avoiding the pitfalls of going electronic

8/6/2019 Avoiding the Pitfalls of Going Electronic

1/3

PERSPECTIVE

n engl j med 358;16 www.nejm.org april 17, 20081656

available because of the level ofexplanation required and physi-cians concerns about sharing their

personal thoughts, although thepatient has the rightto examine the en-tire chart.4 Exam-ples of portals arePatientSite, developedat Beth Israel Deaconess Medi-cal Center in Boston, which hasabout 37,000 active users, and

MyChart, outpa-tient medical rec-ords developed by

Epic Systems. Ver-sions of MyChartare used by an es-

timated 2.4 million patients,4including about 120,000 at theCleveland Clinic and 103,000 atthe Palo Alto Medical Founda-tion, nearly half of all adult pri-mary care patients. Portals canallow for secure messaging, in-cluding prescription, referral, andappointment requests, but they

typically do not support data in-put from the patient or outsidepharmacies, laboratories, physi-cians, or hospitals, nor do theycommunicate with portals atother institutions or work at allsites of care.4

Other personal health records,including some be-ing established byAetna and Well-Point, are based oninsurance claims.

After portability standards areimplemented, patients who changecoverage should be able to trans-fer their data between companies.Although insurers can providedata from administrative claims

and can sometimes supplementthem from other sources, suchrecords lack detailed clinical in-formation.

Dossia was announced in De-cember 2006, Microsoft Health-Vault in October 2007, and GoogleHealth in February 2008, sotheir collective impact is not yetmeasurable. Although some phy-sicians and patients will embraceincreased use of the Internet for

health care, others may prefer towatch from the sidelines as thebugs are worked out. Moreover,because legal protections havenot kept pace with technologicaladvances, Congress may wish toamend HIPAA or enact new leg-

islation5 to safeguard personallycontrolled electronic health data.If concerns about privacy, secu-rity, and commercial exploitationcan be allayed, this nascent en-terprise should have a smootherbirth.

Dr. Steinbrook ([email protected])is a national correspondent for theJournal.

Hing ES, Burt CW, Woodwell DA. Elec-tronic medical record use by office-basedphysicians and their practices: United States,

2006. Advance data from vital and healthstatistics. No. 393. Hyattsville, MD: NationalCenter for Health Statistics, 2007.

Bright B. Benefits of electronic health rec-ords seen as outweighing privacy risks. WallStreet Journal. November 29, 2007.

Pagliari C, Detmer D, Singleton P. Poten-tial of electronic personal health records.BMJ 2007;335:330-3.

Halamka JD, Mandl KD, Tang PC. Earlyexperiences with personal health records.J Am Med Inform Assoc 2008;15:1-7.

Technologies for Restoring Users Securi-ty and Trust in Health Information Act, HR5442, 110th Cong. 2nd Sess (2008).Copyright 2008 Massachusetts Medical Society.

1.

2.

3.

4.

5.

Personally Controlled Online Health Data The Next Big Thing in Medical Care?

Off the Record Avoiding the Pitfalls of Going ElectronicPamela Hartzband, M.D., and Jerome Groopman, M.D.

Many of us remember search-ing frantically for a lostchart or misfiled laboratory result

in the wee hours of the morningas we cared for a sick patient inthe emergency ward, or request-ing in vain the most recent notefrom a specialist about a patientwho returned to our office aftera consultation. The ultimate goalof the electronic medical record a technological solution beingchampioned by the Bush admin-

istration, the presidential candi-dates, and New York Mayor Mi-chael Bloomberg, as well as

Google, Microsoft, and many in-surance companies is to makeall patient information immedi-ately accessible and easily trans-ferable and to allow its essentialelements to be held by both phy-sician and patient. The history,physical exam findings, medica-tions, laboratory results, and allphysicians opinions will be col-

lected in one place and availableat a single keystroke. And there isno doubt that these records offer

many benefits. We worry, howev-er, that they are being touted asa panacea for nearly all the ills ofmodern medicine. Before blindlyembracing electronic records, weshould consider their current lim-itations and potential downsides.

