My mom found out about her metastatic pancreatic cancer diagnosis when her CT results were released in mychart. As her son I had to walk her through it. (She knew it was bad). She did not speak to a physician until two days after seeing those results.
When I was in the Navy, EMR was initiated and within just a few short years, the notes were terrible. No one ever updates the problem list, medications, labs, etc. Before you know it the first 2 pages of the new progress note was just full of outdated useless crap to weed through. Fast forward to EPIC, which is a little better. I do think the note quality is marginal as many providers just cut and paste. When patients have access to results immediately before consultation, it can cause a lot of unnecessary worry. The best part of EPIC, is no lost medical records, legible notes, easy prescribing and we have a "care everywhere" button. I can find stuff from all over the state and sometimes out of state 10 years back.
The EMR resulted in the record being full of false findings. Physicians switched to templates instead of just writing what they did in the most helpful way for the next provider. The result was increased billings, fake notes, and the real story buried in the garbage.
As a patient, I have my drs email and private mobile phone number, and he's never complained about my use of them... Even encouraged me to email peer reviewed articles to him so he can look at them and we can discuss them, and didn't even mind the 6am text conversation about whether I was well enough to go into work that day (a fitness to practice issue)... But I'm also very mindful about respecting boundaries.
But I've seen patients panic over iron deficiency pathology results when they just had the path read out, (poikylocytosis - does that mean I'm gonna die?) and can imagine open access could be a double edged sword.
This is a system I don't think we have access to in Canada yet but I will say of the times I've talked to my doctor more often than not I think it could have been an email to save us both time. I can also see how being too available would lead to too many emails.
I was disapointed when the clinic discontinued phone visits. It's not a billing issue, I think they feel they can do a better job in person or enjoy it more, I haven't used our limited time to ask.
Subbed for my partner the other day in clinic while he was at conference. Told one of his favorite patients “that he was in rehab, but he’ll be back next week”. She grew very quiet then said,” Isn’t that a HIPAA violation”. I said, “No not really, because when he comes back, I’m going.”
She’s still laughing.
I didn’t put that in the EMR. He’ll have some explaining to do when he gets back.
I am a retired physician who took pride before and after the introduction of the EMR. When one of my fellows forwarded a progress note to me, I found such a lack of attention to key information about really updating the "progress" of the patient and any really thoughtful assessment of the diagnoses and problems leading to hospitalization. Insurers need to use AI to patrol the EMR for complete copy and paste jobs without new information. The clinician who has written or signed off on such notes should NOT be reimbursed for that day's care. That should be quite straightforward.
A new problem is that my cadre of an internist and multiple specialists involved in my care all do limited physical exams but document a full exam with almost all systems appearing to be included. This, my dear colleagues, is fraud and we need to address it.
Yup. As a medical student, I was gobsmacked at what was documented as having been done versus what actually happened... My respect for my preceptors is at base so low, I know the are good ones out there... I've met one
This is a terrific essay. And the large number of very thoughtful comments attest to the chords it rings in caregivers and patients.
It has been years and years since I have encountered an inpatient progress note in the electronic record of a sick baby that contained more than a listing of problems, unhelpful physical exam, (all) labs since admission, and an impression that reacts to the latest results of essentially unhelpful surveillance labs. No discussion of disease process or evolution, no differential diagnosis if the nature of the illness is unclear. Essentially no thought at all. H&P and progress note templates can be excellent time savers, but not at the expense of the clinical impression.
As a patient, I hate to message my doc through MyChart, knowing how busy he is. (And what’s the appropriate way to acknowledge his thoughtful response to my question, without forcing him to read yet another patient message?) I have leaned to save text messages for true emergencies.
And when I see his name pop up on my ringing phone, I know that he values me — to tell me what he needs to with the ability to listen to my emotional response to the news.
Ease of access to anything is a blessing and a curse. Look at the Internet. What I tell people in my field (technology) is that "Searching is not learning" You can look up at anything, but that's not learning. EMR have the same problem as email. Great Godsend when it was MCI Mail, but quickly evolved into just noise. Then Instant messaging was great until it, too, evolved into noise. Text/SMS repeats the cycle.
After my NSVT, NSPE (embolism), and Aneurysm (funny how it all showed up after 2021 to a healthy male), I realized that *I* am the KOC. What's KOC, you ask? Keeper of Continuity. You cannot expect silo'ed specialists to keep track of everything for a patient that he/she sees for 15 min AT MOST. I know because I've put garbage into those paper forms - like 120deg fever - and NO ONE called me on it.
