The Electronic Medical Record and a little note about illness as memory
First, a couple months ago I wrote an essay titled "Illness as Memory". Originally, I thought the idea was so compelling that it should be a book, but the energy to do the research for a project that big has not welled up in me, yet. But the idea is alive. Today, on the website QuantaMagazine this article appeared: https://www.quantamagazine.org/stem-cells-remember-tissues-past-injuries-20181112/. Stem cells may have memories of previous injuries and how to fix them. These memories may give rise to a variety of autoimmune diseases. If my essay interested you, I suggest you take a look at this link.
Another theme in several of my posts has been the harm done to the profession of medicine by business people. In a recent New Yorker article, Atul Gawande, writes about the electronic medical record program EPIC. Here is the link: https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers.
And here is my take on this issue. But first I want to back up a couple decades. When doctors hand wrote their patient's charts, sometimes they were hard to read. This was a problem for other doctors who needed those notes to evaluate the same patient for a new problem or if they were taking a fresh look at an old problem. For this reason, it made sense to doctors to dictate their notes and have them transcribed into legible type and, with the age of computers, digitized. The businessmen thought this was a good idea too, but not because of the patient care advantages, but because of the billing advantages. Most medical insurance payers wanted to know what they were paying for. What did the doctor do to justify this charge? So insurance companies, Medicare included, began to list the criteria they expected to see in the record to justify paying. The more the doctor did, the more he was allowed to charge. If he asked questions about fourteen body systems he could charge for a "full review of systems". It was quicker to say all this than to write it. So when dictation came about, the doctor could speak fast and get paid more because the transcribed note was filled with a lot of details he might skip over if he was obliged to write everything long hand.
The business people loved dictation and it spawned a whole new department in hospitals - the medical dictation department. Doctors bought in because they had charts that could be read by their colleagues and they made more money. And so did the business people.
The electronic medical record grew out of dictation and for the same reasons. It was justified by the businessmen who run hospitals, some of whom are physicians, by saying it would reduce duplication of services, reduce errors, and make records transferable from one system to another if the patient changed health care insurers or providers. I know of no studies to document that any of these benefits has come to pass.
You may think, from what I have said, that I am against electronic medical records. In their current state I believe they are a failure from the standpoint of patient care and a success from the stand point of increased billing for patient care. The businessmen have gotten what they want at the expense of the patient-physician relationship. An electronic medical record could easily serve both patients and doctors and, possibly, the business interests but it will need to be much more sophisticated.
The medical research literature, so far, shows little improvement in patient care after the introduction of the electronic hospital record or the clinic based electronic medical record. These systems cost hundreds of millions of dollar to install and train practitioners to use. The question is should physicians be using these tools at all if there is not evidence they improve the quality of the care delivered. Reading Dr. Gawande's article, one might conclude, that in fact, these tools have harmed the patient-physician relationship. This brings up the question, if this is true, should physicians use these system at all. Physician would not give medication or surgery to patients without some objective evidence that the medication or surgical procedure was beneficial. Yet the implementation of these expensive and intrusive record keeping systems have been forced on many health care providers without evidence to support their use.
Perhaps in the near future we will have Alexa in the patient care rooms with us along with a video camera to record the entire patient-physician encounter. Then, an artificial intelligence program will analyze the encounter, transcribe the pertinent parts, and create a clear, concise, summary of the visit and its outcome. This would take the keyboard out of the room and let the doctor focus on the person in front of them. We haven't arrived at this kind of system yet. Until we do, we will all, I guess, need to put up with either our doctor keyboarding as we talk or another person in the room keyboarding as our doctor talks to us. Should we have instituted this kind of system? Should technology be used just because it can be? Or should it be used only when it produces a measurable improvement? I think the later, personally. Too much technology, especially digital technology, is used simple because it can be, spending hundreds of millions if not billions of dollars on systems that have not been proven to improve anything except billing efficiency.
Hopefully, the time will soon come when the details of the patient-physician encounter is recorded and summarized without destroying what is left of this delicate relationship. It is time to make outcomes the bottom line rather than incomes.
Another theme in several of my posts has been the harm done to the profession of medicine by business people. In a recent New Yorker article, Atul Gawande, writes about the electronic medical record program EPIC. Here is the link: https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers.
And here is my take on this issue. But first I want to back up a couple decades. When doctors hand wrote their patient's charts, sometimes they were hard to read. This was a problem for other doctors who needed those notes to evaluate the same patient for a new problem or if they were taking a fresh look at an old problem. For this reason, it made sense to doctors to dictate their notes and have them transcribed into legible type and, with the age of computers, digitized. The businessmen thought this was a good idea too, but not because of the patient care advantages, but because of the billing advantages. Most medical insurance payers wanted to know what they were paying for. What did the doctor do to justify this charge? So insurance companies, Medicare included, began to list the criteria they expected to see in the record to justify paying. The more the doctor did, the more he was allowed to charge. If he asked questions about fourteen body systems he could charge for a "full review of systems". It was quicker to say all this than to write it. So when dictation came about, the doctor could speak fast and get paid more because the transcribed note was filled with a lot of details he might skip over if he was obliged to write everything long hand.
The business people loved dictation and it spawned a whole new department in hospitals - the medical dictation department. Doctors bought in because they had charts that could be read by their colleagues and they made more money. And so did the business people.
The electronic medical record grew out of dictation and for the same reasons. It was justified by the businessmen who run hospitals, some of whom are physicians, by saying it would reduce duplication of services, reduce errors, and make records transferable from one system to another if the patient changed health care insurers or providers. I know of no studies to document that any of these benefits has come to pass.
You may think, from what I have said, that I am against electronic medical records. In their current state I believe they are a failure from the standpoint of patient care and a success from the stand point of increased billing for patient care. The businessmen have gotten what they want at the expense of the patient-physician relationship. An electronic medical record could easily serve both patients and doctors and, possibly, the business interests but it will need to be much more sophisticated.
The medical research literature, so far, shows little improvement in patient care after the introduction of the electronic hospital record or the clinic based electronic medical record. These systems cost hundreds of millions of dollar to install and train practitioners to use. The question is should physicians be using these tools at all if there is not evidence they improve the quality of the care delivered. Reading Dr. Gawande's article, one might conclude, that in fact, these tools have harmed the patient-physician relationship. This brings up the question, if this is true, should physicians use these system at all. Physician would not give medication or surgery to patients without some objective evidence that the medication or surgical procedure was beneficial. Yet the implementation of these expensive and intrusive record keeping systems have been forced on many health care providers without evidence to support their use.
Perhaps in the near future we will have Alexa in the patient care rooms with us along with a video camera to record the entire patient-physician encounter. Then, an artificial intelligence program will analyze the encounter, transcribe the pertinent parts, and create a clear, concise, summary of the visit and its outcome. This would take the keyboard out of the room and let the doctor focus on the person in front of them. We haven't arrived at this kind of system yet. Until we do, we will all, I guess, need to put up with either our doctor keyboarding as we talk or another person in the room keyboarding as our doctor talks to us. Should we have instituted this kind of system? Should technology be used just because it can be? Or should it be used only when it produces a measurable improvement? I think the later, personally. Too much technology, especially digital technology, is used simple because it can be, spending hundreds of millions if not billions of dollars on systems that have not been proven to improve anything except billing efficiency.
Hopefully, the time will soon come when the details of the patient-physician encounter is recorded and summarized without destroying what is left of this delicate relationship. It is time to make outcomes the bottom line rather than incomes.
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