Home Forums Discussions General Discussion Interesting article on evolutio the medical record

There is an article in the current Annals of Internal Medicine and accompanying editorial about the evolution of the medical record that I found spoke to my feelings about the EHR quite eloquently.
(The Clinical Record: A 200-Year-Old 21st-Century Challenge
Michael S. Barr
Ann Intern Med 2010;153 682-683
http://www.annals.org/cgi/content/full/153/10/682?etoc)

One quote that really struck home is:

"Electronic health records should be used as a tool to support clinical curiosity and critical thinking rather than simply to expedite clinically meaningless documentation in order to bill higher codes. We are in danger of repeating history by once again overstructuring the clinical record and overloading it with extraneous data."

The practice of medicine has evolved substantially over the last 150 years.

Consider, if you will, that most antibiotics were introduced after WWII and that PCN was so rare it was extracted from soldiers lucky enough to get it during WWII. Sure, they had heavy metals like lead and arsenic which were bacteriocidal although also toxic to patients.

Hospitals were a place to die more than to get well. Things have changed.

Medicine has become an effective art, albeit an expensive one. To justify the cost of medicine, documentation has become the key. Some documentation is truly important. The rest, well...

We are not expected to care for a few hundred patients as was the case a hundred years ago. The average PCP has between one to three THOUSAND patients. We can no longer remember everything about every patient.

There are third party interests that want justification that their sheckle has been wisely spent. Then they will try to reduce it.

This system was overlayed by HCFA recommendations created by the AMA which had little relation of value to the scale of medicine although it was called a relative value scale. Procedures were valuable, outpatient care was junk. Medicine has become the product that the payment systems created. Now it's becoming increasingly difficult to have an adequate supply of primary care docs.

Superimpose the fact that lawyers began to see the medical arena as a gold mine. Documentation became defensive to the point that the final product was almost irrelevant to the original visit. Case in point is most ER notes in which you have have wade through piles of BS in order to actually understand the point of the visit. You think we are bad? Look at nurses notes.

Into this area comes EMRs. They have the ability to focus a note, but many are simply able to produce dribble efficiently. Templates are one way to do this, although there are others.

Don't get me wrong. I use templates extensively, and for the most part I actually do most of the things in my templates. I guess my point is, if the CC is ear pain, checking the reflexes is probably irrelevant unless there is suspicion of CNS progression of an infection.

Sometimes it can take more time to erase irrelevant facts than to add them. Of course, you can have templates about every CC and disease process, but after a certain point, it becomes troublesome to look through the lists to find them.

AC is set up very much the way we were taught to chart in medical school. CC to HPI to ROS to PMH to SH to FH to PE then A and P, with allergies thrown in somewhere.

It is efficient and effective and that is why it is one of the most respected EMRs in the field. The fact that Jon Bertman is a no nonsense, down to earth guy who practices his business with the same ethics we like to practice medicine is a total plus. Basically the product works well, is intuitive and is practical. It gets the point that the form IS the function. It helps us to practice medicine better.

If it allows us to bill a higher code, that is fine, the codes are not properly valued anyway and we are simply meeting the ridiculous standards set up by third parties.

Sure, there are things that other EMRs have that have nice features.. There are things on AC that need to be fixed like spelling and letters and on and on. There is a dedicated cadre of practitioners that use this program because it works. Many other programs can accomplish the same thing, but AC makes it intuitive. AC has and continues to be a work in progress. All of the EMRs are as well, they just are not honest enough to admit it.

OK time to get off my rambling soapbox. Now, what was your point?

Well said. I guess my point, if any, is a lingering fear that using an electronic record is going to blow up in my face when "they" decide to lump my fairly careful notes in with all the masses of garbage out there, just because they are now electronic, and in so doing justify defining my care as irrelevant. The references cited reinforced my worries.

Unfortunately, I was only able to read the synopsis, but it sounds like an interesting article. You need a subscription, and I am not in the hospital to pull it down by another means.

We have long ago given up controlling the fate of medicine. Some of this is good, we have better and more EBM based protocols. Some of this is bad, it is easier to dismiss the need for providers of health care.

Ultimately, you have to live for now and work on other fronts to control the destiny of health care.