It's not the doctor's fault. I know where the fault lies. I'm an engineer. I know how to diagnose a broken system. A patient who gets serviced by party A, but party A gets paid by party C who get paid by gov't or party D. So a patient pays a doctor who gets paid by insurance who gets paid by the gov't or employer. The feedback loop is broken. EXCEPT in fields where insurance is not paying the bill. That, of course, explains why lasik and plastic surgery keeps getting better and lowering prices. There's a feedback loop that works.
This is another reason why concierge medicine is making a comeback. It's what we all used to have. A doctor that knew you as a whole person. Not a lab test and 18 pages of notes from other specialists. Hell, people won't even read a forum post if it's too long. You think a specialist is going to read a note from another specialist who's four degrees removed?
Electronic medical records...if my recent experience is telling, it's a buffoonery operation filled with promises never delivered.
Besides, all this electronic stuff can be hacked. How nice to have our private medical records floating around in the dark web. There have dozens of breaches that many don't know about. Your EMRs are NOT safe and never will be.
Then there will be the A/i bloodsuckers...sucking the writing right of off your EMR and doing who knows what with it.
Establishing 'strict legislation' to preserve the privacy is a dead end: as soon as it's established it's boundaries will be targeted by skilled lobbyist. As language is endlessly flexible, the boundaries will start to shift. The only safe option is physically not having unified storage systems
"The harm comes in two forms, excessive access and providing patients AND doctors the option to avoid conversations — actual, necessary human to human conversations that need to be had."
You are viewing this from the perspective of a practitioner, and not a corporate hack. That is very much to your credit, but myopic in one very important sense.
Electronic records are ephemeral, and data storage costs money. Triage may well be a medical term in its most common usage, but I assure you that everyone must perform triage. The ephemeral nature and maintenance costs, lead to access metrics for retention. I speak from the bitter personal experience of having records digitized and deleted when the practice was bought by one of the myriad parasite corporations that beggar small practices, absorb them and defenestrate unprofitable patients.
Electronic records rely on software. McLuhan's seminal "The Media Is The Message" was prescient in many ways. Data structure conforms to the interface, the interface does not conform to the data compilation requirements. All is compromise, settling for the least bad design. This changes communication modalities. I have watched it evolve from the beginning, and there is no way 'round it; software companies are not charities.
Because the business side of practice is now controlled by corporate hacks like me, the business case rules. Set aside the disingenuous tripe about "nonprofit," there would be no network expansion without accrual. The iron law of institutions obtains. Simple mechanisms like appointment telephone reminders for those not obsessively online, do not meet the business case driven by the prosperous demographic that prefers to avoid human interaction.
Scenario: you are a good surgeon working the ambulatory center of a parasitic corporation expanding its market base. Your last colorectal surgery was a delightful success, but your patient is allergic to all OTC NSAIDs but aspirin. There is only one option; celoxib. You are "strongly discouraged" from issuing a paper prescription and forbidden (or refuse) to transmit that non-scheduled medication prescription before the surgery. You dutifully transmit it while your patient is in recovery. You go home, knowing all is well.
But the prescription is never recieved by the pharmacy. Because you are in a wing of a hospital complex. You transmitted that prescription from an IP address inside a hospital, and your corporate masters instructed the IT department to route all prescriptions not previously reviewed by the predatory underwriters, into a utilization review queue reserved for inpatient dispensation. The patient is ambulatory, not admitted, and the prescription will never be received by the offsite pharmacy because of that corporate hack cost-effective IT instruction.
Your patient didn't need the narcotic for more than a few hours, but he needs that celoxib badly. He is hurting and he calls in. The on-call has no time or patience, and the patient becomes increasingly frantic because no one will do anything but push keys that do nothing. Days go by, the patient gets a message to you, a detailed message that is shortened by reception. You dutifully transmit that prescription again, but it goes nowhere.
By now, the patient is frantic after five days of nothing but a narcotic, but no one in your organization will do anything for him about that prescription, because no paper is allowed. You won't issue the paper because you have no idea what scam this guy is trying to pull. You're not an IT guy and have no idea what's happening.
Finally, the patient figures out what's happening and contacts his attorney, then forces his way via telephone to your IT guy, who is not allowed to view any patient activity, and cannot assist anyone, however much he wishes to. The IT guy can do one thing, though; he connects the patient with the hospital pharmacist, the person your gatekeepers could have spoken with, and finally gets the problem solved by making personal contact with an offsite pharmacist she knows.
