Wednesday, March 02, 2005

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 (

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.


Blogger Phil Marrow said...

The rather large entity for whom I work will also switch to EMR in the coming months. I have the same trepidation about data loss or system crashing (as will happen at times). I think the loss of eye contact and focus on the computer instead of the patient is just as problematic when patients already feel like interlopers in the exam room with some providers. The loss of data to outside sources is no different than losing them to an unscrupulous medical records clerk. Or the records that are constantly misfiled. How about the charts that are simply stuck in the file room anywhere only to sucked into that black hole that we all know exists "down there"? The templates are there to facilitate the note, not supplant the brain and be a cookie cutter exam. Our system has (by way of preview) a method of adding or subtracting from any template on which we write a note. By the way, I saw where a physician wrote a note weeks later for a day in question when it was noted that he had made no entries for his rounds (he was caught). As of now we rarely get the chart of the patient that we are seeing for a scheduled visit or see for what the consulting physician was sending the patient to our clinic. I have my reservations. But I'm willing to give it a chance (I have no choice in the matter). P. Marrow.

March 02, 2005 10:36 PM  
Blogger Phil Marrow said...

The article to which you link states that "since coming on line in 2001, the [system] has prevented 99,000 potentially life threatening drug interactions." What is the usual rate of improperly written prescriptions within the civilian population? Is 25,000 per year an unusually large number for wrong medications (remember it didn't say a wrong dose or number). Has that number increased since PAs have started writing (use whatever euphymism you wish) prescriptions? P. Marrow

March 03, 2005 8:22 AM  
Blogger chargemaster said...

At my hospital and clinics we call them IMRs (Internal Medical Records). So far they have been of great use for people off-site in clinics and such. But their main use I believe is for easier storage of records and such for HIM.

As for privacy issues, everyone in the health industry needs to follow HIPAA standards for privacy issues. As far as I know there are some pretty hefty fines and possible jail time for breaking these rules.

Here is the HIPAA website:

In the future, I believe EMR will vastly improve health care by getting answers and information faster. But the current problem is that programs set-up now by individual hospitals do not communicate with each other. If you want to make a lot of money, be the first to create a system everyone can use.

March 09, 2005 2:50 PM  

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