As we have increasingly usedelectronic medical records in ourhospital and received them from

Copyright 2008 Massachusetts Medical Society. All rights reserved.Downloaded from www.nejm.org at KOO FOUNDATION SUN YAT-SEN on February 21, 2010 .


2/3


PERSPECTIVE

1657

other institutions, weve noticedseveral serious problems with theway in which notes and letters arecrafted. Many times, physicianshave clearly cut and pasted largeblocks of text, or even completenotes, from other physicians; we

have seen portions of our ownnotes inserted verbatim into an-other doctors note. This is, inessence, a form of clinical pla-giarism with potentially delete-rious consequences for the patient.Residents, rushing to completenumerous tasks for large num-bers of patients, have sometimespasted in the medical history andthe history of the present illnessfrom someone elses note even

before the patient arrives at theclinic. Efficient? Yes. Useful? No.This capacity to manipulate theelectronic record makes it far tooeasy for trainees to avoid takingtheir own histories and comingto their own conclusions aboutwhat might be wrong. Senior phy-sicians also cut and paste fromtheir own notes, filling each notewith the identical medical histo-ry, family history, social history,and review of systems. Though itmay be appropriate to repeat cer-tain information, often the pri-mary motivation for such blanketcopying is to pass scrutiny forbilling. Unfortunately, these kindsof repetitive notes dull the reader,hiding the important new data.

Writing in a personal and in-dependent way forces us to thinkand formulate our ideas. Notes

that are meant to be focused andselective have become voluminousand templated, distracting fromthe key cognitive work of provid-ing care. Such charts may satisfythe demands of third-party payers,but they are the product of a wordprocessor, not of physiciansthoughtful review and analysis.They may be efficient for the

purpose of documentation but notfor creative clinical thinking.

Similarly, electronic medicalrecords can reproduce all of a pa-tients laboratory results, oftendropping them in automatically.There is no selectivity, because it

takes human effort to wadethrough all the data and isolatethe information that is pertinentto the patients current problems.Although the intent may be toensure thoroughness, in the newelectronic sea of results, it be-comes difficult to find those thatare truly relevant.

A colleague at a major cancercenter that recently switched toelectronic medical records said

that chart review during roundshas become nearly worthless. Hebemoaned the vain search throughmeaningless repetition in multi-ple notes for the single line thatrepresented a new development.Its like Wheres Waldo? hesaid bitterly. Ironically, he hasstarted to handwrite a list of newdevelopments on index cards sothat he can refer to them at thebedside.

True, handwriting in charts issometimes illegible and can leadto miscommunication. It mightseem that the printed (or at leasttyped) word, which we are all con-ditioned to respect, would alwaysbe more definitive and have moreimpact than text written by hand.But we have observed the electron-ic medical record become a pow-erful vehicle for perpetuating er-

roneous information, leading todiagnostic errors that gain mo-mentum when passed on elec-tronically.

An advertisement from a healthcare network touts the electronicmedical record as the avatar ofHigh Performance Medicine. Thead, whose headline reads Medi-cine That Doesnt Forget, shows

a country doctor carrying a blackbag. Remember when physiciansknew everything about their pa-tients and carried all that theyneeded in a little black bag? thead asks. The electronic medicalrecord, it asserts, is the modern

physicians equivalent of that littleblack bag. Only better. But theattempt to link this form of tech-nology with nostalgia for the fam-ily doctor who spent time in ex-tended conversation and careseems rather incongruous. Indeed,this humanistic depiction of theelectronic medical record contrastssharply with the experience ofmany patients who, during their15-minute clinic visit, watch their

doctor stare at a computer screen,filling in a template. This is per-haps the most disturbing effectof the technology, to divert atten-tion from the patient. One of ourpatients has taken to calling an-other of her physicians Dr. Com-puter because, she said, Henever looks at me at all onlyat the screen. Much key clinicalinformation is lost when physi-cians fail to observe the patientin front of them.

