DoD's Electronic Medical Record

Just an interesting article I saw about the Department of Defense's electronic medical record (EMR). As one could imagine, the logistics of maintaining accurate, up-to-date medical records on a massive and highly mobile patient population is daunting. This system described here is far more all-encompassing and advanced than I'd realized.

There is also apparently significant interest in making some components of the system available for use in the private sector (AMEDNews.com).

I have mixed feelings about EMR's:

Obviously we run into the usual problems of computer security. Digital data is easily examined, copied, moved, transferred, intercepted not to mention maliciously altered. Considerable protections need to be in place to solve these privacy issues which I consider almost intractable.

The software obviously has to be mission-critical ie. it has to be essentially infallible and uncorruptible. Data loss could be catastrophic.

Having ready access to labs, imaging studies, billing data, demographics, pharmacy, etc. at the push of a button is obviously a great and convenient thing. I'm not so sure about the utility of digital progress notes which make up the final frontier of a paperless medical record. I was once part of a group that used a completely electronic medical record.

Each exam room had a computer terminal and while interviewing the patient, we'd be typing on the keyboard. It is the unusually facile computer user (and typist) that can maintain the necessary eye contact and emotional connection with the patient at the same time he's correcting typos. Also, electronic progress notes tend to use a lot of templates (eg. a separate template for backpain) and a lot of "cut and paste".

This tends to diminish the narrative properties of a progress note and eliminate their more improvisational charactor. The result is often a generic note not really descriptive of that particular patient interaction. It is not at all unusual for notes to simply be copies of previous notes.

I once saw a colleague's patient in my office when he was off and I noted a very loud, worrisome heart murmur. All of his previous notes documented the generic phrase "no murmurs, gallops or rubs". Thinking I was dealing with a brand new problem in this otherwise assymptomatic patient, I was ready to send him immediately for a same-day echocardiogram.

I called my colleague at home and he reassured me, "Oh yeah, he's had that murmur for years. We checked it out, echoed him, sent him to a cardiologist, etc. It was nothing."

So much for electronic progress notes.