Can Facebook save us?

At some point, this gets to be ridiculous. Online, I can buy any item from anywhere at any price, pay any bill, watch any movie, listen to any song, order dinner, schedule car repair or read about any subject on Wikipedia.  I can determine the weather in Rio, sport scores of Barcelona, Parisian traffic or by GPS the location of my kids, just down the block.  However, I absolutely cannot learn anything at all of the health history of the flesh and blood cancer patient sitting right in front of me.

Today, I am seeing long-term patient, Thomas R.  Father of three and a really nice guy, Tom is a medical challenge.  He is immunocompromised and status post 20 years of complex chemotherapy, radiotherapy, a bone marrow transplant and several bizarre complications, we barely understand.  In the last two months, since his last visit with me, he has seen an internist, a dermatologist, a podiatrist, a neurologist, a dentist and an infectious disease specialist.  These doctors ordered X-rays, lab tests, blood cultures, an EMG, a skin biopsy and several new medicines.   These are confusing tests resulting in confusing diagnoses with confusing therapy in a confusing patient. What records do I have of all this new complexity? Nada. None.  Moreover, based on our files, all these other physicians have none of ours.

Yesterday I saw Ellen T.   This highly intelligent woman was previously in excellent health, but two years ago she suffered devastating hematological complications of routine surgery.  She presently takes 21 different medicines from a laundry list of specialists, including several surgeons, kidney specialist, physiatrist, rheumatology, gastroenterology, cardiology and endocrinology.  On January 1, 2013, two things went wrong.  First, her blood sugars skyrocketed dangerously and remain over 300.  Second, she changed her health insurance and most of her doctors do not participate in the new plan.  She needs to immediately transfer her records and establish a new care team. Do we have a copy of all this information from all these locations?  Not at all.

Bob M. dropped by the office to get a lab test after four months of chemotherapy.  A tooth is causing pain, and it needs to come out.  His dentist sent a note asking whether Bob should stop taking his blood thinner.   Our records have no mention of any blood thinner.  Bob never told us, because his primary care doctor has been prescribing and adjusting that unstable medication.  We shudder at the thought of how the blood thinner interacted with the chemo.

Would you go to a bank that required you to carry a paper ledger of all your deposited money if you moved from one branch to another?  Would you fly a commercial airline whose arrival at its destination airport was always a surprise?  Shop at a supermarket with unlabeled aisles, food piled in bins, and secret prices that had to be looked up, one item as a time, when you checked out?  We continue to tolerate a health care system where our personal information is kept locked in unconnected, non-communicating silos, so that every time we see a new practitioner we have to start again and the only thing that protects us from disaster is our own memory of our medical past.  The result is duplication, error and instead of treating each patient based on their health history, doctors must guess about the best care, without knowing its possible impact.

Our entire medical histories, drug lists, allergies and complaints should be securely stored in an accessible common file much like Facebook, bank accounts or Amazon. Each of these maintains a master file on us, which can serve as a model.  With our permission, doctors, pharmacists, nurses, podiatrists, chiropractors, hospitals and even nursing homes, should have easy, secure, on-line access.  When you see a new caregiver, they should open this master file to understand who you are and, critically, record new diagnoses and treatments in that common electronic vault.  A unified universal Electronic Medical Record (EMR) should be the foundation of health prevention and therapy, and not be some holy grail we never seem to reach.

There remain significant hurdles to reach this critical goal. We must push the techies to solve the obstacles to full universal EMR implementation, which include the challenge of data input, the rules for internal organization (what does the e-chart look like?), a national backbone and vital security.  We must insist that health providers fully commit to this core project. Finally, we must allocate needed dollars to build this vital part of our infrastructure.

Will a universal EMR save dollars?  Not right away, but in the near future, absolutely.  Will it improve the safety, quality and efficiency of medical care and thereby save lives.  Definitely.  Is there any reason to maintain our system of primitive individual medical isolation?   None at all, continued delay would be ridiculous.



  • Maggie
    I agree with every complaint you've raised about the present situation. But I despair of EMR, and the more 'mandatory' it gets, the more despairing I feel. I work in a hospital now, doing a job that is NOT medical (but IS charted). Nobody here likes our EMR, but of course everyone is using it because we must. And I can't even address the problems of cross-institutional EMRs not communicating, of privacy-walls and firewalls and paywalls. But just in our institution: A well-designed database should be able to produce any report you need, but ours offers a series of 'structured reports' based on the practitioner's job description or department. Though I never speak with the patient's MD team, every report I can print uses a column to name the patient's primary in-hospital doctor, thus forcing me to leave out at least one field that would be useful to my actual job. Because the computer is so slow and there are never enough terminals, I end up seeing a dozen patients and then coming back to the office to chart -- which means I have to take longhand notes in a notebook and then try to forcefit my observations and interventions into a 'structured note' later, instead of while they are fresh. The computer translates my checkmarks into sentences that LOOK like human notes, but aren't. Often the computer introduces inaccuracies because I don't see the sentences that result from my checkmarks at the time I'm making them. It takes me eleven clicks to find out that this patient has already been seen by one of my peers today. It takes ten clicks to find out that this patient has already refused our services. My peers are also charting at the end of rounds. The predictable result is that, too often, I'm bothering a patient who has already dealt with our department and doesn't need me -- wasting their time, and mine. Sometimes my services are 'ordered' on a rush basis, but there's no way for me to know that unless I look at the record of each patient on the 'order' list, one at a time. I can't ask the computer 'which of these orders are routine and which are urgent' because it doesn't know, except in the chart of the individual patient. I remember the days before we had a computer on every desk. Computerized information is wonderful but only if you can access it freely. HELP?
    • James Salwitz, MD
      I absolutely agree. I have a new "smart phone." It is intuitive and adjusts quickly to my needs. I can talk to it, instead of typing, and it gets my instructions or words right almost every time. It integrates a dozen platforms easily (I climbed in my car and the two machines immediately and seamlessly connected). We need the smart people who design that high quality technology to fix the frustrating, antiquated EMR systems that presently dominate the market and drive us all NUTS!. jcs
  • Hard not to agree with the vision, need and direction. Getting there is the hard part. While my medical record at my hospital is well integrated, any tests outside the hospital are not. Ontario has struggled with EHR implementation, and that is with the advantage of single payer. But the contrast with our experience in all other areas of our life and health is ridiculous in this day.
  • As your son I'm compelled to ask how you are tracking my GPS location? Never commented before so I thought this would be a fun time to say hi to the sunrise rounds community!
    • James Salwitz, MD
      Only because I care. Jcs

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