Sunday, April 19, 2009

More concerns about Government mandated and financed electronic medical records

To reform medical care we are told that we need three things; 1)electronic medical records (EMR), 2)comparative effectiveness research (done by the federal government)(CER) and 3)more efforts at prevention . From these elements we can derive care for all,better quality care and great cost savings.(Why does this remind me of "cheap,fast and good-pick any two"?)

Concerns about the government mandated EMR have been recently expressed regarding the following issues:
1.The Legacy issue
2.The error problem
3.The monopoly problem.

While Dr. Michael O'Connor of the blog The Ether Way eloquently writes (see here) about a more fundamental problem with the EMR, namely that it is,at least in part, a cut-and-paste tool of the administrators and the regulators and not so much of the physicians caring for the patients and as such serves the ends of the first two groups much better than those of the physicians and patients and that physician sometimes resort to "shadow charts" as a work-around to the constraints of the EMR.

Dr. Wes offers this posting about the" Legacy problem" with EMR. This is easily related to by anyone who remembers floppy discs ( remember the kind that were really floppy) and how your current computer does not even have slot for those now. Some may have experienced how various drivers did not work when their new PC was driven by Vista and they were not supported by this new improved Microsoft product.Read the trajectory of frustration ,wasted time and money that is explained in detail on Dr.Wes's entry. As computer systems evoke, incompatibilities arise with older system still in use which can lead to increased costs or partial or complete abandonment of the system.

Another serious matter is discussed in detail on Junkfood Science.See here. The main point is that electronic records can be erroneous (errors creep in from various often unrecognized sources) and those errors can be lethal and good luck getting those changed or even finding out what they say.For a detailed description of just some of what can and does go wrong with electronic medical records, go here for an alarming essay by Dr. S. Silverstein (AKA MednformaticsMD) who has tirelessly been educating the readers of Health Care Renewal about the many problems with medical IT.

Still another issue is raised by a commentary in NEJM about which there is a WSJ article ( see here).Since the stimulus bill gives the government power to define and approve which programs and systems will be used there is the power to create a medical high tech monopoly leaving innovation and corrective improvements out in the cold.

Dr. O'Conner's critique of the EMR should be read in its entirety but here is one good quote.

Many EMRs read like Madlibs(for those of you old enough to remember what they are), because they are in fact cut-and-pasted snippets of data from other parts of the EMR, put in place to fulfill some billing documentation requirement or some regulatory imperative. Free text annotation is often discouraged, and frequently impossible to juxtapose next to the appropriate snippet of information in the chart. Some systems make it very difficult to generate any kind of free form documentation, and consequently critical events in the course of a hospitalization are never documented. In most or all hospitals, practitioners have developed a shadow chart that incorporates all of the critical information that practitioners need to know to care for a patient. The existence of these shadow charts has been driven by the hijacking of the medical record for billing and regulatory purposes. The creation of these charts represents additional effort for everyone who directly participates in the care of patients. That such busy people are willing to do this is striking. Little you want to know is in the chart; everything you need to know is in the shadow chart.

I'll admit I had not heard about shadow charts since I have been away from clinical care for a while. Perhaps a reader can inform how widespread this is.

We are told that to reform medical care, billions will be spent to ensure EMRs will cover
everyone's medical records and we can watch as the quality of care is monitored from "this perch" which may well consist of coarse grain and often erroneous data extracted from various EMRs (including the notoriously inaccurate coding information) often excluding the important nuances of the real medical world.


Chuck Brooks said...

I've some bridges for sale, with one in Minneapolis St Paul having a lot of upside potential.
Chuck Brooks
FutureWare SCG

Angella said...

I agree with parts of your posting, but feel compelled to point out a couple of things. It is unfortunate that billing and regulatory agencies are driving documentation. However, it is even more unfortunate that professionals are so lax in their documentation that they require prompts in an EMR to ensure completeness. Also, there are numerous coding errors that are laregely related to insufficient documentation by the physician. Frequently you see 'general' documentation in the chart that does not specify the severity of the disease/illness being treated. Certainly this is not the sole reason for coding errors, but it is a significant part of the problem. Some of the EMRs have hard stops to ensure regulatory documentation compliance which in reality improve quality of care and safety in many ways. The downfall, in my opinion, of the EMR is that is removes the need for good critical thinking skills. Why should you know which beta-lactam would appropriately treat a pneumonia patient with pseudomonal risk when the EMR prompts the appropriate selection for you? Why wouldn't nursing notify the physician of critical lab values? Heaven forbid they actually 'think'.