The patient comes back for his follow-up and explains what happened, but you're a corporate employee and you will not step out of your lane and make any waves, because you know what happened to the last surgeon who cared enough to do something so rash as to try to defy an administrator who told him to shut up and stay in his lane.
Nothing changes, because the business case isn't compelling enough.
Digitization is automation, full stop. That's all it is and all it does. Automation selects for automatonic behavioral response.
I could go on, with example after example. You, doctor, exhibit intelligence, compassion and concern, and hence are unlikely to serve your own complacent self-interest by means of the mendacious dismissal "but that's an outlier and 'patients' are better off now."
No, you wouldn't do that because you are well aware that you are a practitioner, not a public health officer who deploys the utilitarian calculus exemplified by the classic trolley problem. You treat individuals, not aggregate statistical cohorts, abjuring the practice of hiding behind spurious correlations.
You and those like you, are increasingly becoming statistical outliers.
As a DVM our EMRs are local (ie only used in a single practice) & have been a boon to patient care. I cannot begin to describe how hard it was to find charts, let alone read them pre EMRs!
As patient, I really appreciate having my chart access to my records & those of my family.
Like so many things there are two sides to the Epic EMR coin and I can see how it could be frustrating to madening for those in human medicine.
Pros include immediate access for all caregivers (professional & non), legible, detailed info, reasonable communication path between caregiver & patient (though patients can be unreasonable), easy of sending Rxs, ease of transferring medical info...
Cons: Too many boxes to check that have little or no application to many patients, repetitive redundant entries, no master problem list that prioritizes the problems, clients can panic when reading reports before speaking with their caregivers, difficulty deleting things such as medications no longer being taken & erroneous or outdated entries (at least in my local area, it seems most staff can't simply code that the SMZ-TMP was only used once 2 years ago for a UT!)...
My mom found out about her metastatic pancreatic cancer diagnosis when her CT results were released in mychart. As her son I had to walk her through it. (She knew it was bad). She did not speak to a physician until two days after seeing those results.
When I was in the Navy, EMR was initiated and within just a few short years, the notes were terrible. No one ever updates the problem list, medications, labs, etc. Before you know it the first 2 pages of the new progress note was just full of outdated useless crap to weed through. Fast forward to EPIC, which is a little better. I do think the note quality is marginal as many providers just cut and paste. When patients have access to results immediately before consultation, it can cause a lot of unnecessary worry. The best part of EPIC, is no lost medical records, legible notes, easy prescribing and we have a "care everywhere" button. I can find stuff from all over the state and sometimes out of state 10 years back.
The EMR resulted in the record being full of false findings. Physicians switched to templates instead of just writing what they did in the most helpful way for the next provider. The result was increased billings, fake notes, and the real story buried in the garbage.
As a patient, I have my drs email and private mobile phone number, and he's never complained about my use of them... Even encouraged me to email peer reviewed articles to him so he can look at them and we can discuss them, and didn't even mind the 6am text conversation about whether I was well enough to go into work that day (a fitness to practice issue)... But I'm also very mindful about respecting boundaries.
But I've seen patients panic over iron deficiency pathology results when they just had the path read out, (poikylocytosis - does that mean I'm gonna die?) and can imagine open access could be a double edged sword.
Maybe your patient just didn't want to become a victim of the medical industry? I'd be your patient, better dead than food for the EMR
This is a system I don't think we have access to in Canada yet but I will say of the times I've talked to my doctor more often than not I think it could have been an email to save us both time. I can also see how being too available would lead to too many emails.
I was disapointed when the clinic discontinued phone visits. It's not a billing issue, I think they feel they can do a better job in person or enjoy it more, I haven't used our limited time to ask.
Subbed for my partner the other day in clinic while he was at conference. Told one of his favorite patients “that he was in rehab, but he’ll be back next week”. She grew very quiet then said,” Isn’t that a HIPAA violation”. I said, “No not really, because when he comes back, I’m going.”
She’s still laughing.
I didn’t put that in the EMR. He’ll have some explaining to do when he gets back.
I am a retired physician who took pride before and after the introduction of the EMR. When one of my fellows forwarded a progress note to me, I found such a lack of attention to key information about really updating the "progress" of the patient and any really thoughtful assessment of the diagnoses and problems leading to hospitalization. Insurers need to use AI to patrol the EMR for complete copy and paste jobs without new information. The clinician who has written or signed off on such notes should NOT be reimbursed for that day's care. That should be quite straightforward.
