Halleluiah! Love that EMR!

One of the spinoffs of being an oncologist is that you do not to take the world for granted.  Each morning, I walk around the yard and smell the morning breeze. I am thankful for my children, my wife and my own health.  I am thrilled, if occasionally skeptical, to have the opportunity to pay taxes in a Country that I love.  So, who would believe I would take our Electronic Medical Record (EMR) for granted?

I know, shocking, isn’t it?  How could I overlook a key factor in the success of our practice, ever since we ditched paper records, 13 years ago? Nevertheless, it is true. Day-by-day, the keyboard and screen became just another device, like a stapler, paintbrush or pocket comb.   I began to use it out of simple necessity, and neglected to sit in awe of its power and glory.   I ask the geeks of Silicon Valley, to forgive me.

We have been binary in our office for a long time, but not in our main hospital.  In the office, everything flows by electron, but at the hospital we have been using a kind of EMR-light, call it E-decaf.  Maybe we turn on the machine to check a few labs, order the occasional test, and perhaps send an email.  Thus, even though the docs of our practice spend more than a hundred-fifty hours a week on the wards taking care of 60 patients a day, we were still paper-binder-chart-bound.

But, last week it happened … we crossed the Rubicon … in a blinding flash of bits and bytes, clicks and clacks, copy and paste, we went full-on-no-holds-barred, every-piece-of –data-for-itself electronic and converted to the EMR.  It was glorious!

In the hospital, I had long gotten used to the appalling inefficiencies of the crayon and papyrus world.  First, find the chart (good luck… I am sure I have lost a year of my life hunting). Then, read the prior notes (which for many doctors, including yours truly, is impossible).  Find the labs.  Find the X-ray reports.  Check the images.  Call the lab and radiology for the labs for the results that you could not find.  Seek and then check the vital sign clipboard.  Read the I&O record (different clipboard).

Now, there’s time, barely, to see the patient.

Then, painfully, ridiculously, illegibly, write down what you just found, repeating everything you also wrote yesterday (except what you forget or can’t read, which is probably critical) and then put the chart back in the rack (maybe), so that the next doctor can start this whole process over again.

You think I am kidding? Exaggerating? Not the tiniest bit. What I described is what every doctor using chisel-stone-tablet records does every day with every patient and if you have a lot of patients in the hospital it takes a very long wasteful time and is guaranteed to result in error.  Ask any doctor to pull any binder at random from any chart rack anywhere and read it carefully and there is an almost 100% chance you will find a mistake in that record.

In brilliant contrast is the EMR, I used today.  No need to find the chart, just a computer, and we have lots of those. Open the patient’s file.  Read the clear notes from other doctors consulting on the case. Then, turn to my note from yesterday.  Download directly into the note, with a couple of clicks, today’s labs, x-ray reports, pathology reports, I&O, medication lists (ordered & actually given), vital signs and any other relevant data.

See the patient (which I have more time to do).

Modify my note with today’s findings and conclusions.  Write, in the computer, any new orders.  The orders are instantly checked for allergies, compatibility, dose, availability, redundancy and communicated to the proper department.  Complete.  Legible. Efficient. Accessible and transmittable (via encrypted form).  Even fun.

The quality of medical care because of clarity, accuracy, speed and the quality of communication is multiplied, probably exponentially. Problems are not forgotten. Errors are quickly identified. The valuable efforts of patient and professional are not wasted.  The time needed to create extraordinary medical records is cut at least in half.  The medical record is not just another device, like a pencil, tape measure or paper chart. It is a tool to guarantee, amplify and create quality.

Is the future here?  Are present day EMRs the Holy Grail?  Not yet. They still have major problems in data input, across system compatibility and universal access. However, they a stunning technology that saves cost not only by saving time, but by improving the quality of the record and therefore the quality of care.  In the future, not to far away, EMRs will interface with medical information and research databases and work with each doctor with each patient on each day to assure the most accurate diagnoses, the best treatment and the best chance of cure.  Even now, they are revolutionary.

Therefore, I ask the IT guys in the trailer out-back to forgive me.  I did not mean to take them, bowtie-pocket protectors and all, or their electronic children, for granted.  Never again.  EMRs are not just a brightly colored tool; they are the key to a future of medical quality, health care delivery and experimental breakthrough.  How very cool it is to practice e-medicine today.



