Special Note: Dr Fisher (my wife) and I discussed my recent blog on EMR. As a Gastroenterologist at the Durham VA Hospital and faculty at Duke Medical Center, she has a different perspective on EMR. I asked her to share her views in this blog entry.
Last December, while my husband was out of town, our daughter demanded to know The Truth about Santa Claus. Unfortunately, she asked the parent most likely to tell The Truth. Without going into the gory details let’s just say that my discussion with her about the facts of life went better and involved fewer tears. For several years now we have been hearing about the wonders of the electronic medical record (EMR) and how It Will Save Us. But, of course, The Truth is not quite as rosy. A recent NY Times article points out some of the pitfalls and highlights the chasm between The Promise and the current state of things.
I work in a setting that has been using an EMR since the 1990s and has been consistently using a linked comprehensive EMR system since 2000. We actually have national inpatient administrative records going back to the days of disco, but the real push to go completely electronic happened with the Y2K scare. Just as we were worried that everything from our timed coffee makers to our banks would crump on January 1, 2000, the Veterans Health Administration (VHA) demanded that we give up the pen for ALL documentation – orders, consults, medications, outpatient visits, inpatient notes, everything – and start typing. And under the pressure of No Other Choice we did it.
Before launching back into curmudgeon mode, I want to openly state that most days I actually think having an EMR is a wonderful thing. As a clinician I cannot only find, but actually decipher (illegible handwriting eliminated) all medical records from any VHA facility in the country. Also I love that I don’t have to repeat ALL data in my medical notes, but can highlight the important findings that support my conclusions and recommendations. As a researcher the comprehensive EMR has made many of my studies not only feasible, but more accurate and much less costly than they would be if I conducted the same studies in a setting without a linked comprehensive EMR.
After Katrina, VA patients were about the only ones from the affected areas with retrievable medical records of their prescription and other vital medical information. VHA has been a leader in quality measurement and attaining and surpassing quality benchmarks in part because the comprehensive EMR facilitates auditing of performance and facilitates interventions for improvement (such as electronic reminders). In fact, we have been in the quality measurement business so long and by current measurements so successfully, that we are moving onto the next generation of quality measures.
So what are the problems? At the patient level I think there has been a decrease in the satisfaction of their interactions with health care providers. While they like that the information “should be in the computer” patients don’t like the computer getting between them and the doctor. With time pressures of restricted duty hours, the volume of data available, and inexperience our trainee doctors have a bad tendency to make more eye contact with the screen than the patient (see KC blog). Unfortunately, that is a difficult habit to unlearn. I recently had a patient who actually thanked me for talking to him and not the computer.
Physicians are also negatively impacted. I have been observing my university affiliate colleagues struggle through the growing pains of a new comprehensive EMR on their side of the street. Part of the landscape of EMR is that it shifts work that nurses and clerical staff previously did to the doctors. Rather than dictating or hastily scrawling (in illegible handwriting) our thoughts, orders and recommendations we have to enter them ourselves. Then there is the learning curve of a new system. This all takes time away from all the other duties of a physician. The interruption in workflow is difficult to underestimate and since time is money very costly.
If once you learned the system it could be applied anywhere the investment would be worthwhile. Unfortunately this is not the case and that system problem is the greatest in my opinion. The VHA EMR, while not perfect, is linked for over 150 hospitals and hundreds of additional clinics. Many academic centers use the same vendor, but each makes so many changes in their adaption that the end products are no longer necessarily compatible. Further, each facility seems to make its own templates for various clinical notes. This entails physician committees, programmers, administrators… each time. Some private sector EMR systems are not even compatible within facilities of the same health system. And even VHA records are not seamlessly compatible with non-VHA care.
It is a huge waste of time and money to reinvent the wheel for every hospital in the US and it is hard to believe this will in any way ultimately save money. That is why the chances of EMR saving us in any manner are low in the current modes of implementation.
This entry is a guest blog by Deborah Fisher, MD, MHS, The extra letters after the MD indicate that she spent time getting yet another degree (in clinical research). She is a gastroenterologist and outcomes researcher at the Durham Veterans Affairs Medical Center and an Associate Professor of Medicine at Duke University. She is married to the President and CEO of KROC Consulting, LLC and carries the empty title of Vice President. On the other hand, she is the my wife and the benevolent dictator of the Campbell household. The blog represents her views and not those of the Federal Government or Duke University.