Interruption of the Doctor-Patient relationship:  As I have mentioned in a previous blog, we must take great care NOT to allow the computer to come between doctor and patient.  We must continue to practice the art of medicine which requires that we actually talk and listen to our patients. We must not forget the value of interacting with patients, looking them in the eye, and providing them undivided attention.  Computers, laptops, and ipads in exam rooms foster distractions–I make it a point to leave my laptop at the workstation and put my notes in the EMR after the patient has left the exam room.  This often leads to finishing notes after hours.

The Future?
The EMR has an important place in the practice of medicine going forward.  However, I believe that we are rushing forward, blindly running to implement flawed systems in order to meet arbitrary government deadlines.  I believe that we must take a step back, evaluate the good, the bad and the ugly about EMR.  Only then can we work to craft a system that will accomplish what everyone in medicine wants–more efficient patient care, improved outcomes, increased patient safety.  

One response to “The Perils and the Potential of EMR: The Good, The Bad and The Ugly

  1. Your list nicely distills the issues with EMR systems. Numerous examples that underscore each concern are easy to find – but it doesn’t have to be this way.

    Design is critical. It’s the difference between “I can’t live without it” and an annoying mandate.

    In place of “meaningful use” we need “obviously useful”. Done right, no one needs to be force fed.

    I use a simple test. With a skillfully architected system in place, a physician will resoundingly agree with the following statement:

    “The system makes my work easier and more efficient, increases the quality of care I’m able to provide and assists me in keeping more accurate records:”

    Since these systems impact people’s lives, anything less than a resounding “yes” is a failure. Correctly tuning the human machine interface (HMI) is one of several keys to success.

    Unfortunately, in some IT firms, marketing expertise significantly outweighs that of the design and implementation teams. Many of the available systems are overpriced and, as you’ve described, negatively impact care and efficiency.

    You make a good point about the refusal to pay for unproven treatments while there is no such restriction that withholds payments for ineffective technology. The short term impact will be “fertilizing the weeds” along with a few flowers.

    We’re in a period of transition. I’m hopeful that EMR systems will soon be viewed as an essential part of quality care.

    In the interim, physicians beware! Thanks for the contribution to this important and timely topic.

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