  • D Someya Reed
    I do not understand how you can imply that an EMR because of its method of input (keyboarded directly by doctor or transcribed by other) is either less likely or cannot have a mistake yet a paper record is almost 100% guaranteed to have inaccuracies. GIGO (garbage in/garbage out) applies no matter what the data entry method. If your system makes it impossible to log any wrong information or for the wrong patient or any sort of inaccuracy (ever!), I would love to see those algorithms. Is your security as infallible? I'm not being a "smart mouth." This is a very serious area for me both professionally and personally.
    • Liz
      Identity theft via medical records is a growing crime, as is medical insurance identity theft. Usually there is far more access to enough information to steal identity via medical records than, say, banking records. There is also significantly less control over who can access that information and the odds of a background check being performed is much lower. Considering that banks, the pentagon, etc. have all been hacked, and they are well protected, I'd say hacking medical records would be relatively easy since what I have read they mostly have low level security, many computers are in a relatively public place (for example patient rooms where patients are in there unsupervised) where if someone forgets to log out the information is there for the taking… Not discounting the up side which is significant, just echoing concerns about issues that are not yet adequately addressed.
  • Liz
    I hope someone address how to fix input mistakes that are put in there. I have spent the better part of 3 years trying to fix several mistakes in my medical record (mistakes that matter about past history) and while someone will update notes to say what is listed is in error and here is the correct information, there appears to be no way to fix things by REMOVING mistakes (the mistake just got repeated again because someone looked at the original and not the updates that said, "that was typed in in error" and so repeated the mistake). I understand medical records are legal documents but there needs to be a way to REMOVE mistakes that are entered in error. In a paper record you could cross it off and make a correction right there. In electronic records it would appear the geeks didn't make this possible, at least at the comprehensive cancer center I am using.
  • meyati
    I agree with Liz about an inaccuracy-my cancer diagnosis is listed wrong-and I've been laughed at when I said that I had surgery and radiation. I had to change PCPs in Sept. Early Dec. I called up a GYN for an appointment. I'm an old woman and do this about every 10 years. They called me to confirm my appointment, and they wanted to know why my PCP wanted them to call him, when I entered their office-this is my old PCP. I told them the name of my current PCP-that I hadn't had contact with my old PCP since early August, and please don't give him any information. I got hold of the HMO and filed a complaint a few minutes later. I had strep for 5 months, and that set off boils, urinary problems, symptoms of a heart condition-.I want him to leave me alone-stay out of my chart and don't contact my new doctors, or my old ones either. I told them to look at the lab work-I had a TSH, visited him, had a change in thyroid dosage-and my thyroid went further out of range, and there are all of those positive strep tests. I told the HMO complaint department that I didn't file any complaints about the old PCP-this whole situation makes me look like a nut case. He'd been a good doctor for about 3 years, and something happened. I was very unhappy having strep, and thyroid out of range-but I stayed out of his face, I didn't file any complaints, I didn't call his office or anything, I just walked off-with a cardiologist's help in cutting red tape. I told her I don't understand why he's in my chart about the GYN-it just doesn't make sense. When I went in for my TSH, in Dec. the lab told me there was lab work ordered by 2 other doctors-one by my oncologist for a regular check-up, and one by my old PCP. I figured what the heck, maybe he might have an idea about something, so I said-OK-either I have something or I don't- Then this got my new PCP up on the bit for several reasons. I reminded him that the plan doesn't allow me to have several PCPs, and I was broke from from sending my uninsured family members to Urgent Care to see if they had strep-and if we were giving it to each other. We are officially a strep free family-I was the only one with it. The fact that on my own, I had all of my family members go to doctors for strep tests, and I paid cash really got her mad about the whole situation. Why would any doctor do any of this? it doesn't make sense. Why would he even remember my name?
  • Jean
    I am happy that your experiences with EMRs have been positive. However, that isn't always the case. As others have noted, correcting errors in EMRs is a major issue. I have not found a way to have this done, and I've been trying for several years. Default settings may be part of the problem, but removing wrong information doesn't seem to be within anyone's realm. There is no accountability, either, as to who actually entered said information. Another problem is that physicians can opt to have important information entered by medical assistants with minimal training. Chief complaint, medication lists and history of the present illness are routinely filled in by MAs, not RNs or MDs. I shudder to think what will happen this year when EMRs are scheduled to communicate with systems from other vendors.
