Sequel to Automated Malpractice and Digital Dishonesty, the first in a series dealing with the disaster which has befallen our health care system.
The single, most powerful tool employed by every physician in the care of patients is the medical record. It is the tool that impacts the care of every single patient. It is the tool that makes difficult diagnoses possible. It organizes and makes possible treatment modalities of every type. It allows collaboration between multiple health care practitioners. It prevents redundancies, harmful treatment interactions, errors in therapy. It makes possible quality improvement. It is the basis of clinical research and the datum upon which discoveries are made and ineffective treatments eliminated.
The medical record is the fundamental instrument of all patient care.
Take away the medical record and you might as well eliminate the use of antibiotics, of vaccines, of anesthesia, of blood typing–because every aspect of these treatments and their safe implementation requires an accurate, accessible medical record.
We are currently in the process of destroying the patient medical record as an accurate, dependable tool in the care of patients. As a direct consequence of our current actions, patients are being harmed. Quality assurance programs are being compromised. Future research will be flawed.
This phenomenon is being witnessed across every aspect of medical practice and in every patient care venue in this country. It is being experienced by every physician, nurse, and allied health care provider. It is incontrovertible. It is, quite simply, a national disgrace and a health care emergency.
The previous system of writing notes and orders with a pen in a paper chart was flawed, of course. It had the drawback of being, on occasion, uninterpretable. This led to errors. It had the drawback of being difficult to access. This led to inadequate communication, redundant testing, inadequate treatment. There was a definite and defined need for a better system. No one would argue differently. The new system needed to be:
i. accurate, ie., legible
ii. accessible to all patient care providers, including physician offices, emergency departments, hospitals, clinics, researchers, auditers
iii. systematically better than a bunch of pieces of paper stapled together: that is, it should intrinsically avoid dosage errors, medication conflicts, redundancies, etc.
Obviously, the new electronic medical record should be better than paper. Paper required health care practitioners in the form of nurses, PA’s, and pharmacists to interpret a physician’s desires and catch our mistakes before they reached the patient. If I ordered an antibiotic for a patient and the patient had a history of allergy to that antibiotic, a key patient fact that I was not aware of at the time of treatment, I relied on a clinically astute nurse or a pharmacist with the patient’s allergy flag to catch it and stop me before I injured the patient. Obviously, this was a problem, because some nurses and pharmacists, just like some physicians, are more experienced, conscientious, knowledgable, and savvy than others. Better to have a system that automatically and consistently checks every order against the patient’s documented record for such a life-threatening conflict.
The intent, at the national/governmental level, was to create and mandate the implementation of just such a system, a system to address the known failings of the existing paper-based system and improve patient care. But the reality rapidly superceded the intent. Through a tortured labyrinth of governmental committees and corporate boardrooms, we allowed the private, profit-motivated sector to leap into the gap between good standards and mandated implementation. In retrospect, we all should have seen this coming from many miles away. A government mandate that would require the purchase of a product by every doctor, hospital, and clinic in America? How much was that worth? Obviously, a great deal. So why wait for standards? Why develop a good system, a worthy product, when we can beat the competiton and sell a cheap, untested, poor product and require these guys to buy it whether they like or not, whether it works or not, even if it’s intrinsically dangerous?
Which is how we arrived to the point we find ourselves at now. Hospitals, physican practices, and clinics have been forced to expend millions of dollars to purchase poorly designed electronic medical record systems. Physicians across the country are now required to spend dozens of hours training up on a variety of unstandardized systems. They are required to become facile in the care of patients utilizing deeply flawed instruments that do not approach the minimum level of quality to allow safe patient care. The problems exhibited by the current state of the governmentally mandated art range from the simply irritating, to the amazingly stupid, and all the way to the point of the systematically murderous. I do not exaggerate. Allow me to provide examples:
The simply irritating: Each hospital at which I care for patients has its own brand of electronic medical record (EMR). Each EMR requires a unique user name and password. But some of these hospitals also have a separate system for charting in their Emergency Department. Many have a separate system to access electronic ordering, or another system to view radiology images, and another system to complete medical records, and yet another system to access labarotory results. Additionally, a separate system exists for electronic prescribing (also mandated), not to mention the required State Narcotic Abuse Database Access, also with a unique user ID and password. None of these systems, user names, or passwords are centralized or mutual in any way. And in the name of patient security, every one of these systems requires that I change my password every thirty to ninety days. But not in the same thirty day cycle. And not to anything that remotely resembled my previous password. Which leads to the constant juggling of multiple passwords with no chance of providing anything near efficient patient care. Maddening.
