OT: Electronic Medical Records

[Slinky]

Has anyone's doctor gone to electronic medical records (EMRs)?? My family doctor hasn't. I asked him if he intended to and he said no, not yet and not for quite a while yet. The systems are expensive and there's no consistency between the various systems available.

I was with my husband to see his family doctor recently and almost the entire office visit was spent w/his doctor hunting and pecking on the keyboard and searching the monitor. I wasn't impressed. He spend very little time actually talking to my husband either to ask questions or to explain treatment and medication. It was hard to catch his attention to even ask a question.

And I was just reading a news article this week that electronic prescriptions hadn't reduced medication mistakes at all. The percentage of errors remained the same whether handwritten or electronic.

[cflame1]

Some of my docs... and even my dentist are on Electronic medical records, but some aren't. The ones that are, the nurses that do the check in spend the time getting the history right, the doc doesn't really even look at the record (unless I'm asking for something specific).

Script stuff isn't any better (or any worse!)

[sleepingatlast]

My PCP has gone electronic. He even submits prescriptions by clicking a button. I like it because given the placement on where his monitor is, I can see (and read) everything.

[nighthawk38]

My care is through a university hospital, and I have access to my electronic records through a system called MyChart. I can check appointments, see what my blood pressure, weight, etc. have been over time, see when a surgery took place years ago, whatever. Can email my doctors with questions and they can email back. All kinds of useful things. They also can see each others' notes. Very convenient for everyone.

[6PtStar]

Slinky you hit a real nerve with this post. I have always felt this was a bad idea because if they were out there they were available to people I did not want to have them. They are also available to be hacked. With this said I have run into a system that I don't know what to do about. My PC doctor has not gone electronic and I don't know if he has any plans to yet. My M-I-L (who has the same PCP) recentally went into the hospital and spent 5 days there. Our PCP no longer makes "House Calls" at the hospital. The hospital has a group of doctors they call Cogent Doctors. If you go into the hostital you are assigned one of these doctors. They have no access to your records which are in a paper folder in the PCP office. The Cogent Doctor does not even notify youir PCP doctor that you are in the hospital. Explain to me why you are building a medical history!! The Cogent Doctor knows nothing of you medical conditions except what you might tell them. They call all the shots while you are in the hospital. They ran 5 days of tests, some were duplicates of what our PCP had already run. After 5 days and a consulant doctor that was called in said they had still not found the problem and more tests were needed. At that point the Cogent Doctor discharged her and overulled the consultant doctor.

After she got out she called her PCP and told him she had been in the hospital. He said he would get a report from the Cogent Doctor in a few days and he would look at it.

I have talked to a lot of people and can't figure a way around this system. Unless the records are electronic what good are they? Thought about changing doctors but so far have not found one that has not signed on to the Cogent system and might still make "House Calls". Also lookinmg for one that might put my records on electronic so at least the hospitals could have my medical history

Jerry

[Slinky]

In our area, we have what are called "hospitalists" and our admitting doctor can elect to "utilize" them or not as I understand it. Some of our doctors elect to continue making their own hospital visits, others have elected to go w/the hospitalists. Our hospital has gone to the EMRs tho so at least any records of hospitalizations, ER visits, outpatient, radiology testing, etc. are available via the EMRs. We use their outpatient lab so even all our lab work is available.

[billbolton]

The systems are expensive and there's no consistency between the various systems available.

In my experience that's usually General Practitioner code for "I need a substantial incentive payment (aka bribe) from <insert some payer or other here> before I will do it"

There is a whole raft of health informatics standards, developed over the past decade or more, that allow medical records to be interchanged between systems if clinicians really have a mind to do it. Do a Google search on "Health Information Exchange" and you'll see how much activity there is already in that area.

Those crafty canucks have a whole Province up and running on Electronic Health Records (http://www.manitoba-ehealth.ca/ehr/index.html), and the Danish have EHRs for their whole nation (http://www.time.com/time/health/article ... 09,00.html)

Cheers,

Bill

[PST]

I have become a fan of both electronic medical records (EMR) and hospitalists. Both can help reduce medical error, although neither is a panacea and both present dangers of their own. EMR will become universal in hospitals and is spreading quickly through large physician practices, especially those that are owned by or affiliated with hospital systems. Small groups and individual practitioners will be slower, but many hospitals are trying to make it easier for them to get tied into a hospital's EMR system.

In my work life I spend a lot of time traveling to hospitals to talk to risk managers about their malpractice claims and what the hospitals are doing to improve the quality of care and increase patient safety. I would say that there is a consensus among hospital administrators and malpractice insurers that EMR reduces errors. The area most often cited is physician order entry (POE). In the hospital setting, orders may be given at any hour of the day or night by a series of doctors who may have never seen the patient before. A major virtue of POE systems is that they have built-in checks to flag potential errors, like medications known to have adverse interactions, doses that are outside normal ranges, or possible drug allergies. All these are things that doctors, nurses, and pharmacists are supposed to look out for, and they do, but humans are fallible, and an extra set of precautions helps. This kind of system doesn't replace a doctor's judgment, but it will notice a thousandfold error, for example, like those that can be introduced by a mix-up between "milli" and "micro" units. It can make it impossible to use an ambiguous or non-standard abbreviation. It can remind care givers that someone allergic to penicillins is more likely than average to be allergic to cephalosporins. (I think all doctors know that but I don't know enough to give a more realistic example.)