  • What a wonderfully refreshing report from you again. You are a true credit to your profession on so many levels. You are a good man and a great and caring and compassionate doctor...I would love to shake your hand in person! Mimi
  • Ray
    Excellent Blog!! what caught my eye was reference to "pocket protectors". I still have some in my drawer, they are a dead giveaway to an engineer of the 60s
  • I envy you your love of the EMR. The one I'm privileged to be driven crazy by ... is considerably harder to review than paper. Every note is on a different 'page' but it takes 3 clicks to tell the page to load and then it takes ... its ... own ... sweet ... time. If it's not, after all, the page I need to read then I get to repeat the process. I could have flipped a dozen paper pages, one by one, in the time it takes to read one page in the electronic chart.
  • D Someya Reed
    Have you stopped to consider the expectations you are creating in patients and the general public with your zeal and evangelization of the EMR? EMR’s are not a bad thing and do have benefits over paper records when used correctly on systems capable of supporting them. But, can any physician achieve the results you’ve stated here with the superlatives that fill your sentences, such as “assure the most accurate diagnoses, the best treatment and the best chance of cure,” “a tool to guarantee, amplify and create quality,”…“assure”…”best”… “guarantee”…not to mention “complete,” “instant,” “extraordinary, ” “exponentially”…really? Do all the members of your “bowtie-pocket protectors” bunch totally support you on this? Do they even know that this absolutism is a requirement or expectation of their work? Or, perhaps, maybe THEY are the ones telling you that these will be the “amazing” results? Creating a perception, as you imply here, of a facility and its staff being superior because they use EMR’s over paper is akin to saying that any surgeon, by virtue of having a somewhat sharper scalpel, is automatically a better surgeon and guarantees best results. So many other things not even related to scalpels (or EMR’s) come into play for this to happen. Just as some surgeons may be able to work wonders with a kitchen knife and a bottle of rubbing alcohol, not every surgeon possesses that skill even if they had identical education, internship, etc. EMR’s are only as good as the skills of the person using them, the brain instructing those hands at the keyboard and how well the IT guys listened and understood during the requirements gathering phase to develop parameters, write code and build the systems they run on. You write as though the ease of downloading information into one area (“a couple of clicks”) eliminates any need of interpretive skills by a physician in reading them and putting all the pieces together… like it was being handled by artificial intelligence(AI) which we really don’t have. To “dangle the carrot” of doctors free to spend more time with patients…knowing that this is the number one desire or complaint (due to lack of time spent) of almost all patients…well, would you please ask your IT bunch to calculate how much extra time EMR’s will give you for this and let us know? I have been asked related variations of this many times while being told to “press your magic button and get it instantly.” Nothing, including EMR’s, works this way. We may one day have the world you envision today (but not just from the tool, nothing more, that is the EMR). Maybe we’ll even have the ability to “data/skill dump” directly to a person’s brain and create not only the knowledge but the muscle memory to carry out being that “sharper scalpel surgeon” with just a couple of clicks (though likely by then the mouse will be long gone). Much in Sci-Fi becomes Sci-Fact. In some cases, EMR’s will make you more informed and, in most cases but not always, informed faster. Can anyone guarantee that faster information is always correct or even always comprehensible? Don’t a lot of people have to do their jobs very well, if not perfectly, to make this happen? And this does not even include the “impeccable logic” necessary in the foundation of the systems your IT staff will continuously create and re-create along with the MAJOR (not major) hurdles to create the “interface with medical information and research databases and work with each doctor with each patient on each day to assure the most accurate diagnoses, the best treatment and the best chance of cure” that you predict. This is not even in addition to the nationalization and global internationalization of data you espouse in the RWJUH Medical Minute. EMR’s are simply a different format which may ultimately suffer from the same problems of disorganization and ineptitude of entry as the paper they will eventually replace. They have no inherent skills and do not supersede the skills of the people who use them correctly. One of the worst things that any of us can do in any profession or even personal relationship is to over-promise for what we know we cannot provide. Will EMR’s truly guarantee that physicians can provide all as you’ve stated it here? If not, or even “might,” the public needs to know that EMR’s are not a panacea because if they are led to believe that they are (through over selling their virtues), they will hold you to it. As always, thank you for letting us debate these issues with you.
    • James Salwitz, MD
