Over the past year, there has been increasing pressure
placed on physicians by the federal government to adopt electronic health and electronic medical record keeping (EHR/EMR) into their practices.
While this "encouragement" may have good intentions, it is not being embraced by the medical community.
This may be for good reason, and part of that may be the lack of skills among many in the medical profession to properly keep records the "good old-fashioned way" -- and those old-fashioned skills are a prerequisite to EHR/EMR.
Last week, a blog in the Houston Chronicle cited some staggering figures about the Texas Medical Board's announced disciplinary actions against 70 doctors, 12 of whom were in the Houston area alone.
Of those 12, nine lost their licenses, were financially penalized, or are required to attend training because of their lack of proper medical record keeping. Four actions were specifically related to failed record-keeping practices.
And this isn't the first time this has happened in Texas by a long shot -- in November 2009, 75 actions were taken against physicians, and 28 of those were related to improper record keeping.
Hopefully, Texas will set a precedent and other states will start taking a harder look at this issue, especially with the pending incentives to increase the use of EMR/EHR.
I think this points out what I (and many others) have said previously, however: Simply moving from physical-format records to electronic records is not going to improve the quality of diagnostics and healthcare.
It may in fact have just the opposite effect if a physician lacks the skill to capture information in an effective manner. Of note in the recent Houston Chronicle article was the fact that many of those who were cited are being required to attend CME (Continuing Medical Education) training for medical writing.
This begs a question: What training is being developed to ensure that those being asked to create medical records in electronic formats know how to adequately prepare and manage these records?
Further, effective EMR/EHR isn't just about creating good records. There's also the aspect of records management, including:
How files are saved
How metadata is entered
How systems are backed up
How content is protected against accidental or improper access
How systems are restored following a power outage
How systems are protected against a disaster or other emergency
How content is taken offline and/or transferred to others
And the list goes on. Naturally, physicians themselves may not be performing many of these systems management functions, but based on the recent citations by the Texas Medical Board, it appears they are held responsible for the proper record keeping of their offices.
Managing records in electronic formats will place increased burdens on both physicians and front-office staff. These burdens will include learning how to place controls on access and privacy and ensuring the ability of persistent access to a growing volume of data, much of which will be in proprietary formats.
Extensive training will be required for backing up data daily and storing backups in places other than the primary place of business. It also will involve periodic conversion and migration as formats change, since many systems used to generate medical information are proprietary rather than open source.
And this doesn't even consider electronic data interchange with others… But that's a topic for another post.
— Larry Medina has spent 37 years in the Records and Information Management (RIM) profession.
I for one am very pleased that the <a href="http://www.drfirst.com/">electronic medical record</a> is getting so popular. There is a great one I've been using at http://www.drfirst.com that has been hugely convenient for me to use. I recommend that anyone interested try the free demo out and see for yourselves.
The portion of the comment you replied to was related to what happens when the technology takes an unscheduled break. I think we've all seen this happen in offices and businesses- servers fail, communications systems go down, and not everyone has double redundancy built into ensure the "beat goes on".
In electronic medical records systems which are being built and deployed as we speak, there are issues with reliable WiFi connections because (in part) of interference between signals from devices used to monitor patients (medical telemetry), communications platforms (pagers and cell phones), and the tablet interfaces Doctors are using to take their electronic notes. So the assertion that they "continue treating patients and take their notes electronically straight away" isn't always the case.
THOSE were the instances I was referring to when they need to have a bridge, capture things manually and then transcribe it. Power outages due to system overloads (backup generators are provided for emergency lighting and ER/ICU/NICU equipment only), natural disasters that cause power interruptions (earthquakes, hurricanes, tornadoes), and other such instances will occur periodically.
There are many aspects of the medical profession that are concerned about the lack of Standards for interoperability of these systems and protection of data. As the link indicates:
“There are no standards most of the time, and when there are standards, there is no enforcement of them,” the report said. The software industry has plenty of guidelines and best practices, “but in health IT, there are none,” the report said.
Vendors reported that they use proprietary industry guidelines and general software to develop usability.
Among other recommendations, the researchers said that vendors need to adhere to formal user-design methods and to test their EHR designs throughout the product lifecycle with more diverse groups of customers than computer savvy individuals.
... but they will have to continue treating patients, taking their notes on paper, and then transcribing it electronically.
The way it works is: Doctors continue treating patients and take their notes electronically straight away. They also add his comments and recommendations to other doctors who would be in charge of the follow up or recommended treatment. There is no transcription of notes as that would be a waste of time.
Interesting comments Rimman. Your last paragraph can be taken as a summary of the situation. I answer in order to what I can, remember, she studies, I don't. These are my ideas as an observant, and do not represent hers:
Todays med students are in fact so better schooled that almost no one in the faculty or the hospital can follow them technologically speaking. They simply can't communicate with anyone there. In fact, frequently it is them who tell the IT crew of the university how to connect the equipment and get presentations going on.
