'How I Learned to Stop Worrying and Love the EHR'

July 21, 2012

When my group practice added a comprehensive electronic health record to our computer system, I was dubious. Slowly, I came to see the benefits to patient care and myself.

"E-prescribing!" my colleague beamingly declared a couple of years ago. "It's the first step to the way everything will be - and Medicare is going to reimburse you for doing it!" As the newest member of his multi-specialty group, I tried to match his enthusiasm. I added, "I am sure there will be a lot less paper waste, medical errors, and writing." His eyes looked as if they went on screen-saver mode: "Oh yeah, those are good reasons, too."

With the arrival of e-prescriptions, prescriptions can be zapped off to my patients' pharmacies without any slips of paper given to my patients. No longer would a prescription get lost. No longer would a pharmacist excoriate the side of her head in anguish as she tried to decipher if my handwriting requested 500 mg of Flagyl or 500 mg of Fentanyl.

Despite my assertions, I wasn't sold on e-prescriptions. I had just started to practice medicine, and already a basic act was disappearing. Handing a prescription to a patient was part of the medical tradition, like white coats and golf clubs. I was not ready to lose any part of my concept of what it meant to be a doctor. I was even disappointed that esoteric phrases like qhs were becoming digitally replaced with mundane words like "at bedtime."

I knew not everyone had a nostalgic attitude like I did. One evening during my internship, the on-call teams dined together in the cafeteria. The question surfaced of what prn stood for. My intern said, "Um, that means 'per registered nurse,' like if the nurses want to give it, they can." After the appropriate ridicule this entailed and the mental notations to check over his work, many of us still did not know the meaning. Pro re nata is a Latin phrase meaning "for the thing born" or more loosely "for the need that arises."

The lack of these phrases in electronic prescriptions made me face the fact that this particular jargon will go extinct like the dodo, or become archaic like the diphthong. However, as I started my career, I found that I had to concentrate on many more medically-relevant matters. Numerous updates in medicine had occurred, even from what I had learned just recently in residency. I worried less about quaint Latin phrases. Medical knowledge always expands while old practices quickly become dated. I realized that this not only applies to antibiotic and chemotherapy regimens, but also to the routine parts of practicing medicine, like prescription writing.

When my group practice added a comprehensive electronic health record (EHR) to our computer system, I was again dubious. I was not nostalgic for our piles of paper charts; I understood that the EHR was something to which we had to adapt. However, I questioned some of its touted values. A "paperless" system is never actually paperless. The more something is computerized, the easier it is to print, over and over again. In the hospital, I witnessed reams of paper being consumed in preparation for rounds, sign-outs, and orders. Many times those papers contained meaningless data, or data in triplicate separated by blank spaces.

Just as a paperless system does not eliminate significant paper, it doesn't eliminate medical errors. In 2011, Harvard researchers did not find a significant decrease in errors (minor or serious) compared to written orders. Previous studies have documented a Pandora's box worth of errors that are peculiar to an electronic system. Many of these errors are errors of omission, like forgetting to scroll down a list for an item that would never have been forgotten if written by hand.

When I asked a non-medical friend about his level of satisfaction with his healthcare, he did not point to any problems with the quality of medicine. He expressed amazement at the level of recent technological health advances he has seen, from artificial hearts to cochlear implants to face transplants. As a patient, however, he was frustrated at the low level of technologic development within the business of medicine. I was forced to admit that medicine lagged behind other sectors of our economy in its use of technology for its business.

Inter-office communication, medical customer support, and billing have been more reminiscent of the Flintstones than the Jetsons. Now that my practice and my local hospitals share a unified EHR system, I can obtain data from other locations and eliminate the need to duplicate tests. The EHR system delivers automatic reminders to patients about their appointments and gives me reminders about when surveillance labs are due. Billing has become easier because the computer lexicon provides me with any ICD or CPT code after a few keystrokes. Since the incorporation of an EHR, I have experienced some of its drawbacks, but I have also reaped many more benefits.

Though it has its flaws, the growing pains from computerization will improve and EHRs will become necessary and beneficial to our profession. But we must be cognizant of its limitations and costs. In an age when stroke patients see their neurologists on LCD monitors attached to robots, the personal interaction between physician and patient is changing. Home visits are almost unheard of, whereas doctors are increasingly advising and treating patients over e-mail. Patients complain when doctors pay more attention to keyboards than to them. I see EHRs as tools that can optimize physicians in the science and business of medicine, but not in the art. The most sophisticated robot cannot take the place of a human soul.

Communication with the people under our care needs to be maintained and strengthened. Like most forms of technology, EHRs are only good or bad depending on how we employ them. Even though our EHR has made us a paperless system, my practice has mandated that every patient leave with a paper reminder of their visit. Patients often remember less than half of the information told to them during a clinic visit. Our EHR provides patients the dates of their future clinic visits, their medication lists and their instructions in a legible printout. This works much better than allowing the only palpable reminder of their visit to be when they receive a bill in the mail.

Meaningful use of an EHR should mean giving physicians more time to concentrate on our patients' needs rather than business needs or time-consuming tasks like checking drug interactions or retrieving outside records. EHRs do not make us into good doctors, but they make it easier to be good doctors.

Albert H. Khine, MD, is a gastroenterologist at The Portland Clinic in Portland, Ore. He no longer has writer's cramp, but worries about carpal tunnel. He can be reached at editor@physicianspractice.com

This article originally appeared online in the Physicians Practice website, July 2012.