The worst kind of electronicmedical record requires fillingin boxes with little room for freetext. Although completing suchtemplates may help physicians sur-vive a report-card review, it directsthem to ask restrictive questionsrather than engaging in a narra-tive-based, open-ended dialogue.Such dialogue can be key to mak-

ing the correct diagnosis and tounderstanding which treatmentbest fits a patients beliefs andneeds. One pediatrician told usthat after electronically verifyinguse of seat belts, bicycle helmets,and other preventive measures, shehas scant time to explore clinicalissues. Electronic medical recordsmay help to track outcomes and

Off the Record Avoiding the Pitfalls of Going Electronic



3/3

PERSPECTIVE


adherence to guidelines, but theymay also force doctors to givestandard rather than custom-ized care.

These problems, we believe,will only worsen, for even as weare pressed to see more patients

per hour and to work with great-er efficiency, we must respondto demands for detailed documen-tation to justify our billing andprotect ourselves from lawsuits.Though the electronic medicalrecord serves these exigencies, itsimultaneously risks compromis-ing care by fostering a generic ap-proach to diagnosis and treatment.

We are not Luddites, opposedto all technological interventions;

we can see that electronic medi-cal records have many benefits.Mountains of paper are replacedby the computer screen, with rapidaccess to complete and organizedinformation, with risks such asdangerous drug interactions au-

tomatically f lagged. But we needto learn how to use this powerfultool in the way that is best forpatient care, regardless of wheth-er its the most efficient way.

We should instruct house staffthat they must create independent,

personal notes by talking to thepatient and verifying the medi-cal history themselves. We shoulddiscuss with payers what consti-tutes real documentation of timeand effort rather than sleight ofhand. We should use electronicformats that require us to selectand insert specific, relevant lab-oratory results.

Perhaps most important, weshould be cautious in using tem-

plates that constrain creative clin-ical thinking and promote auto-maticity. We must be attentive tothe shift in focus demanded byelectronic medical records, whichcan lead clinicians to suspendthinking, blindly accept diagno-

ses, and fail to talk to patients ina way that allows deep, indepen-dent probing. The computer shouldnot become a barrier between phy-sician and patient; as medicine in-corporates new technology, its fo-cus should remain on interaction

between the sick and the healer.Practicing thinking medicinetakes time, and electronic recordswill not change that. We need tomake this technology work for us,rather than allowing ourselves towork for it.

Drs. Hartzband and Groopman reportholding stock in Microsoft and Google.

Dr. Hartzband is an endocrinologist at BethIsrael Deaconess Medical Center and an as-sistant professor of medicine at Harvard

Medical School, and Dr. Groopman is a he-matologistoncologist at Beth Israel Dea-coness Medical Center and a professor ofmedicine at Harvard Medical School both in Boston.

Copyright 2008 Massachusetts Medical Society.

Off the Record Avoiding the Pitfalls of Going Electronic

Physician Workforce Crisis? Wrong Diagnosis,

Wrong PrescriptionDavid C. Goodman, M.D., and Elliott S. Fisher, M.D., M.P.H.

Related article, page 1741

Despite the fact that there arenow more physicians per cap-ita in the United States than therehave been for at least 50 years,the Council on Graduate Medi-cal Education (COGME) recently

predicted a 10% shortfall of phy-sicians by 2020. Public concernabout access to care, reports ofdifficulties in recruiting physiciansin many specialties, and discus-sion of the looming collapse ofprimary care all contribute to thesense of crisis. The Association ofAmerican Medical Colleges hasresponded with calls for a 30%

expansion of U.S. medical schoolsand a lifting of the current capon Medicare funding for gradu-ate medical education so that fed-eral dollars can support the ex-pansion of the workforce.

Before acting on these recom-mendations, we should carefullyconsider the accuracy of the di-agnosis and the likely conse-quences of the prescription. Threeobservations should give policy-makers pause (see Table 1).

Physician supply varies dramati-cally by region of the country.COGME is concerned about a 10%

shortfall at a time when the re-gional supply of physicians variesby more than 50% (see Table 1).An analysis of the countrys hos-pital-referral regions (regionalmarkets for tertiary care) in which

regions are categorized into quin-tiles on the basis of their per-capita supply of physicians re-veals that the ratio of the supplyin the highest-quintile regionsto that in the lowest-quintile re-gions is 1.56 for primary care,1.89 for medical specialists, and1.43 for surgical specialists.

But the presence of more phy-


avoiding the pitfalls of going electronic

Documents