Today was my twentieth anniversary at the academic medical center where I practice. When I arrived in 1993, all charts were kept on paper, with different departments maintaining separate file rooms. As a specialist, if I wanted to see notes from other providers, or lab work, or test results, I eventually learned how to hike around my building to each secret stash of records, submit a requisition and get answers, sometimes legible, sometimes not, to my questions. Under that system, it was usually easier just to repeat a test or assessment, rather than spend time reviewing what was done before.
That was then, this is now. But have things really improved?
A recent story on NPR by Elana Gordon reveals extensive consolidation in the market for electronic medical records companies. The Federal Government has, in addition, offered physicians and hospitals billions of dollars in incentives to adopt an EMR. My particular hospital and practice adopted an EMR almost a decade ago, and has replaced big pieces of it several times since. Surely it is time for congratulations all around. Well, maybe.
In the first five years of our EMR—the time of the unregulated wild west of the EMR market--our emergency room, our inpatient hospital units, and outpatient practice group each adopted its own EMR, based, I suppose, on how a good salesman convinced some purchasing agent that a particular version of the record was the best for a particular setting. In retrospect, this did little more for the care of patients than the snake oil salesman coming into a frontier town, selling a case of tonics “good for what ails ya”, and leaving before anyone realized the tonic’s main ingredient was alcohol and opium. Our three records did not allow for communication across settings. If I needed an ER record, I hiked over to the ER, even if I was treating a patient sent to me from there. If a patient had been seen prior to the date we adopted the EMR, the paper chart remained my main source of clinical information. I now spent time trying to retrieve lost passwords, navigate between screens cluttered with boilerplate and cute but uninterpretatable icons. (Who, for example, thought it a good idea to make a “parking lot” symbol the icon for contextual information?). I still repeated a lot of tests and assessments.
Eventually, at significant expense, the medical center consolidated three records into two, and all the old paper records were scanned into them. Things are better—I can find past information in the records I use regularly, send notes to other doctors who share the same record, and answer requests from outside providers reasonably efficiently. Occasionally an alarm appears on the screen, if I am trying order a prescription that a patient has refilled too soon, or if there is a theoretically possible interaction between two different prescribed medications. Most of these notices add nothing to patient safety, but I still appreciate the reminders and see that under certain circumstances, a record could prevent me from making a major error.
What the record now does best, of course, is manage billing, though I have to go through five discreet steps to enter each charge.
Therein lies the root of my distinct lack of enthusiasm for the EMR. Like many other proprietary or commercial elements of our health care system, money intended to improve patient care or safety has been quietly diverted to improve the bottom lines of for profit enterprises. Instead of a universal record template for clinical information, one that in the best of all possible worlds would intersect with a Personal Health Record (PHR) that patients could maintain and carry from provider to provider, we have competing companies marketing incompatible formats and blending all sorts of clinical and financial data together. As the NPR story acknowledged, in the race to consolidate the market, the big EMR companies have yet to make electronic records a source for the sort of information that would genuinely enhance patient care, at the individual and population level. And if one or the other succeeds in driving another out of business, lord knows what will happen to all the information that we have so patiently collected and stored.
I know that in theory the EMR has the potential to prevent duplication of services, avoid errors, track important trends and so on. But until we have a health care system, not just a market, these advantages remain at best theoretical. Yes, we should recognize that we have made some progress in taming the unruly health care information frontier, but we have barely begun to create the well ordered communities that are needed before we can send for the women and children and provide the services that make for a truly civilized society.