Letter From Dr. Bragg
The Electronic Medicine Revolution
One of the biggest revolutions in the delivery of medical care in this generation is currently underway. The shift away from paper charts and prescriptions began several years ago and is rapidly progressing to the point where many of us may not have seen a paper chart for months or years. The Affordable Care Act accelerated the move because it mandated either a switch to electronic billing and the use of the electronic medical record (EMR), or a reduction in reimbursement beginning next year. So what’s behind this change and why should we as Osteopathic Internists be aware of it or involved in it? The quality of American medical care became a major issue when the Institute of Medicine first issued its report, “To Err is Human,” in 2001. It was estimated that as many as 98,000 deaths a year in American hospitals were caused by medical errors. Their follow-up report a few years later, “The Quality Gulf,” increased the concern that there were too many mistakes being made in the delivery of health care in the United States.
The fallout from these reports is too great to detail in this column, but one result has been the conviction by many that one way to decrease the amount of errors in medicine would be to switch to the EMR and e-prescribing. There’s good literature to support this contention. (1) Among other advantages, the EMR eliminates bad physician handwriting as a source of medical error. It also greatly reduces the possibility of records getting lost or misplaced. Unlike a paper chart, multiple members of the health care team may view a patient’s chart at the same time with the EMR. With other modalities that are available with the EMR, such as clinical decision support systems, massive amounts of information in a chart can be sifted through and only what is needed at the time can be made available. Alerts regarding potential drug-drug interactions can improve patient safety, as well. (2) This all sounds pretty good and, if true, it becomes a moral issue if it means delivering safer, faster care to our patients. There are, however, some real and potential problems with the EMR. For one thing, they are expensive, especially for a solo practitioner or small group. Estimates vary, but sources indicate that it may cost several thousand dollars to convert an office to a paperless system. (3) It may take longer to do charting with the EMR, especially when it’s new. Time is a precious commodity to a doctor. Work flow is changed, which may disrupt your normally well-functioning office system and cause delays in seeing patients. Patients complain, as well, that when the computer is in the exam room the doctor pays more attention to it than to them. (4) There are system difficulties as well. Security is a constant issue and with HIPAA rules and regulations security can’t be ignored. Most of the EMR systems can’t talk to each other yet, so it does nothing to improve the flow of information from one office or hospital to another. There now is a growing body of literature indicating that the use of the EMR may actually increase the number of errors in medical care. Some of these are due to the equipment, itself, and some due to human error. (5) Berner states in her article that, “The general consensus from informatics experts is that faulty implementation, inadequate training, poor system design, and inadequate evaluation of the systems prior to widespread use were the main reasons for the increase in problems with use of the systems, not the use of electronic systems per se (Sittig et al., 2006; Ammenwerth et al., 2006).” You must do your homework before choosing a system and spending thousands of dollars. It may be wise to work with your hospital and get compatible systems to facilitate the exchange of information. There are accounts in the literature of individuals and offices that have made the switch and learned valuable lessons doing it. Their advice is free and available. (6) It’s clear that with the push from the Federal Government paper charts will soon be a thing of the past. CMS will financially penalize anyone who doesn’t keep up. Several authors have reported that physician resistance is one of the greatest barriers to acceptance and initiation of the EMR in the office or hospital, but as others have shown, physicians desire to remain on the cutting edge of quality and safety for their patients. They also can be the driving force behind taking this most important step into the future of medicine.- Beers JB, Berger MA, Medical Error-Sources and Solutions; Session 17 Annual Healthcare Information and Management Systems Society Conference and Exhibition, Feb. 4-8, 2001.
- Berner ES, Ethical and Legal Issues in the Use of Health Information Technology to Improve Patient Safety. HEC Forum (2008) 20(3): 243-258
- Miller RH, et al Electronic medical records: lessons from small physician practices. Accessed at www.chcf.org/topics/view.cfm?item ID=21521 on 27 October 2004
- Shachak A, Reis s, The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review. Jou of Evaluation in Clinical Practice 15 (2009) 641-649
- Harrington L et al, Safety Issues Related to the Electronic Medical Record (EMR): Synthesis of the Literature from the Last Decade, 200-2009 Jou of Healthcare Management; Jan/Feb 2011; 56, 1; ABI/INFORM Global pg. 31
- Baron RJ, et al Electronic Health Records: Just around the Corner? Or over the Cliff? Ann Intern Med. 2005:143: 222-226
Jack D. Bragg, DO, FACOI