The electronic medical record: Diving into a shallow pool?
ACCURACY VS COPYING AND PASTING
A recent Veterans Adminstration study found that 99% of progress notes in EMRs that were examined contained copied or duplicated text.15 Ten percent of 98,753 examined records contained an instance of what was considered “high-risk copying.” Weir et al16 manually reviewed a set of 60 inpatient charts at the Salt Lake City VA Health Care System and found an average of one factual error introduced into the electronic record per episode of copying.16 The clinical accuracy of the EMR is therefore questionable. Physicians pressed for time are more likely to introduce errors in the EMR, and the information put into the EMR is unlikely to be questioned—and may well be perpetuated by copy-and-paste methodology.
A THIRD PARTY IN THE EXAMINATION ROOM
Considerable information is available about the effect of the EMR on doctor-patient interaction. Margalit et al17 studied videotapes of physician encounters and noted that physicians spent an average of 25% (in some cases as much as 42%) of each visit gazing at the computer screen. They also noted that screengazing seemed to be particularly disruptive to psychological and emotional exchange.
Ventres et al18 reported that in the examination room the EMR is “much like a third party to a conversation”18 and contended that the widespread use of EMRs would have intended and unintended consquences on the cognitive and social dimensions of the physician-patient encounter. They concluded that these issues demand thoughtful consideration as the use of the EMR proliferates, “not only to forestall problems but to maximize the effectiveness of this burgeoning medical technology.”18
DEVOID OF REAL MEDICAL THOUGHT
Notwithstanding data errors and the cutting and pasting of prior notes in the EMR, we still know very little about how the EMR affects how doctors express their thoughts and communicate with one another. My particular concern is with menu-driven or templatedriven notes: they produce reams of important data, and they help ensure that coding requirements are met. But this way of writing notes about a patient is devoid of real medical thought. To describe a patient in templatedriven fashion as “an 88-year-old white male” pales next to a personalized description such as “an 88-year-old World War II B-17 bomber pilot shot down three times over Europe.”
A colleague of mine recently lamented, “I can no longer make use of my partners’ templated notes, as they convey no real information.” I do believe we should be concerned about the undesirable effects that such changes in record-keeping may produce.
LET’S CHECK THE WATER BEFORE DIVING IN
What should we do as we face these issues?
First, we should be aware that governmental and financial pressures and the availability of new technology are pushing us rapidly into new, poorly understood territory. This awareness is critical, as it at least permits a more open mind and allows the potential for honest dialogue, rather than just following directives from above.
Second, we should recognize the gaps in our understanding of the overall effects of the EMR on medicine as a profession and begin to more critically study these effects: ie, we need to be proactive rather than reactive. Denying that we lack answers to key questions about EMRs is clearly counterproductive.
We live in the electronic age. EMRs will continue to proliferate, and they have the potential to be cost-effective, care-enhancing, and time-saving. Obviously, there is no turning back the clock. However, the issues I have raised here—and other issues such as additional physician time,1 potential “billing creep,” and the opportunity for outright fraud (rarely discussed in physician circles), not to mention cost—are deeply concerning and worthy of notice and careful consideration.
My thoughts here are meant to serve as a call to reassess the possible unintended consequences of the federally mandated rush toward an as-yet poorly integrated system of EMRs. Perhaps we should check the water first, lest we find we are diving into a shallow pool.
