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ABA Health eSource
November 2009 Volume 6 Number 3

Electronic Medical Records: Current and Future Challenges
By Gary Gechlik, 1 MD., J.D, San Jose, CA

AuthorAs electronic documentation advances, healthcare providers will face new challenges. Electronic documentation offers many solutions for healthcare providers. The solutions include timely and transparent documentation. Traditional errors such as legibility of prescriptions are likely to disappear. Real time access to the records will likely improve some aspects of healthcare delivery. However, these systemic improvements will come with some social costs. These hidden costs will likely be ignored initially. Electronic documentation changes social relationships. Understanding these complex social relationships helps explain the difficulty in universally adopting electronic medical records.

Electronic Documentation Creates More Accurate Records - Sometimes

For the provider, electronic documentation promises more accurate records. Clearly, electronic documentation solves a historical legibility problem. Legibility has been a frequent source of medical error. In one nationally noted case, a cardiologist prescribed Isordil 20 mg four times per day. 2 The pharmacist misread this as Plendil which has a maximum dose of 10 mg. The patient subsequently took the Plendil as prescribed by the pharmacist. The patient had an adverse reaction and died two weeks later. The legibility of healthcare professionals has been formally studied and supports the commonly held belief that physician legibility is usually poor. 3 Electronic medical records and computer generated prescriptions decrease the communication gap between physicians and pharmacists.

However, a challenge remains when the computerized prescription is not filled out properly. The traditional system of writing a prescription is rapid, portable, and efficient. In contrast, when using electronically generated printed systems, physicians frequently miss terms such as the frequency of dosing or the number of pills prescribed. In such cases, pharmacists confirm the prescriptions directly with the provider. Furthermore, some providers circumvent the electronic system. They refer back to the tradition of written prescriptions, leaving a partial electronic record. This is not uncommon when a patient has an additional request for medication before discharge. In such cases, it becomes impossible to electronically track the change in medication. Other providers relying upon the electronic medical record may make incorrect assumptions regarding whether narcotics were legitimately prescribed. These are common examples where electronic documentation can solve one part of the problem. However, the electronic solution involves a tradeoff in terms of data entry versus direct patient care.

Multiple Real Time Access Improved

Electronic documentation also allows multiple real time access to the same record. This solves a very complex systems issue. Often, multiple healthcare providers must document their assessments in parallel. The technologist is often responsible for the initial interaction including obtaining vital signs, the nurse for a primary assessment, and the physician for a definitive evaluation. Electronic records allow multiple points of access where the medical information is aggregated in real time. In traditional paper system, there is direct access to written data but it is not easily reproduced. Often, healthcare providers are literally "fighting for the chart", and often the charts cannot be found on a timely basis. Consider the common "Code Blue" situation. The initial assessing nurse is often not available and the admitting physician is not present. In these emergent situations, a new team of nurses and an emergency physician often manage the near terminal situation. During a "Code Blue", written notes are simply not useful. The physician must rely first on verbal information such as the presenting complaint, recent changes in medication, and changes in condition. Fortunately, emergency physicians as well as hospitalists are trained to directly respond to emergent threats to life despite limited information. However, in the period of post-stabilization, access to the medical record becomes essential. The complex impression of surgical specialists and medical consultants is often determinative in terms of the treatment pathway. Dictated and electronically transcribed reports remain the most efficient means to read through multiple assessments.

System Improvements v. Social Cost

Electronic documentation offers a variety of system improvements. First, it allows the identification of the various healthcare providers involved in the patient’s care. In the past, it was often difficult reviewing the record to determine the name of the technologist, nurse, or consultant, although the name of the primary attending physician was obvious. Because electronic medical records are keyed to unique identifiers and passwords, the records of interaction become clear. Furthermore, most systems generate automatic time stamps allowing a review of the records. This is very helpful in directly improving patient care, patient satisfaction, and quality assurance. In many cases, despite being assessed, patients wait significantly for medication and discharge. From a systems perspective, the challenge is always the interaction between machines and people. Electronic systems require that the data be entered in real time.

This data entry is not without a social cost. For instance, many nurses resist entering a long medication list electronically. The temptation is to enter "see list". Electronic circumvention is a process of referencing back to the paper system. Obviously, entering a list of twenty medications is a time consuming process. Even with the most advanced systems, the process could take between two to five minutes. Each step in the electronic system tends to add two to five minutes. Subsequently, it becomes apparent that for many patients, the traditional paper system was far more efficient. The problem remains that electronic systems silently compound time. In a 2008 study, only 37 percent of physician time was spent on direct patient care. 4 When electronic medical records were introduced, this fell to 29 percent. The length and quality of interaction with the healthcare provider certainly determines outcomes and the risk of litigation.

From an evidentiary perspective, all electronic systems generate large amounts of metadata that can be searched. Most of this metadata is not very useful. Even electronically generated time stamps do not have universal validity because the obligations of direct patient care must come before real time documentation. One significant challenge is that the electronic record may be legible but not very decipherable. Many documentation systems are "click-based" and generate textual fields. These click-through-systems offer benefits to hospital coders and billing companies but significantly impede quality assurance. Traditional written and dictated charts involve a professional impression that is not easily simulated. While not directly affecting the area of medical negligence, these electronic systems will certainly affect the practice of insurers and administrative agencies. Because of the cost of the U.S. healthcare system, billing issues have become more legally significant than the quality of medical care. Most often, the modern quality of care is uniform because it is pathway driven. The financial relationships of private insurers, state insurance programs, and federal insurance programs demonstrates far more complexity. Considering the national debate on healthcare, very little discussion has occurred regarding healthcare practice. The primary focus has been a discussion of payment whether that is a "public health care option", private insurance reform, or reforms to the employer insurance tax structure. As a direct example, most pharmacy calls are not driven by medical error. In modern practice, the patient wants the prescription to be covered under the insurance plan. The discussion between the pharmacist and physician is not commonly a medication error or a drug interaction. It is most commonly a search for reasonable substitutes that will satisfy the patient through an acceptable co-payment.

Conclusion

In summary, the electronic medical record is a double edged sword. It promises a great deal of improvement and the ability to retrieve records in real time. It comes at a social cost of data entry and social complexity that is often ignored when electronic systems are introduced. There will be some problems like legibility that electronic medical records will solve. Major issues will result from the hidden social costs. It is hard to predict how various providers will react. Some will circumvent the electronic system, whereas others will demonstrate obligatory participation. From direct experience, the real catalyst for electronic medical records is cost containment and revenue capture. It is not clear if these economic drivers will directly improve patient care. Given the high social costs of data entry, electronic medical records can paradoxically decrease the quality of care leading to adverse outcomes and litigation.


1 Gary Gechlik, MD.,J.D. attended Stanford Law School and practices Emergency Medicine in San Jose, California.
2 Vasquez v. Albertson 3, Inc., No. A-103,042 ( Tex., Ector County Dist. Ct. Oct. 19, 1999).
3 Ronan Lyons, Christopher Payne, Michael McCabe, and Colin Fielder, Legibility of Doctors’ Handwriting: Quantitative Comparative Study, BMJ, September 26, 1998 at 863.
4 Phillip V. Asaro and Stuart B. Boxerman, Effects of Computerized Provider Order Entry and Nursing Documentation on Workflow, Acad Emerg Med. 2008;15:908, 915 (2008).

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