Slips of the Fingers: Are Electronic Medical Records More Foolish Than Managed Care?

My first exposure to electronic medical records (EMRs) was when I saw my own primary care physician about 3 years ago. I didn't like it. Neither did he. For me, it seemed like he had to pay as much attention to the computer as to me. We spent less time talking. He laughed as he typed, joking that once everything was in the computer, it should save time and make for better care. I responded that we heard the same promise with managed care.

Towers of Babel
Months ago, it was our turn as the last medical specialty to go the EMR. As with managed care, we had to learn a new language. Instead of utilization review (UR), medical necessity, and authorization, we got encounters, smart tools, and visit navigation. "Encounter" actually seemed to fit both EMR and managed care. Just as I battled managed care companies, I now battled the computer. I wouldn't win unless I completed all the requirements, whether I thought they were relevant to my patient care or not. "Smart tools" seemed dumb to me, so I tried to get around them, at least in part, by maintaining a narrative of each unique patient instead of using the checklists exclusively.

Invisible Paper
Then, the amount of "paperwork" also resembled managed care. To my surprise, there was more paperwork on the EMR than the actual paper chart! Instead of filling out the UR form for managed care, there were all the checkpoints that had to be negotiated to get through the EMR and actually get the patient's prescription done.
 
Now This is Confidential
Confidentiality concerns seemed comparable. Of course, the loss of confidentiality due to managed care companies' insistence on record reviews was a major dilemma. At least they promised it would be for quality improvement. In EMRs, the challenge seems to be in protecting the information from others. Imagine my surprise, then, when compliance reviewers within our system seemed to somehow have ready access and pointed out to me what I was not doing well, especially to obtain reimbursement. Now, with the paper chart, I must confess that I purposefully scribbled my notes, in part to preserve confidentiality. Only I -- and sometimes my secretary -- could fully read the notes. I justified this by concluding that if someone needed my information, they could ask me directly, which indeed they often did. For required interactive formats, like prescriptions or UR authorization, I did print quite legibly.

Do More in Less Time
Time has also turned out to seem similar. Once I got past learning how to do the EMR basics, it still took much more time than handwritten. I could no longer jot down notes as I talked to the patient and simultaneously maintain eye contact. More was required when I later processed the EMR note, just like managed care required documentation of medical necessity and the treatment plan. It even took more time to look through old notes in the EMR; "flipping" the pages was slower and page by electronic page. I was again doing more in less time, but, paradoxically, the 15 minute med checks had to become a casualty. The "catch 22" is that with both EMRs and managed care, I was still expected to be more productive in less time!

The Costs of Care
Both managed care and EMRs have promised to reduce costs and improve care. Especially if you figure in administrative costs, neither goal has been reached so far. Because they must be potentially good businesses, there seem to be as many EMR systems as managed care companies (or, at least as many managed care companies when they first became popular). In requesting the experiences of other psychiatrists, virtually all broached almost as much frustration with EMRs as I recalled from the introduction of managed care. Only the VA system received accolades for its EMR, just like Harvard Pilgrim often did for a managed care company.

Slipping
Somewhat like Freud's slips of the tongue, frustration with EMRs seems to cause "slips of the fingers." While I often heard "mangled care" instead of managed care, I would mistype the letter "y". The reason why must be in my unconscious.
 

Coping Skills
Many of us seem to develop similar coping skills as we did with managed care. First, there was anger-- at least for those who were not computer nerds. One clinician said she started to swear at the computer with the patient in the room, just like she once did over the phone to the utilization reviewer. The anger often evolves into humor, so that the patient and I together could joke about our common enemy, the computer, like we once did with the managed care company.

Fools Gold or Real Gold
Despite all the apparent foolishness with a lot of managed care and EMRs, just like with Shakespeare's fools, there may be some wisdom that will emerge. Maybe our Fools Gold can transform into the real gold of a not-for-profit managed, single payer system, where a  single EMR system monitors and enhances quality of care. I suspect, though, that the EMR will never be as valuable for psychiatry, where the narrative story and need for confidentiality are more important than in the rest of medicine. Time will tell.

"The Fool Doth Think He is Wise,
But the Wise Man Knows Himself to be a Fool"

--Shakespeare, from As You Like It

Happy April Fools Day!

CHARLES HUFFINE, MD, ADDS...
I want to make a movie where a medical staff gets together to storm key offices that determine medical records requirements, wrecks these programs horrifically with support staff sitting around horrified and shrieking. The docs then make a PA announcement that the medical staff has taken over medical records and hospital administration and any interference on the part of the administrators, such as calling the police or any other form of retribution, would meet with a complete work stoppage-except for the small amount of work hours devoted to relating to patients. Relating to patients more might even be done in an act of defiance.

In all of this, docs would agree among themselves what "normal and useful" clinical notes were relevant to the clinical status of patients. These would be written in a more narrative format that would be scrawled (as always) in semi-legible writing that only other doctors could read. Any obstructing hospital officials or medical records personnel would be placed in seclusion rooms. There would be a public uproar in favor of the docs who would organize street protests against objecting insurance companies and government offices that they also storm, kind of like Kirghistan without the guns.

The opportunity for romance in this movie would be fabulous. The hero would be a young, very handsome, psychiatrist who would offer a romantic subplot as he convinced a medical transcriptionist to participate in the sabotage of the computers which had the formats for obsessive and voluminous notes. They would stand together in front of an admiring crowd of citizens who had risen in protest against evil paperwork wrecking their health care.