Dr. Michael Fine: What’s crazy about electronic medical records

You know the drill:  the doctor, nurse practitioner, or PA walks into the exam room, sits down at the computer and looks at the computer screen, not at you.  And then reads a bunch of questions for you to answer, many of which you’ve answered a hundred times before.  And then said clinician types in your answers, clicking boxes as they go, and looks at you only when they stand up for a quick examination.  When the visit is over, at which time they hand you some print-outs — some prepackaged patient information material and a record of today’s visit, none of which appears to be meaningful at all.  Read this, they say.  And call or email if you have questions, as if they don’t know it is nearly impossible to get a live person on the telephone to answer any questions anymore.  Use the portal in My Charts if you want to know the results of your tests.  You end up feeling like a number, not a human being with thoughts and ideas.  Why go to the doctor at all, you wonder?  Why not just go online?  I just wanted someone to answer a few questions.  Or to fix a problem.  To make me feel better.

Truth be told, I implemented the first electronic record in Rhode Island, in 1992, before Windows, when PCs themselves were still a new invention.  EMRs were simple then, without too many rules, and the early electronic medical records fixed a couple of problems with medical care: they made doctors writing legible, and they let us keep track of a growing volume of information – laboratory studies, x-ray and CT reports, hospital discharger summaries, and letters from consultants, all of which made paper charts progressively more difficult to maintain.  In those early days, we were able to write our own templates, formatting the information we needed so it matched our style of asking questions, and so that early EMR actually helped us do our work more effectively and efficiently.

But I’m also old enough to remember the time before electronic records.  In 1991, I inherited a county practice of a beloved older physician (who was younger than I am now).  That doctor kept his records on index cards.  His notes were one or two lines.  And yet somehow, those notes told me everything I needed to know to take care of the five thousand people Dr. Spencer took such good care of for so many years.

Now, when I read electronic medical records, I usually can’t tell what the heck is going on.  There are pagers and pagers of language, most of which is repetitious and meaningless.    There is little real data in those records, presented in a way that I can understand what the other clinicians are or were thinking and why. I have to burrow through pages and pages of reports and numbers.  And I have to work hard to find what I need.  If I want to see records from a new hospital or clinic, it takes days and weeks for me to learn their EMR and how it works, just to be able to find what I need. 

It’s gotten to the point that I refuse to learn new EMRs, partly because the process of learning each new record is long, boring and frustrating, and partly because I have the very real fear that I’ll miss something buried where I can’t find it and hurt a patient because of what I don’t know.  So when I work in the practice of a colleague, which I do one or two days a month to give that colleague, a true public health hero who cares for the most medically needed population in the state, a little time off, I work with what’s called a scribe, a person who uses the EMR for me, and transcribes what I write and say.  My notes are all still on paper.  And I take a medical history from every single patient myself, so I listen and remember.

But my handwritten scribble, written while I’m in the exam room with each patient, is good enough for my colleague to understand what I found, what I thought, and what I did.

How did it get like this?  Medicine has become way more complex that it used to be, you might say.  Many more drugs and treatments to track.  Many more recommendations to follow.  Lots more prevention to keep track off.  And the US’s venture into EMRs was orchestrated by good people.  Our own Senator Sheldon Whitehouse was, if memory serves, a sponsor and advocate of the HITECH Electronic Medical Records Act of 2009, which brought EMRs to almost all medical practices.  Dr David Blumental, the nation’s first real expert of quality in health care, was the first administrator of the Office of the National Coordinator, which oversaw the implementation of the law.  Other countries have EMRs their clinicians love, EMRS that help them take great care of their patients, inside and outside the hospital and clinic.  Why shouldn’t we have the best EMR in the world?

It got the way got is because our EMRs are about billing, not about patient care, and have reduced me and my colleagues to billing clerks.  Do you think all that data your doctor has anything to do with taking care of you?  No.  Almost none of it serves that purpose.  Your doctor, nurse practitioner, or PA has to sit there a click a thousand little boxes only to justify billing you and your insurance company at a certain level, so they get paid a certain amount. And to justify the highest bill imaginable, which the insurance company will try to whittle down anyway, in an endless and useless game of cat and mouse.

 None of this data entry and billing has anything to do with taking care of you. 

And then the pages and pages of meaningless garbage?  That’s there to allow some lawyer to defend your doctor in case she or he gets sued, or in case some bureaucrat wants to make sure that your doctor is doing what the bureaucrats told them to do, whether or not what said bureaucrat told them to so makes any sense at all.  Which it usually doesn’t.

Remember those little note cards I talked about earlier, the ones the country doctor whose practice I inherited used to keep track of what was happening with each patient?  Truth be told, all the information we need to take care of you can actually fit on those cards. (Okay. We do need a good way to keep track of consult notes, hospital discharge summaries, labs and x-rays.  But mostly the recent ones.  No one should have to wade through pages and pages or clicks and clicks of old stuff to see what’s most recent. And important. )  The great bulk of what’s in the EMR is useless or distracting, and the overwhelming majority of the work that goes into creating that electronic record is unnecessary and meaningless as well.

We could have an electronic medical record system that supports patient care, like patients and doctors in other countries have.  But we don’t.

That we have let our need to let the people make money off health care decide what’s going to be in the EMR, let our willingness to let bureaucrats make any decisions at all about health care, and let our failure to put someone in charge of building a health care system, not a market, that is not for profit and serves all Americans, that’s well beyond crazy.  That’s bull flip stupid.  And completely insane.