Unrelated, but I’ll ask anyway: what do you think of ICD-10 mandate and EHRs. Are they worth it in your opinion? Or, would do you prefer the traditional chart?
I don’t want to go off track here but i doubt enough people are interested in this answer to justify a separate post.
As far as ICD -10, I understand the rationale but i personally believe it places an undue burden on primary care physicians such as myself. ICD-10 requires physicians to add another level of specificity to their diagnosis codes presumably for research purposes but for generalists like internists and pediatricians who need to use a wide variety of diagnosis codes the change to ICD-10 means we may have to now increase by a factor of ten the number of codes we are familiar with. Thats a lot to ask of the class of physicians that are already over worked and underpaid compared to the rest. My personal take on this is that I am going to do my best to ignore ICD-10 partly in protest and partly because I dont have the resources to do much else.
EHR’s are a mixed blessing. The story the public is getting in the media is as usual completely inaccurate. I am speaking as someone who is highly computer literate and has already implemented an EMR in my own office for the past 2 1/2 years. The proposed advantages of EMR’s were supposed to be, better access to records for physicians and patients, improved safety for patients, reduced costs of health care ( through decreased duplication of services), improved care, and greater efficiency for physicians. I can say with good authority after the first few years of this experiment in my office that none of these goals have been met and while EMR’s have definitely improved some aspects of medical practice in some areas EMR’s have had the opposite effect. specifically:
1) Better access to records - The idea was that all EMR’s could communicate so that doctors could easily access records you had compiled through visits with other doctors. In reality none of our systems communicate with those of other offices. This is partly due to privacy concerns but it also has to due with the structure of medical practices. For example, in the community where i practice hundreds of doctors are employed by the local major hospital. Within that system every doctor has access to every other doctors records. Those of us in private practice do not have that type of connectivity though. The system i purchased is the exact same one the hospital uses with its doctors and despite the fact that I am an attending physician at the hospital my system cant share info with theirs. On the plus side I do now have access to a patients records if they are in the ER and the ER doc needs some information from me after hours.
When it comes to patient access to records the situation is not much better. The original idea was to have patient portals where patients could look at all their results and records. I did not agree with this approach in its original form so I am not all together disappointed that it hasn’t materialized but while some systems do have patient portals many do not or they require the doctor to pay an additional fee to implement this feature. EMR’s are so expensive that few physicians are likely to chose that option if there is an added cost.
2) Improved safety - Our EMR has some features which actually do improve safety. Prescriptions are now cross referenced to the patients allergy history at the time that they are ordered in the system and a warning will come up. Unfortunately as an example of poor implementation, the system flags so many irrelevant or unimportant issues that physicians automatically ignore the warnings after a while because 99% of them are inconsequential and it wastes time having to read through them.
Another safety issue that come up with a lot of physicians has to dot with the accuracy of the record. As an experienced physician I now how to draft my note so that the important items are in there and the unimportant stuff is left out. Its the difference between reading a 10 page long history and physcical written by a first year med student who examined a patient with a cold and reading a 5 line note by a doc with 20 years experience during a similar visit. The med student note may be more detailed but it may miss important points and the pertinent items are buried in pages of useless fluff. Current EMR’s are like a first year med student. Notes produced in an EMR are generic, long, and not as informative as they could be because the most important facts are buried among pages of useless info. In addition EMR’s tend to slow physicians down so most of us start looking for shortcuts to try and recoup some of the lost time. These shortcuts come in the form of templates for the exam and history. Instead of checking off a hundred boxes for a normal physical you can check a box that says “all normal” and all the boxes get checked for you. The problem is that you may be checking boxes for things you didn’t actually do not because you are trying to cheat anyone but simply because you may forget what’s in the standard physical for that particular template. The first 2 months that I had an EMR every patient I saw had a rectal exam.. or at least thats what the EMR said because I didnt realize the person who made up the templates thought a rectal was part of a brief exam until i noticed the error.
3) Reduces costs of healthcare - Briefly, untl the correct the interoperability issue and allow all systems to communicate this will never happen.
4) Improved care- this was supposed to happen by allowing systems to incorporate standards of care so that when a doctor is treating a diabetic for example the system would remind us that the patient was overdue for a foot or eye exam if it hadn’t been done in the prescribed period of time or if a woman over 50 had not had her mammogram in the past year etc. While some systems have this feature many do not so there is a lot of inconsistencies in implementation of the stated goals
5) Greater efficiency - This should have happened but has not primarily because the people designing these systems are computer engineers and not doctors. They dont understand our work flow or our needs and since they don’t they have no idea how to design a system that would allow us to work more efficiently. I am very active with our computer vendor in suggesting things that need to be improved but the responses have been luke warm because they are more interested in satisfying the governments demands and those of the insurance industry than they are in making the system work for the actual health care providers.
The biggest flaw in the entire plan is that despite their heavy involvement, the government never demanded that all EMR vendors use a common database. It take weeks or months to evaluate a system and while the cost of purchasing the system is high the cost of implementation and data entry is a huge investment. By the time we determine a particular system is not the best fit we have invested so much in data entry that we cant afford to switch. If there was a common data base someone could throw a switch and we could change to a new system with minimal costs. This would have forced vendors to create better systems because there would have been real competition. The way it is set up now, once they have us we are prisoners to the system we have chosen and they have no incentive to innovate very quickly.
Essentially, EMR’s were a great idea that have been very poorly implemented.