In those practices that require efficient clinical care, the implementation of the EMR has been uniformly disastrous. Patient office visits are now characterized by a screen interposed between the patient and the clinician, eye contact being a thing of past. Documentation is terse, inadequate, and often plain untrue. Most opthamologists and many other physicians have been forced to hire a new category of health care worker, the EMR documentician, to follow behind the physician and enter information into the computer. This has led to enormous additional expense and a new avenue for inaccuracy. I routinely hear from my colleagues how they have to spend their evenings at home doing EMR documentation from the patients that they saw during the office hours earlier that day, as if anyone could expect to recall the subtleties of dozens of patient interactions six hours later. Simply insane.
Amazingly stupid: Two of the hospitals I work in utilize the Allscripts EMR system. This system features the amazingly stupid feature of not superceding previous orders when such a feature is obvious and required. The diet order is a case in point. When a physician enters a diet for a patient, the previous diet order should be stopped. But no, this is not the case. So my patients routinely have several, conflicting diet orders running contemporaneously. I have discussed this on over a dozen occasions with the IT department, the physican IT laison, and presented to the IT/Patient services committee. No patient, I explain repeatedly, ever needs more than one diet at a time. They all patiently explain to me that such a change is not possible in this system. So my patients routinely receive trays for clear liquid diets, full liquid diets, regular diets, specialty diets, all at the same time. We depend on the dieticians to sort this all out on a daily basis. The waste in effort and food, not to mention the costs associated with cancelled procedures and the morbidity of inappropriately administered diets, is intolerable, but apparently unfixable with the current state of technology.
Systematically murderous: As I have mentioned, the key to good medical care is the conscientious application of patient information to allow informed decision making. The old system of paper charting was deficient in this aspect. A new, electronic system, should permit artificial intelligence applications to prevent many common errors, such as administration of inappropriate medications, wrong dosage, or duplication of treatments or testing. The system should be designed to enhance patient care and safety. Instead, we have a system that actually decreases patient safety and requires constant vigilance on the part of all health care providers to prevent system-incurred errors. This is the exact opposite of what is needed and appropriate, but it is happening constantly. In the postoperative setting, needed DVT prophylaxis medication is often ordered, but the system fails to reliably discontinue the same prophylaxis order from the preoperative period. This results in two or three doses of the blood-thinning medication arriving on the floor for administration to the patient. Usually, the nurse is sharp enough to detect the duplication and send the extra doses back to the pharmacy, but if there has been a shift change or breakdown in communication, extra doses may be administered with resulting complications. The system must be designed to make us better, not require us to police new, intrinsic challenges to good patient care. The current situation is unacceptable.
Not to mention, medicolegally compromising: One of the nationally implemented EMR systems fails to close out patient encounters when the patient is discharged. This leads to the occasional situation wherein a treating physician accidentally places multiple orders into the system for a patient, not realizing that the orders are being entered into a patient encounter that is no longer appropriate. There is no systemic prevention for such an error. So in the middle of the night when an emergency patient requires admission to the ICU or is to be taken emergently to the OR, dozens of orders are entered, but not implemented. The physician is told that his orders are missing, so he or his associate/resident/PA re-enters all the orders. But now there exist a slew of orders added to a past encounter that were never acknowledged or administered. Lord only knows what will be made of that when the chart is eventually reviewed for quality or legal concerns. Good luck with that in a court five or six years after the occurrence.
What is obvious from the foregoing tirade is that the current implementation of the mandated EMR fails to meet the minimum requirements that I laid out in the beginning of this post. It is legible, but it is inaccurate. It is not accessible, due to a complete lack of interoperability standards. As a system, it fails to improve patient care, but rather introduces an entire new class of systemic challenges to good, safe patient care. The current system is simply unacceptable. In the next post, we will discuss the remarkably simple solution to the current situation.