The electronic medical record: Learning to swim
EDUCATION: AN AREA FOR INNOVATION
Dr. Hanlon notes that research on EMRs for medical education is in its infancy. But infants grow rapidly. While it may be true that students might have to learn to use different EMR systems at different institutions, these students have grown up with rapidly changing computer systems and can learn and adapt at a remarkable rate. Therefore, education is a wonderful area for innovation and research on the EMR. It is not a reason to fear the EMR or the present diversity of EMR systems.
ACCURACY CAN BE IMPROVED
Dr. Hanlon is correct that the problem of cutting and pasting of previous notes, potentially propagating an initial error (so-called high-risk copying3) is profound within the EMR. But I prefer to look at this as an area for innovation— such as nonerasable tags to identify copied material.
While errors in medication lists are possible, especially if practitioners use cut-and-paste methods and thus perpetuate a previous error, systems and workflows are being developed to overcome such problems. Some of these include special alerts when certain high-risk drugs are ordered, drop-down menus with drug dosing included, and links to databases that allow quick access to information on drug interactions.
And again, medication errors are not unique to the EMR. They also occur in paper charts as a result of photocopying, illegible handwriting, and transcription errors.
Compared with the paper chart, the EMR is more legible, and the ability to instantaneously transfer unchanged important and valid information potentially enhances the completeness and logic of a given note and provides the physician more time to spend evaluating (and looking at) the patient. So, rather than focusing on the negatives of the current problem of cutting and pasting, I prefer to focus on how to improve it. That is, how can we make the information in the EMR more accurate, catch errors, and then make the latest information easily accessible to users?
STAYING FOCUSED ON THE PATIENT, EVEN WITH A COMPUTER IN THE ROOM
A major complaint by patients and caregivers is that using an EMR makes the physician focus on a computer screen rather than looking at the patient. This concern is valid, but I think we can learn to stay focused on the patient, even with a computer in the examination room, and still take advantage of everything technology has to offer.
This issue will disappear in less than one generation. Young people are remarkably able to multitask while typing. They are able to talk with their patients while typing and to look them in the eyes. And typing letter by letter will become obsolete as soon as voice-recognition software and ways to edit its output accurately are perfected. Many of us at Cleveland Clinic use a combination of templates, typing, and voice-recognition dictation, and find this to be effective.
When we tell our grandchildren that we used to type each individual letter on a page, they will be as amazed as we are to hear that cars used to be started with an external crank.
DOCTOR-DOCTOR COMMUNICATION IS ENHANCED
I agree that template notes written by physicians who cannot type very well can lack the substance and color found in a well-reported medical history and examination. But voice-recognition transcription can help flesh out key parts of the history, differential diagnosis, and management plan. Further, the note can be produced on the spot, the patient can check the note for accuracy, and the conclusions can be shared instantaneously with all involved caregivers. Doctor-doctor communication is thus enhanced.
EVERY REASON TO MOVE FORWARD
Dr. Hanlon is also concerned about EMRs and the potential for “billing creep” and outright fraud. But fraud is as old as billing. What is required is continued vigilance and system controls, which actually might be more effective in an EMR system than in a paper billing system. Integrity will be neither enhanced nor diminished by digitization, unfortunately.
In summary, while Dr. Hanlon sees reason to slow down the move to EMRs, I see every reason to move forward. The problems he describes are part of the growing pains of any new technology. He is right that we cannot move blindly, ignoring the challenges of this technology. But slowing down will only delay its benefits.