As I get older, I see more doctors and my memory gets worse. Every time I fill out a medical history, I know I forget things. Even something as simple as the dosage of a pill I take every day is easy to forget. All I have to remember every day is that I'm supposed to take the green pill at breakfast. How am I suppose to retain whether it's 30 mg or 60 -- or how to spell the name. I wish I could get everything down accurately once and then just add to my history as necessary. It would be nice if every doctor I ever see again could just refer to the most polished version of my medical history and then ask me what's bothering me today. EMR is the necessary prerequisite for the sharing of health information. I predict that ten years from now, that will be the norm for most of us. It will come about like the use of e-mail: something most people never heard of in 1988 that everyone was using by 1998. There are changes occurring in reimbursement (both public and private) methods in the U.S. that will push even the laggards in that direction.

Hospitalists are internists who work full time in a hospital and specialize in the care of acutely ill hospital patients. There is something disturbingly impersonal about hospitalist care, but at least they are present 24/7. I used to see way too many malpractice cases that hinged on second-guessing a nurse about whether he or she should have realized how serious a patient's symptoms were becoming and telephoned the admitting doctor at home in the middle of the night. If a doctor got such a call and elected not to come in, there would often be disagreement later about what the nurse said. With hospitalists there is a doctor on the scene, but it takes good communication to make that work, and EMR is an important part of that process. It can also facilitate more rapid transfers to centers with more advanced levels of care when that is necessary and reduce redundant testing.

Working with hospitals may produce a bias in my perceptions, but I believe strongly that a culture of quality improvement and patient safety has become pervasive in U.S. hospitals, with strong gains over the last 25 years. Even now with high unemployment, I know hospitals that can't find all the safety specialists they want. At the same time, the frequency of medical malpractice claims has been dropping in most locations, including those without tort reform. EMR and hospitalists are part of the reason, and EMR is going to keep getting smarter.

[GumbyCT]

Jerry,
When I cared for my dad I carried a folder with most of his records (on paper) for those who didn't have immediate access to his records. It was quite bulky (kept in a briefcase) but what I found useful was a paper from one doc that listed all of his Dx's.

To do that I had him sign a "Healthcare Representative" form which gave me authority to act on his behalf and hand delivered to each doc/hospital records agent when we went. Most in healthcare will no longer talk to family without a signed release.

I will provide a link to the CT Atty. Gen. site where I got the idea if you are interested, let me know. This helped tremendously and relieved any burden from the provider. Also consider a Living Will if you haven't already.

Edit: I had one doc ask how I was related to the patient, my reply was with this I don't have to be and smiled.

[LinkC]

For better or worse....welcome to the future!

My PCP converted a couple of years ago. So far it's worked well. He often looks at previous treatment on a laptop, but it's not particularly time-consuming. He also makes current entries in real-time. He speaks as he types, so I hear what's going in there.

[djr1215]

The systems are expensive and there's no consistency between the various systems available.

In my experience that's usually General Practitioner code for "I need a substantial incentive payment (aka bribe) from <insert some payer or other here> before I will do it"

If the doctor sees Medicare patients, he'll be using EMR eventually. Medicare's EMR incentive program starts this year. In 2015 doctors will get payment reductions if they aren't using a certified EMR.
http://www.cms.gov/EHRIncentivePrograms/#BOOKMARK3

[HoseCrusher]

I think that EMR is great... Flawed, but a great improvement.

As far as medical care goes, I think a good approach is to have a partnership with an advocate. The role of the advocate is to monitor everything that is going on and to make sure that the medication given is "on the list" and at the dose that is "on the list." My wife is first on my list, with my son who has had some EMT training second.

[Rick D]

Don't confuse EMR's with PHR's (personal health record). They are NOT the same, as any doc will tell you. Much of the above stated problems people have had would be solved with a PHR used in conjunction with an EMR. I use EzMedicalDiary dot com as my PHR and my docs all love it.

[Slinky]

THE problem I see w/EMRs is the lack of coordination/consistency. Various companies going off willy-nilly developing their own systems - that WON'T be compatible w/each other, i.e. our Resmed and Respironics CPAPs, etc. so that ultimately what we will be FORCED to accept is one large data base w/EVERYONE's medical records stored. Another victory for "big brother" subject to hacking. "Organized crime" must be absolutely drooling at the prospect.

Just color me a crochety little ole paranoid, grey haired lady.

[billbolton]

THE problem I see w/EMRs is the lack of coordination/consistency. Various companies going off willy-nilly developing their own systems - that WON'T be compatible w/each other, i.e. our Resmed and Respironics CPAPs, etc.

In clinical terms, the various xPAP vendors do produce compatible clinical records. If you want exact raw data compatibility, that is something quite different and generally unnecessary. There are standard taxonomies for representing clinical data, such as LOINC and SNOWMED-CT, and this is the level at which EHRs need to be consistent, not the raw data level.

so that ultimately what we will be FORCED to accept is one large data base w/EVERYONE's medical records stored.

There are numerous EHR patterns for clinical record repositories, including several that support distributed repositories, so there is no intrinsic need for one large data base.

The biggest issue for central versus distributed repositories is around who maintains the data - or rather who gets paid to maintain data quality. In many cases the primary care providers are simply not much interested in data quality maintenance, so that undermines many of the distribited repository approaches.

Cheers,

Bill