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Your Voice: EHRs can’t replace face-to-face patient care


EHRs, physician shortages, patient records are the latest topics of discussion in this issue's Your Voice.

Elizabeth Pector, MD, regrets that electronic health record (EHR) interoperability is sub maximal. (“An interoperability report from the field: It’s not pretty,” October 10, 2015) That prevents the flow of continuity of care documents and hence clinical usefulness.  She ascribes this to those who insist on using old technologies such as “Egyptian papyrus” and even ‘facsimiles.”
I am, however, perplexed. All doctors, even technomanics, are heavily besieged to practice EBM (evidence-based medicine) and we should. EBM is based on clinical studies, either randomized clinical trials, or retrospective studies.
But there are few studies for EHRs. So would it not be instructive and useful, if the profession had a large study, 100% interoperable with CCD’s, over many years using a large cohort?  That would prove that EHRs lower costs, and improve morbidity and mortality (M&M).
But we are in luck. There is such a study–retrospective–35 million people over three years, in my native Canada. And did it reduce M&M? Nope. But it did save a lot of money–$750 million. But that is only 0.2% of all medical spending in Canada.
So Canada presses ahead with the folly but at least has made EHRs optional, except in hospitals. And so has Western Europe, including the UK after spending billions on interoperability, CCDs and other acronymic addictions.
So once again the U.S. insists on mandatory EBM but not EBSM (evidence based social engineering.) In return for such folly the technomanics have again conned the profession into another Trojan horse.  The winners are the EBCPV, (ecosystem of bureaucrats, coders, publishers and vendors).
The losers, once again, are physicians who are forced to spend billions on systems, and of course, lose more autonomy. And above all, the sacred patient/doctor interface is further dehumanized by morphing doctors into sterile wedges.


But there is hope for Dr. Pector and real clinicians.  It is the mother of all acronyms, TAHBLATTOTD (taking a history by listening and talking to other treating doctors.) It was a technology developed by an ancient teacher – Sir William Osler. It is accomplished by two simple actions:
1) Sitting face to face, rather than face to keyboard, with a live subject and talking and listening.
2) Using a device called a telephone. It’s very simple. And it has great advantages over the other EHRs. It is hack resistant, HIPAA compliant, costs much less than $50,000 per user, seldom needs IT repair, is user friendly, interoperable, portable, and reaches all 50 states in real time.
Above all, it excludes about 95% of the vapid, useless information in current EHRs. It is also Osler compliant: “observe, record, tabulate, communicate use your five senses.  Learn to see, hear, feel, smell and become expert” (ancient adage, circa, 1920).
I am far from being a Luddite but the current infatuation with EHRs to the exclusion of all else borders on lunacy. It should not and must not subsume clinical medicine.  It should augment and not replace face to face.  Such is rarely mentioned in articles by technocrats.
Unfortunately  the combo probably won’t catch on. It prevents profiteering by EBCPV. So the profession will absorb this latest Trojan horse fostered upon us by those who created 40 years of acronyms “HMO, PPO, HPS, DRG, RPR, PQRS, MU, etc., none of which have slowed costs or improved much care.
Which reminds me, in keeping with Dr. Pector’s theme, of another ancient papyrus.  It is an observation although non-Egyptian – “there is no new thing under the sun” (Ecclesiastes 1:9, circa 300 BCE.)

Calvin Ennis, MD
Pascagoula, MiSsissippi


APRNs can help relieve physician shortage

In any discussion of scope of practice (“Moving the conversation forward on scope of practice,” November 10, 2015) it is important to consider how the role of the traditional primary care doctor has changed.  
Many primary care doctors no longer take care of hospital or nursing home patients. Many no longer do office surgery or pediatrics. These doctors have had to limit their practices in response to the heavy load of administrative duties and coordinative functions that have become routine in medical care. They refer many of their complicated cases to consultants.
So it may be argued (against those who say that the longer training period of a doctor better prepares them for primary cares than a nurse practitioner) that the longer training is no longer needed.
In this context a well-trained nurse practitioner is capable of providing many of the primary care services that are now provided by doctors. Of course in some rural areas some general practitioners provide a wide array of services because no specialists are available. But this is unusual.
Although some APRNs will work in a collaborative practice with MDs, there are others whose training and confidence will move them towards independent practice.
The point is that there are not enough primary care doctors around and already APRNs have rights in over 20 states to practice independently. Once requirements for CME are worked out by boards of health for licensure, APRNs will become a respected part of the primary care workforce.

Edward Volpintesta, MD
Bethel, connecticut



Physicians, too, have a claim on patient records

I understand the point that Dr. Scherger is attempting to make regarding ownership of records. (“Medical records belong to patients, period,” December 10, 2015). However, significant monetary costs and amounts of man-hours of work are put into the compiling and creation of these records. With the massive increase in costs to providing care in an electronic era, combined with ever-decreasing reimbursements our current model is difficult to sustain.  
If he is so adamant about patients owning these records that physicians are mandated to invest in and create, then possibly the patients (or insurance industry) should play a bigger role in paying for the process by which these records are created. In a way, the records have become intellectual property of the originating physician and could be treated as such on a purely economic scale.  

Chad Diamond, DO
Hattiesburg, Mississippi


I just finished reading Dr. Scherger’s “First Take” article in the December 10 issue of Medical Economics, “Medical Records Belong to the Patients. Period.” Actually, the physical ownership of a patient’s medical record is very straightforward.
1. First of all, who wrote the check for the computer hardware and software containing, processing, and storing the EHR?
2. Who pays the salaries of those generating entries into the record?
3. Whose words are contained in the record, or who marked the boxes in the templates?
4. Who writes the check for the licensing updates, web storage, etc.?
5. Who gets sued if the privacy and confidentiality of the records is not protected?
Certainly the patient is not writing the checks for these things, so the patient is not the owner, so the patient does not legally possess the record. It is generally the physician or health system who writes these checks. Therefore the medical record belongs to the physician or health system-not the patient.
These are my opinions formed by not only the medico-legal courses I took in medical school, but also medico-legal seminars I have attended during CME and professional meetings.
Thank you for taking on these issues in your publication.

Gregory J. Kosters, DO, FACOFP
Sibley, Iowa

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