Posted by: notdeaddinosaur | August 23, 2010

The Ideal EMR

I love computers. Really, I do. Despite my oft-repeated claims about the shortcomings of electronic medical records in their current form, I do believe that information technology has the potential to be of great help to me and other physicians in providing quality care to Americans.

Stop laughing. I really mean it.

I do not believe, however, that IT best serves the medical needs of our patients when used to create non-interactive silos of information sequestered in the offices and clinics of individual doctors. Even hospitals and large integrated health systems information remains stuck within that system, providing limited utility when patients travel, or even go to a doctor not affiliated with the system. Although some (especially in government) seem to feel that expanding those kinds of integrated systems is the way to go, the problem is that not all patients want to get their care from Mayo Clinic clones across the country. Still, I have an idea for using currently available technology to vastly improve the way medical care is delivered anywhere in this country.

I would like to see a nation-wide database of:

  • every single laboratory test
  • every diagnostic image
  • every immunization
  • every prescription filled
  • every surgical procedure

received by every single person in this country.

Notice what I don’t want in that database:

  • Diagnoses
  • Allergies
  • Hospitalizations (all the labs and images should go in the database separately)

Lots of people come to me or other new doctors wanting a fresh set of eyes looking at their problems, a mindset that cannot be achieved when looking at a list of previous diagnoses. Not every diagnosis is correct. The allergy record is likewise subject to all kinds of mischief. I’d rather have a database available for objective information only, allowing me to put things together myself.

Notice that I’d like to see diagnostic images on the database, not necessarily including reports. What I’d really like to see is the technology advance to the point where ultrasounds and MRIs become significantly cheaper, and then not require a doctor’s prescription for an MRI. Not so with X-rays and CT scans, though. What’s the difference? Ionizing radiation. Keep that under prescriptive control, especially when a national database makes tracking cumulative radiation doses child’s play.

What about all those “worried well” who want MRIs for every headache and knee sprain? I say, let them. No doctor needed. Let everyone pay for all the ultrasounds and MRIs they want. What’s that, you say? You want a radiologist or another doctor — someone with years of highly specialized training and experience — to interpret the images, explain to you what they show, and make recommendations for further medical care? Well now, that’s not “just an MRI”; that’s a doctor’s visit. But if the images are all online, it speeds things up at the point of care.

Many states, including Pennsylvania, are trying to get state-wide immunization registries up and running. The interfaces aren’t user-friendly enough yet to make it worthwhile trying to access them, either to find or to record patients’ shots. Put it into a great big centralized database, though, and let it replace my office record. Personally, I would love to get out of the immunization business. No more worrying about thousands of dollars of lost inventory from a power outage. Make it part of the culture to get shots routinely at public health clinics.

Can you imagine how much time and effort would be saved if everyone’s med list were online? Not every prescription written, just those filled. It would still be helpful to see the actual bottles and go over with patients which pills they were actually taking, plus all their vitamins and supplements of course, but if you could log on to a national database for a current med list, every office and ER in the country would at least have someplace to start.

The nice thing about surgical procedures is that they’re usually permanent. No more worrying about an acute appy on someone who doesn’t have an appendix, or gallstones in an absent gallbladder. I’ve seen gastric bypass procedures and colostomies reversed, of course, but there are exceptions to every rule. Knowing that someone with chest pain had a stent placed two months ago would be quite handy, though.

I can hear the privacy nazis going berserk. “Anyone could find out anything about anyone! It would be a privacy nightmare!!” No more so than the current situation with things like credit reports. The thing to remember is that right now, anyone can already find out anything about anyone any time they want. That’s the key: they have to want to. If someone wants to find out something about you, make no mistake: perilously little stands in their way. Here’s the thing, though: NO ONE CARES!

Look at it this way: if you or someone you loved were in a horrific traffic accident and landed in a hospital far from home, wouldn’t the availability of this life-saving information far outweigh the theoretical embarrassment of someone finding out you were once tested for HIV? Anyone remember the aftermath of hurricane Katrina? Remember how privacy suddenly took a back seat — hell, it went straight out the window — in favor of expediting appropriate treatment for displaced patients. How much of a non-issue would that have been with the existence of this kind of database?

How about this for security: you need a patient ID number and a valid medical license (like needing two keys for a safe deposit box) to access the system. Set the default patient ID to the last 6 digits of their social security number if you want, then let people change it at will. That way they can go to a new doctor and easily cut the old one(s) out of the picture, if that’s what they want. Try to impress on people how valuable it would be to carry their current ID number in a way that’s easily accessible (wallet card; RF chip; medic alert jewelry) in the event that they are unconscious or otherwise indisposed and in need of medical care.

But who’s going to pay for it, I hear you ask. Tell you what: why not use some of that $73 million set aside by CMS to supposedly pay doctors as incentives to adopt EMRs. Don’t kid yourselves; the way they’ve got things lined up now, perilously few of those dollars are actually going to be paid out, at least to individual doctors. Granted, they’ve finally defined “meaningful use”, but the functions described (ePrescribing — dangerous in its present form; communicating with labs and other health care entities) are basically meaningless. Why not use that money to pay for something that would actually help with patient care?

So there you have it. A modest proposal for a truly useful EMR.

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Responses

  1. And the people said, “Amen!”

  2. So let me see if I get you. Here’s what you want –

    – Op notes (I would also add Path reports)
    – Radiology images (I would add with the report, you can always read it yourself if you want, I am not a radiologist)
    – Lab tests
    – Meds – (Please make sure you separate current from previous, and the whole list of vitamins and supplements can get out of hand, but should be included)
    Immunizations – Agree

    No allergies (I might argue with you on that one – I’d rather have an occasional extra wrong allergy that I can correct than have a patient forget to tell me her allergy)

    No doc notes. No diagnoses.

    You’ve left out every good consult report, every well-written summary and thoughtful interpretation of symptoms and differential diagnosis, every psychiatric condition (which has no test to diagnose). You also don’t allow any consultant seeing your patient to read your thoughtful discussion and insight.

    I’m just sayin’……

  3. I like this, but would also like the a list of allergies (right or wrong) for the potential ER/accident patient who can’t tell you.

    With hand patients, office notes or therapy notes can often be as helpful as the op notes.

  4. I love this idea, but I have to think it would cost orders of magnitude more than $73 M to set up. I think you are right in every particular, though I would like to be able to see previous diagnoses.

  5. Right on! Especially with the bit about not needing a script for lab tests and MRIs. Do an ultrasound on your growing baby every day if you want to. You just have to pay for the test. Would have a funny of limiting one’s desire for multiple tests.

    Mrs. Dr. WhiteCoat just started using practicefusion.com for an EMR. It’s free and simple and all web-based. You should give it a look.

  6. I agree with everything except the claim that no one cares about our medical records; our potential employers will as long as we’re getting our health insurance through them. Cancer survivors & people with diabetes and other chronic conditions either drive up healthcare costs or are believed to drive them up and are easily spotted through surgical records, test results, diagnostic imagery, and/or prescription data, so potential employers would be VERY motivated to find this information before making any job offers.

  7. An ideal EHR would enhance productivity through the following ways:
    1. It will save time–time to learn, to document, to intervene, to review
    2. It will greatly eliminate errors–errors of documentation, of decision making and of treatment/intervention
    3. It will enhance communication: caregiver to patient and caregiver to caregiver
    4. It will overall reduce cost of healthcare–both to the doctor and to the patient


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