      Evening … as always I greatly appreciate your wisdom and input. I believe that EMRs are not just another way of recording information, but are transformational. They represent a evolutionary step in the practice of medicine. They will do this by creating a searchable, transparent, accessable contemporary record of medical care. None of this is possible in the paper record world. This will allow, especially as these systems mature, elimination of error both in the data stored and in the medicine practiced. We will be able to use simultaneous research based support and analysis of decisions. Individual medical records will not be isolated in illegible fragments, but will be synthesized into a single complete personal record. While I freely confess we have a long way to go, in the digital age that time, as measured in years, is likely to be remarkably short. jcs
      • D Someya Reed
        We would all hope that your view is the one that will come to pass but there is so, so much to getting there. Great systems must take the human element into the equation...to protect the users from themselves...from the competent to the incompetent and every level in-between. These systems must proactively protect from erroneous information ever being entered so a way doesn't have to be found to remove it or keep it from resurfacing the myriad of ways possible. Additionally, the further data is extended locally, nationally, globally the greater the security risk of intrusion, capture, deletion or modification and the greater security protection needed. How do we get so many disparate groups (even pursuing the same goal) to agree on everything digital? For years we've been saying or told that cures for many maladies were imminent, right around the corner. But then it is explained that the expectations failed as there are just so many variables that get in the way or refute a cure thought to have been found. The digital world is no different except we come at it from the other end; that is, we "discover" a cure for disease by testing, testing, testing. We "create" a digital world by telling it EVERYTHING we want it to do from the ground up. Nothing can be done in the digital world beyond what we tell it to do. Even responses appearing to be spontaneous are actually based on code that predicted the question/request. Cancer and other diseases would not be the enemies they are if we had this ability to tell them what to do and they would do that and only that. Digital and disease...we're at both extreme ends of a singular equation. Perhaps if we could get from one end to the other we could solve the equation however we chose to look at it.
  • D Someya Reed
    Again, not to minimize your enthusiasm for the EHR, Dr. Salwitz, but the OIG released a report in Dec 2013 which can be found and downloaded at: http://oig.hhs.gov/oei/reports/oei-01-11-00570.asp This highlights just the tip of problems that are associated with the practicalities of using EHR in the working environment. I, particularly, found the discussion of patient involvement and comment on page 13 interesting and especially so the 2nd paragraph starting with "Hospitals reported several barriers to patient access..." The solution to the concerns both with patient access and clinical use are not going to be solved purely technologically. Rather, they will be a combination of tech, standards, policy, financial resources, staff quality, etc. Some "safeguards" will always only be as good as how well or how poorly they are followed by those bound by them. That's obvious, I know, but bears keeping in mind. The copy/paste function was a good catch on their part because it is so commonplace. However, no software I'm aware of allows it to be secured (authorized/not authorized) by user ID. Tracking of changes is also scary both for volume and reason...is it being done to have someone to "blame" for errors or is it being done for a better purpose? How do you secure this audit from anyone's manipulation. In my own career, I have been that person that was entrusted with the ability to make any changes to the system. Sometimes tech doesn't work right and it's necessary to have this capability but extremely worrisome any time you use it. These are the kinds of questions needing to be asked and answered, and likely many times over, in order to have a good final process/product that will truly be the advantage to the patient (first, with outcomes) and the physician (to get the patient there) that you foresee. Unfortunately, more and more as was evident from the problems with the Affordable Care Act website(s), these questions are not being asked and tested by those that need to be asking them or testing them. I love your enthusiasm for the EHR and only challenge it to keep it in proper perspective. In the end, I hope the vision you have of the EHR comes to be the one we end up with.
  • D Someya Reed
    And, just for the record, the OIG's (Office of the Inspector General) duties are to protect the process compliance and assets of government programs, not the protection of patients or their rights. There is a presumption that established program procedures properly followed and funding not defrauded will result in positives to the program beneficiaries. In this case, medical patients. Doesn't always hold true, though. I used to think they were interested in stopping patient abuses but they made it crystal clear on my first call to them that they were not. That's another department.

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