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It's critical that developers or purchasers of electronic medical records systems consider more than billing function.
I fear, however, that if we don't look at the negative side of EMRs during all the hoopla, we might lose something very critical. In my field of internal medicine, patients often have multiple medical problems, multiple medications, and vague, but potentially serious, symptoms. A narrative, detailed patient history and careful physical examination lay the cornerstone for a thoughtful impression and formulation of a differential diagnosis and plan. Nuances of description discriminate among diagnoses and the urgency needed for the workup.
Checkboxes may indicate what symptoms or findings were present, but they are uniformly lacking in clinical detail. Boilerplate templates initially look organized and comprehensive. Seeing the same phrasing over and over again from the same medical group, however, makes me wonder whether these exams were even done. The detail of the physical exam, as judged by the checks, far exceeds the detail and accuracy of the history of present illness. Did the orthopedist really examine the patient's fundi? An internist told me that an outside EMR report on his patient noted mild pedal edema. He was skeptical because the patient had bilateral below-the-knee amputations.
It's much like what a neurologist told me about his experience with spell-check programs on his computer: they're useful, but he's noticed that his spelling ability hasn't improved after viewing the computer's corrections. Somehow, we've allowed the shortcuts to dull our thinking.
When all you see noted about a patient are a series of checked or unchecked boxes, how do you get a sense of what the patient looked like or was feeling? How do you encourage doctors to ask open-ended questions when they are assigned checkboxes to fill in?
I've seen a survey showing that doctors who trained with EMRs were later uncomfortable working in facilities without them. Does that suggest that they can't organize their thinking without them or record a patient's history and physical exam, along with an impression and plan, without the boxes? Can we still add, subtract, and divide without a calculator? I have no objection to double-checking one's work with technology, but it shouldn't be a substitute.
Doctors have complained to me that they have difficulty opening up pages in their EMRs during patient visits. As a result, they concentrate on the screen. Patients complain that their doctors spend more time typing on the computer and looking at the screen than looking at them.
I know EMRs are here to stay. I'm arguing that we ensure that we don't end up with GIGO - garbage in, garbage out. Soon, we'll forget what a detailed history and physical exam look like. Can doctors explain to juries what they were thinking based on checkboxes and terse diagnoses? It's critical that developers or purchasers of EMR systems consider more than the billing function of the system and spend more effort choosing systems that address these shortcomings.
Howard Homler, MD, is an internist in Sacramento, California. Send your feedback to firstname.lastname@example.org
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