Broken record

The electronic medical record (EMR), or computer charting, theoretically allows "doctors and other healthcare professionals to consolidate, store, retrieve, and share medical information about an individual's entire medical history with the goal of making paper records obsolete, saving money and reducing medical errors." Such is the official definition. President Obama says use of the EMR will save $81 billion and will help fund his healthcare overhaul. But despite years of use by many medical organizations, these goals have not been realized.

Study after study finds the EMR does not save money over paper charting. Also, the EMR's effect on medical errors is a mixed bag, with some studies showing improvement in the accuracy of transmitting doctor's orders, but most showing less accuracy than paper charting in other areas.

I am a doctor who has used the EMR for many years. Here is my story.

After an exam, I have my patients come to my office to discuss their problems and treatments. Looking at my computer keyboard and screen, one patient recently commented how pleased I must be to use electronic records as opposed to paper charting. "Oh dear," I thought. I deflected her comment, but she persisted. So, I decided to share my thoughts. Here is some of what I said.

First, I said I had to type my notes into the computer. "Type? You have to type?" she said. She was an executive at a large company and could not believe a doctor would waste time typing. Typing isn't all. The doctor must code visits and diagnoses and also order tests and X-rays. Studies do show doctors see fewer patients when using the EMR. However, instead of typing an entire visit note, almost all doctors use a pre-formatted template. These canned, pre-formatted visit notes are literary monsters containing garbled syntax, different fonts, different line spacing, poor or absent sentence structure, senseless paragraphs, yes-no checklists, inappropriate capitalization, and technical diagnosis codes, such as MENSTURAL DISORDER, NOT OTHERWISE SPECEFIED from a coding manual-a medically meaningless phrase.

In other words, the note would not pass a sixth-grade writing assignment.

These notes are difficult to read and communicate important patient information poorly. Studies also show the most effective way to improve patient care and safety is good doctor-to-doctor communication, communication with clear, concise, readable, informative, and understandable notes, notes sadly lacking in the EMR.

Next, I told her about up-coding. These pre-formatted templates used by nearly all EMR doctors pull unneeded patient information into the note and can make a simple visit look like a thorough going-over with a correspondingly higher charge. "Do doctors do that?" she asked. Unfortunately, yes. I see it every day. A woman treated for a simple bladder infection ends up with a three-page note including all her past surgeries, medicines, allergies, all other medical problems, family history back to her grandparents, marital status, employment, habits, childbirth experiences, seat belt use, a complete review of all organ systems, and a somewhat detailed exam-all blown into the visit note with one click of the mouse. The doctor should have made a brief note with a corresponding low charge. But by including all that unneeded data, the doctor could assign the highest possible code, the code that pays the most money.

This fraudulent activity is nearly undetectable. If audited, the auditor only looks to see if the visit note matches the assigned code, which it does. If the two match up, no fraud is detected. Researchers have noticed this up-coding and attribute this consistently higher coding with the EMR to improved "capture" because of "better" documentation in the EMR. That explanation, however, does not fit with what I see. The documentation isn't "better." Worthless junk thrown into a visit note to increase the charge is not "better."

I attended a meeting of nine doctors and, in that meeting, one doctor asked if anyone actually read all the extraneous material blown into the note. Only one doctor of nine raised a hand. Only the naïve would think a doctor would review three pages of irrelevant data just to treat a bladder infection.

To come: EMR's effect on privacy, cookbook medicine, impersonal medicine, and propagation of errors