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Using an EHR Can Be Ethically Challenging


The inherent flaws in this doctor’s EHR system has created an ethical dilemma, which he says cannot be solved.

My hospital has only recently gotten an EHR. Having used it for a few weeks, I’m reminded of the movie, “Polar Express.” As in the story, I guess this EHR’s “bell only rings for those who truly believe.” My experiences over the past few weeks are straining my credulity.

I first noticed the problem that is responsible for my dilemma during “training “(a single session in which a few screens were displayed briefly and we were able to access a “dummy” patient’s fictional records). We were instructed that it was necessary to complete every component of the encounter that involved data entry before we composed our note. This was because “the note isn’t in the database” and only the data that is already in the database will be incorporated into the note.

Additional orders, we were told, will not become part of the note unless we delete everything and start over. As you can imagine, many were perplexed by this. This single “quirk” speaks volumes about the internal architecture of the product. I was sardonically amused.

Supplied with this “intelligence,” I diligently set about entering data. If I didn’t update the problem list and assign diagnoses before charting, none would appear in the note, and only my typing would. The first patient’s diagnosis (Latent TB Infection - LTBI) was prosaic, but unfortunately the World Health Organization has not seen fit to assign a code to LTBI even though it is the diagnosis for 95 percent of those who are infected with (and test positive for) TB. There are codes for over 500 disease manifestations of TB but not for the most common one, which is a healthy patient.

I was advised to use the code for “abnormal reaction to a TB skin test,” but this in inaccurate. First, if the person is infected, is the positive skin test an abnormal reaction or the expected reaction? Second, not all those who test positive are infected; some have received BCG or encountered nontuberculous species of mycobacteria. Third, not everyone who tests negative is uninfected (But you knew all this, right?). I can’t fix the problem by entering a free-text diagnosis; the ability to add “free text” diagnoses and problems has been disabled.

So where is the dilemma? If I write the correct diagnosis in my note and choose any available code, the note and the codes describe two different patients. Should someone see the codes but not the note, they will draw the wrong conclusions and may take inappropriate actions. If I don’t code it, this does not prevent the conflict because some coder-person will do it for me and they will most likely get it wrong (since it can’t be gotten right.)

I assume this is going on in every specialty in every facility around the country and that the coding data is collected and aggregated on a national level. In fact, I know that it is. This aggregated stuff makes up the “big data” that you hear about. Analyzing this stuff is supposed to give us new insights. These insights will set the direction of future healthcare policy, funding, etc. President Obama is counting on big data to form the basis of “Precision Medicine.”

I can’t tell you what proportion of the data the Feds are collected is all wrong or partially wrong and what’s worse, NEITHER CAN THEY.

How can my charting be accurate? It can’t.

How can I achieve consistency, that is, that every view of my patient’s information will tell the same story? I can’t.

How can I avoid medico-legal liability? – I can’t. Lawyers will seize on any inconsistency they can find as the basis for a claim. Our system virtually guarantees a lack of consistency. There will be items that I charted late but forgot to order and items that I ordered that didn’t get done because some intermediary (nurse) overlooked them. There will be items that I ordered that were pulled into the note but that were changed later in the order system, but not in the note. The diagnoses, problems and allergies in the database will not match what is documented in the notes.

How can I avoid contributing to flawed decision making by healthcare organizations and various level of government? I can’t.

No matter what I do, someone, somewhere, will do something inappropriate to a patient because they will only see incorrect or partial information. I didn’t create this absurd situation and I am powerless to correct it. It will continue on no matter what I personally say or do until someone at the top level develops enough sophistication to comprehend the absurdity and the associated waste of resources, and puts a stop to it.

What can I do in the meantime to resolve the dilemma and avoid the feeling that I’m taking crazy-pills? Your suggestions would be appreciated.

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