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EMRs May Do Away With the Docs that Use Them

May 5, 2009
by sam
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The President has announced his goal to digitalize our nation's medical record system. If achieved, this wonderful and lofty notion would certainly reduce medical errors, increase the quality of care delivered, bring consistency of care to our citizens, reduce costs associated with delivering health care, and quite possibly drive the physicians who are supposed to use them out of business.

The buzzards are already beginning to circle.

Physicians and nurses are the most pressured of all professionals, with expectations of their performance and its unimaginable responsibilities beyond the comprehension of people who have never made life and death decisions hundreds of times a day. With every decision and action comes the risk of being held liable and losing both their profession and their assets. The very mechanics of using electronic medical records in their current state of development has complicated the lives of many clinicians who use them and have been slow in being adopted for that reason. With luck, that will change.

What few people realize is that using a computer to document every decision, every action, and the assessment of every piece of information that streams to clinicians in real time represents a major change in the way clinicians have to think and work, and an audit trail that has begun the salivation process of every malpractice attorney who has finally realized what is about to be imposed on the medical profession. An electronic medical record system can track how long a doctor looked at a document, if he or she scrolled down to read the entire thing, how long it took a doctor or nurse to respond to an alert or notification of an abnormal result, how long it took for them to answer their email, and the accuracy of their every assessment, thought and action. It can track whether their decisions and actions meet the most recent guidelines or research results in a world where thousands and thousands of new papers and research are published every week.

This may sound wonderful for those receiving care, but how many people reading this article would want to use such a system in their work knowing that their every thought and action could be audited and evaluated by others who make their living suing you for everything you own?

The President's plan calls for rewarding physicians who purchase and install electronic medical record systems through a series of financial incentives over a period of years.

Mr. President - thanks for the thought and the money, but if you really want to see this work - call off the dogs before the kennel doors open.

Instead of pouring still more money into yet another system in an effort to eliminate its problems, get to the heart of the matter. Reduce liability premiums for physicians and hospitals that install and use electronic medical records. Protect physicians who will have their every move, thought and action auditable at the most granular level. (Personally, I might like to know that I can finish dinner or brush my teeth before responding to a real time alert that someone's blood sugar was a little high without someone suing me because I took too long to act.) Establish standards of expectation for clinicians who will be working in a world of real time data that is delivered to them as quickly as it is generated. Place limits on what audited user-activity information can be deposed in malpractice litigation, while still providing the opportunity for those who have been victims of genuine malpractice to seek justifiable compensation. There is a middle road wherein standards and expectations of how to practice in a whole new world of real time data can be established and it must be addressed in order to allow those who use electronic medical systems to do their jobs without apprehension and fear.

We have the technology to do wonderful things in healthcare and reform the system entirely through exciting and innovative technology. Most doctors recognize the wonderful benefits that an electronic medical system can bring to the quality of care they deliver, and want to use them. But what we also need is for our physicians and nurses to be able to use these tools without fear of the foxes lurking around the henhouse looking for the tiniest of opportunities to attack. Otherwise what we will end up with is a very expensive and technologically advanced universal electronic medical record system with no doctors who want to use it, and a lot of very rich lawyers.

PS: Here's a seven minute introduction to the Electronic Musical Record



Thanks to Joe and Anthony for your comments. Interestingly, I have found the reception to this argument from non-medical people as one of minimal concern - which I beieve to be tied up in the natural response of not being empathetic to doctors in general, and more concerned with what they see to be the benefits in terms of quality. I do not want to be misinterpreted in my support of the use of EMRs- but I do want to bring attention to the concerns that may accompany thier use. Thanks again for commenting.

Congratulations. I'm pretty sure that was the first video blog to hit HCI. You did have me laughing out loud several times.

To add to your case, a few months back, I witness one otherwise highly intelligent and committed doc tell another one:

"Don't log in and check your patient's results when you're not on call. Because of the audit trail and the legal system, that makes you accountable (aka liable) for caring."

I would just like to add that I am delighted that people are enjoyiing my Electronic Musical Record Demo video as evidenced by how quickly it seems to be spreading. My intent is to make the key point about the need for EMR's to enhance clinican workflow and not complicate it - but in a fun and entertaining way.

Great post, Sam. Until we figure out how to make healthcare IT systems more valuable to the user (the doctor) instead of just to their employers, hospitals, government, or other lawyers we likely will not see widespread adoption. I have to admit we don't think much about how IT will actually foster more lawsuits but you make a very strong argument about "buyer and user beware" :-)

A few key points. Proper documentation reduces malpractice. We don't have to document "every single thing" we do. We need to document the appropriate and necessary information only. Doctors can practice with EHR's in a decent workflow fashion, make a fair compensation (the make money comment seems a bit "cold hearted," believe it or not most of us doctors actually are caring!), and realize its vast benefits.

We need computerized medicine. There simply is no alternative. Its a little disappointing to me that this blog thread is skewed a bit towards the negative side of discussion.

Excellent piece Sam. As I've said before, if we forget doctors are also businessmen that want to make money, while maintaining a reasonable work/life balance, we'll get nowhere. Thus, if we put these highly intelligent people in a position where it is not financially advantageous to practice medicine (due to malpractice insurance rates, EMR infrastructure, etc), we will have very few people going into that profession.

Working for an EMR company, you do pose some valid points. What we have to establish legally is where a blank piece of paper differs from a scripted document. With a blank piece of paper and an H&P, we expect that a physican or other licensed medical practitioner has done their duty to do their professional 'best' when doing so. But my fear is that if I have a structured systems review in my note and nothing is answered, is that handled any different legally than if the practitioner didn't mention it on the dictated H&P or note? I would like to think not. But I can see how advances can be 'misconstrued' to say that 'you should have known'. In designing EMR notes for Clinical Documentation, I often get requests to 'keep the practitioner from doing something unsafe'. While some of that can be done, especially in the form of drug interactions, what I don't want an EMR to be is a 'barrier for a practitioner to practice medicine. I still advocate that you need to continue to use your best medical/nursing judgement and if something doesn't 'sound right' to question it. Don't just blindly follow an order that tells you 'something isn't right'. (There are horror stories that said there was an order to give 100 units of Insulin, IV and the nurse actually gave it). I don't want practitioners or lawyers thinking that an EMR is infallible. Most of it is designed by the hospital staff, with the EMR company as consultants. NO ONE IS INFALLIBLE. So regardless of how 'sofisticated' EMR systems and CPOE systems become, there are always,'defects in software', 'defects in design' and so on. I teach my clients that EMR's are meant to be an AID in practicing your profession. Not a replacement for doing your job. What I don't see being taught or addressed is 'how do we educate Lawyers and Physicians and Nurses and Medical/Nursing Administration on what this actually is? It really is a computerized version of being able to capture a practitioners thoughts. But this is an 'evolutionary process'. Where do you draw the line?

Thanks for listening!
Loren Osborn, RN, PA, MPH