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with Rod Moser, PA, PhD

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Wednesday, April 20, 2011

Electronic Medical Records (EMRs)

The United States government is behind it 100%. Insurance companies and accrediting agencies are giving monetary incentives for health organizations to convert to electronic medical records. No longer will medical care be hampered by illegible doctor scribbles or lost or misplaced charts. Lives will be saved. Money will be saved. Time will be saved. Electronic medical records are a win-win situation. Or, are they?

Our office converted lock, stock, and barrel into EMRs years ago; so long in fact, that I can’t remember not doing it. At first we were suspicious, having used the old paper charts religiously for decades. What was their underlying motivation to do this? It had to be money.

There was a time that I dictated all of my medical records. I would pick up the dictaphone and rattle away. Several days later, I would get a huge stack of transcribed medical records that I would need to review, sign, and have placed in the paper chart. Sometimes, the patient would come back with a worsening condition while the records were in transcription, so we would have to solely rely on our memories to recall what we did. Sometimes, the transcribed dictations were wrong. The transcriptionist may have heard it incorrectly, we may have said it incorrectly, or we were so tired that we just mumbled something and expected her to figure it out.  We were legally required to read them, but I can tell you that most of the time, we just signed them, trusting that the transcriptionist got it right the first time.

We could rattle of completely “normal” exams with the speed of an auctioneer. An annual pap smear is an example. When I got to that section to dictate, I would go into speed-mode: “External genitalia and introitus is normal; no lesions, masses, or protrusions, etc. etc.” One time, instead of “external genitalia” being typed, it came back “excellent genitalia”! This is not something you want to put in anyone’s chart. I didn’t notice the typo and I signed it, much to the amusement of my colleagues who read it. There were hundreds of other errors.

After a busy day in the office, those paper charts would pile up high on our desk. We would come in early the next day,  try to remember what we did and make our notes. The longer the period of time from seeing the patient to doing the notes, the worse it became. One unnamed clinician in a former practice used to take the charts home to work on them. When he quit, it was discovered that he had thousands (not an exaggeration) of unfinished charts stashed in his house. This was not unlike the lazy postman who stashed mail in his garage instead of delivering it.

When I worked in the ER at an Air Force base, an airman was court marshaled for throwing unfiled lab reports and charts up into the crawl space of the medical record room ceiling so he wouldn’t have to file them. He got away with it for about a year, as he denied knowledge of missing charts, missing lab results, etc. It all came to fruition one day when the ceiling caved in from the sheer weight of the charts he was chucking up there through a missing ceiling panel.

In order to cut costs, we were told that our group could not longer afford several hundred thousands dollars a year in transcription fees. We had to go back to hand-written charts. Not to brag, but I gave up cursive writing back in junior high when I developed highly legible and fast printing skills. No one had difficulty reading my notes, but I sure as heck had nothing but trouble reading the chicken scratches of other clinicians. We would usually have the pharmacist, someone who is an expert at bad handwriting, to read them for us, or have the doctor’s medical assistant do it. Some notes were so illegible, that we simply ignored them. I shudder to think what I may have missed because of someone’s careless penmanship.

When our group adopted EMRs, we were not happy. Most of our satisfaction had to do with the fact that we now had to type our entire medical records. Sure, we could develop normal templates (like my normal pelvic examination), but for the most part, we had to type it out. For those of us who actually knew how to type, it wasn’t a major problem, but for doctors who used the “hunt and peck” method of typing, this was going to be a long and painful learning curve.

Doctors started abbreviating everything, even making up their own abbreviations that only they understood. They misspelled words, stopped using sentences, and made their brief, cryptic notes look like a three-year old spy wrote them. I have seen chart notes that consisted of only two words: OM, Amox. Translated, that means “otitis media, amoxicillin“, but I have no idea which ear or how much amoxicillin was given.

I learned to type on a manual typewriter with blacked out keys. My typing teacher, clearly a former prison guard, would walk up and down the aisles, smacking us on the hand or top of the head if she caught us looking down at our fingers, or God forbid, trying to erase a typo so we wouldn’t have to re-type the entire page. To this day, I blame my enlarged knuckles on that nasty woman, but the bottom line is that I can type relatively fast and accurately.

With EMRs, we can instantly see our notes, lab reports, actual scans of x-rays, records of phone calls, messages, etc…all at our fingertips. We have terminals in each exam room and at our desk. For those who are geographically blessed with fast Internet at home, we can basically access medical records from anywhere in the world. I am not one of those lucky ones, so I have to stay late most nights and finish my charts.

A big bugaboo for all of us is the passwords. They change so often that we tend to forget them over a weekend. They have to be a complicated string of gibberish so that hackers cannot crack the code. Basically, if you can remember your password and accurately enter it the first time, it is probably too easy and the computer nerds will consider it an invalid password. In order to access a medical record, I have to go through two or more password layers before seeing a chart. If I have to answer a phone or go in and see the patient, I am logged back out in just a few minutes, and have to do it again.  No sooner than you finally learn your passwords, you get a notice that you have to change it again; and again. Since I have a bit of short-term memory, it is not unusual for me to forget a new password on the same day!

For the last month, I have not been able to work due to medical problems. My already-overworked colleagues are not happy about picking up the slack, even though they would not trade places with me. Recently, someone logged in my work computer as “me”, to snoop around in my electronic medical chart. An investigation is underway, so I am sure they will catch this person sometime tomorrow. Since it is a big no-no to actually look in your own chart, they assumed it was me. The only problem is that I was at home, twenty-five miles away, when I apparently logged in at work. Someone must have looked over my shoulders at some point and memorized my passwords. This is really the only logical explanation, since I sure didn’t give them out to anyone. I don’t even remember them myself now. I am afraid to write passwords down, too.

If they really want computer security, they are going to have to install biometric methods, such as fingerprints or iris scans; otherwise it does not appear to be very difficult to get into unauthorized medical records.

I don’t really have anything medically to hide, but the idea that someone in my office logged in as me, and had a good old time reading all of my assorted medical records infuriates me.  Having someone snoop in your medical records is like someone breaking into your house and nosing around, or hacking into your home computer. If they want to know about my ureter stone and surgeries, they can read my Webicine Blog like the rest of the world.

Posted by: Rod Moser, PA, PhD at 12:13 pm

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