The issue of backtracking is dealt with as many interviews as possible and feasible. Beyond that, the patient is on its own. And that means you and me, thus, we are on our own for our records. We must get a life, not them.
They are trained on information gathering but the consistency issue is dealt mainly by them. Remember, they are the ones in technology, not the faculty.
As I think, not one of them is concerned with the timeframe you mention. They, I've come to learn, live for today and tomorrow. Past tomorrow... who knows or who cares? Someone must be there then and it will be their problem.
Data management and data protection is a problem for our generation. For them is a fact of life. Some IT should take care of that. They are physicians and they expect someone will manage those things for the institution.
Not one of them takes a note on paper unless there is a serious crisis around. You should take a look into the ER room or the operation room. There are Iphones all around. IPads are entering just now.
My friend, we are amidst a continental divide of change in medicine. Our generation problems and concerns will die with us and luckily maybe someone in our family will try to sue someone for what they consider malpractice. Happily, I hope to be, I won't be there trying to see the outcome of those suits. They will get nowhere and the lawyers, as usual, will get the any available money.
A good question, especially seeing as your information is ka-ching backed! =)
True those entering the field now are much better schooled in the use of technology, but that doesn't resolve the problems they will face when hitting the intern stage in facilities that are not 'wired' or that have a mixed bag, where some departments may be adopting practices of EMR/EHR and others that lag behind.
And as mentioned in earlier posts, when they are dealing with older patients (well, in honesty patients of ANY age) who have a portion of their records in paper/physical formats and others in electronic. To be able to diagnose their conditions and properly prescribe treatment of them will require keeping a foot in both worlds, because few practices are performing backfile conversions of physical records.
You might want to ask your son if he is being given any training on how to capture information and if there is any training on ensuring what they do is consistent so that when data is exchanged (as an example) between a hospital, a physician, a lab, a clinic, etc there is no ambiguity in the notes or diagnoses. This will be critical for say... his Dad... if he is treated for a condition while on vacation somewhere, then comes home and has a similar condition and has to either go to the hospital or his own physician to be treated months or years later. If the records use different formats or platforms and can't be read, or the pull down menus they select codes, etc from aren't the same- how will the secondary physician provide treatment?
It might also be interesting to find out what data management and privacy protection skills they are being given, along with training on how to ensure content will be migrated forward for 10, 20, 50 years for patients and how to guarantee persistent access to a patients medical records. What if the patient is this young medical student himself? If he plans to live to be 60 or older, has he given any thoughts to how the systems will be able to manage HIS records (or the records of his future children) throughout their lives?
Most physicians during their intern and resident years work anywhere between 10-12 (or more) hours per day, and 6 days a week or longer. They are trying to drink in all of the training they receive and to practice the skills they have been learning while in school... and now, they will also be spending a portion of their time as IT people- or facing the same problems others face when technology "takes an unscheduled break"... but they will have to continue treating patients, taking their notes on paper, and then transcribing it electronically. Does anyone think this will shorten their days, and if not, will medical care suffer to feed the technology? I certainly hope not.
Which Doctors are we talking about? The ones in practice or the ones coming out of Med School?
I personally know of a lot in Med School who are nothing but TOTALLY electronic. And that is irreversible. I am the proud parent of one, that is, I get the bills, so I know what I'm talking about.
This post is very good. but it is a reflection on the immediate past of the practice. The present and future of the practice, that is, the ones who will treat everyone from the next 5 years on will be Electromeds, or most probably I-Meds for shure. So we better get accustomed.
It may not be common in all locations, but I personally know more than a dozen women who have changed surnames 5 times and mny more with 4 changes. Use of a maiden name may work in some cases, but there are many children who are abandoned at birth and/or that become wards of the court, or raised bt foster parents who receive public medica care.
The reason I mention this and why its important when it comes to EMR/EHR is we're seeing a grater push to adopt these systems in public medical care
You bet it's about time- in fact, it's long past time.
Before the decisions were made to discontinue the use of Social Security Numbers as identifiers, something to replace them should have been developed. But the reason SSNs are no longer used is they were being compromised by criminals, and the only action that was taken was to stop using them.
Not much has been done to establish controls to protect privacy of identifiers or passwords and to a degree, users need to take some responsibility for protecting themselves, but for a unique identifier to be developed, substantial measures will be necessary to add security into the numbers.
Two-step/phase validation possibly including biometrics or a token ID could go a long way towards achieving this.
Lastly (for this recap) think of the concerns for patients’ records when we have no system of unique identifiers available in this country, much less worldwide.
Wouldn't you agree that it's about time the US had a system of unique identifiers which would help in using EMR, among other things?
Yes, I have. Nowadays every and each profession demands learning at least some basic computer skills from the older professionals who want to keep track of changes and don't fall behind with the consequent loss of clients. Why should doctors be the exception to the rule? If so many doctors have been ready for EMR many years ago, how come there are still so many doctors out there unwilling to use EMR?
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