I found this article today that makes one take a second look at the push towards EMR…

Make Mine Paper

From Medscape Business of Medicine, 10/02/2008

URL: http://www.medscape.com/viewarticle/580753?src=mp&spon=21&uac=11326CN

#1 Dinosaur, MD

The earth is flat.
Girls don't understand math.
Electronic medical records improve the quality of medical care.

Each of the 3 statements above shows that repeating something often enough doesn't make it true.

In the Beginning

Back when I started my solo practice, there was no such thing as an electronic medical record (EMR). Computers were still big, bulky, expensive things mainly found in large universities, surrounded by dot matrix printouts on oversized paper with perforated strips along the sides to feed it through the printer. Hospitals had computers, too, but used them mainly to manage orders for drugs and studies. No one but the unit clerks and some of the night nurses knew how to work the esoteric program, though. All the medical record keeping was done by hand: good old pen (blue or black) and paper, usually 8.5 in by 11 in.

When I first set up my practice, there was no reason to consider anything other than paper charts, although there were still plenty of decisions to make about my charting system. I went with color-coded folders instead of an alphanumeric labeling system. I decided how to arrange the items within the chart (progress notes, labs, x-rays, and correspondence). The best decisions I made were to ensure that the patient's name and birth date appeared at the top of each progress note page, and to use the inside front cover of the chart as an ongoing problem list, including medications, allergies, and preventive care tracking. Lab and x-ray results are easily filed. Correspondence from specialists -- all on 8.5-in by 11-in paper -- goes into the chart just as easily, creating a nice, neat, compact patient record folder. After almost 20 years, my system is still working just fine.

Why Switch to an EMR?

Nowadays the big push is for computerized EMRs. All I can say is, "Why?"

"They produce records that are more legible."

No better than my calligraphic handwriting. My charts have been reviewed many times: by QA nurses, insurance flunkies, and lawyers. No one has ever complained of not being able to read my handwriting.

"They produce records that are more organized."

No better than the inside front cover of my chart, where each patient's complete past medical history, family history, and medication and allergy history is on view whenever I lay the chart open on a counter. Each note is written the same way each time. Phone calls and medication refills are systematically documented. Any given piece of information is easily found in every chart, every time. All of those same reviewers with no complaints about legibility have also praised the organization of my charts.

"They're more complete."

Says who? Check the inside cover again and see that preventive care flow sheet at the bottom. Pap smears, mammography, immunizations, colonoscopy: I check every time I open a chart, whether for a visit, phone call, or prescription refill, and I use every one of those opportunities to get people caught up on preventive services.

"They save time."

Like many skilled primary care physicians, I manage to take notes while eliciting the history. Most of the time, my documentation is complete by the time the patient leaves the exam room -- all without worrying about a computer screen coming between me and my patient.

"They improve payment from insurers."

Not unless you enter extraneous information that isn't needed to manage a particular problem, such as documenting a detailed history and physical on a patient with a cold just to bill a level 4 visit instead of a level 2 or 3. I have no trouble appropriately documenting level 4 visits by hand; an EMR is not going to help me get paid for them. As far as "pay for performance" programs, the numbers of dollars actually available through current initiatives are laughably limited.

"They improve performance."

Performance of what? As measured by whom? The usual example trotted out is something like, "How many of your diabetic patients have hemoglobin A1Cs under 7%?" Who cares? I do not take care of populations; I take care of patients, one at a time. Being able to say "87% of my patients are at goal for LDL" is a completely meaningless exercise for me.

Not Yet Ready for Prime Time

At this point in time, EMRs still have major limitations.

Until there is a single, interoperable system in wide use, EMRs will never have the portability and versatility of paper. Just imagine the chaos that would result if doctors' offices used 8.5-in by 11-in paper for their charts, but hospitals all used legal-sized paper; labs reported their results on 4-in by 6-in cards, and x-rays were reported on 5-in by 8-in slips. Trying to keep all of those different sizes and shapes of paper together in 1 folder would be a nightmare. Now multiply that several hundred-fold.

The fragmented market of EMR suppliers isn't just as simple as PC vs Mac; there are hundreds of vendors selling different systems, each of which works differently and none of which are capable of interacting with each other. The only way to transfer records from one system to another is to print it out on paper and then scan or manually re-enter the information into the other.

Even if I were to take the plunge and invest in an EMR system, there would still be school, camp, drivers', and sports physical forms; notes for work and school; patient bills; referral letters, certificates of medical necessity for durable medical equipment; the list goes on and on. The EMRs promise of a "paperless" office is as distant as ever. It's much easier to keep my efficient, time-tested paper charts than lay out thousands of dollars for hardware and software that aren't going to save time or money, or make a single substantive difference in the care that I deliver.

It's not that this dinosaur doesn't appreciate the advantages of living in a computerized world. However, after a careful evaluation of the present-day pros and cons of EMRs, I still say, "Make mine paper."