A new problem is that my cadre of an internist and multiple specialists involved in my care all do limited physical exams but document a full exam with almost all systems appearing to be included. This, my dear colleagues, is fraud and we need to address it.
Yup. As a medical student, I was gobsmacked at what was documented as having been done versus what actually happened... My respect for my preceptors is at base so low, I know the are good ones out there... I've met one
This is a terrific essay. And the large number of very thoughtful comments attest to the chords it rings in caregivers and patients.
It has been years and years since I have encountered an inpatient progress note in the electronic record of a sick baby that contained more than a listing of problems, unhelpful physical exam, (all) labs since admission, and an impression that reacts to the latest results of essentially unhelpful surveillance labs. No discussion of disease process or evolution, no differential diagnosis if the nature of the illness is unclear. Essentially no thought at all. H&P and progress note templates can be excellent time savers, but not at the expense of the clinical impression.
As a patient, I hate to message my doc through MyChart, knowing how busy he is. (And what’s the appropriate way to acknowledge his thoughtful response to my question, without forcing him to read yet another patient message?) I have leaned to save text messages for true emergencies.
And when I see his name pop up on my ringing phone, I know that he values me — to tell me what he needs to with the ability to listen to my emotional response to the news.
Sounds like a role model to me.
Ease of access to anything is a blessing and a curse. Look at the Internet. What I tell people in my field (technology) is that "Searching is not learning" You can look up at anything, but that's not learning. EMR have the same problem as email. Great Godsend when it was MCI Mail, but quickly evolved into just noise. Then Instant messaging was great until it, too, evolved into noise. Text/SMS repeats the cycle.
After my NSVT, NSPE (embolism), and Aneurysm (funny how it all showed up after 2021 to a healthy male), I realized that *I* am the KOC. What's KOC, you ask? Keeper of Continuity. You cannot expect silo'ed specialists to keep track of everything for a patient that he/she sees for 15 min AT MOST. I know because I've put garbage into those paper forms - like 120deg fever - and NO ONE called me on it.
It's not the doctor's fault. I know where the fault lies. I'm an engineer. I know how to diagnose a broken system. A patient who gets serviced by party A, but party A gets paid by party C who get paid by gov't or party D. So a patient pays a doctor who gets paid by insurance who gets paid by the gov't or employer. The feedback loop is broken. EXCEPT in fields where insurance is not paying the bill. That, of course, explains why lasik and plastic surgery keeps getting better and lowering prices. There's a feedback loop that works.
This is another reason why concierge medicine is making a comeback. It's what we all used to have. A doctor that knew you as a whole person. Not a lab test and 18 pages of notes from other specialists. Hell, people won't even read a forum post if it's too long. You think a specialist is going to read a note from another specialist who's four degrees removed?
Electronic medical records...if my recent experience is telling, it's a buffoonery operation filled with promises never delivered.
Besides, all this electronic stuff can be hacked. How nice to have our private medical records floating around in the dark web. There have dozens of breaches that many don't know about. Your EMRs are NOT safe and never will be.
Then there will be the A/i bloodsuckers...sucking the writing right of off your EMR and doing who knows what with it.
Establishing 'strict legislation' to preserve the privacy is a dead end: as soon as it's established it's boundaries will be targeted by skilled lobbyist. As language is endlessly flexible, the boundaries will start to shift. The only safe option is physically not having unified storage systems
.
It's boundaries are being targeted by the ultra skilled data hacker.
I might keep practicing if I didn't have to use EPIC!
I think cut and paste in a medical record should be forbidden
I give my cell phone number to post op patients. They are happy having that access, rarely abuse it and it keeps the human contact.
ditto
"The harm comes in two forms, excessive access and providing patients AND doctors the option to avoid conversations — actual, necessary human to human conversations that need to be had."
You are viewing this from the perspective of a practitioner, and not a corporate hack. That is very much to your credit, but myopic in one very important sense.
Electronic records are ephemeral, and data storage costs money. Triage may well be a medical term in its most common usage, but I assure you that everyone must perform triage. The ephemeral nature and maintenance costs, lead to access metrics for retention. I speak from the bitter personal experience of having records digitized and deleted when the practice was bought by one of the myriad parasite corporations that beggar small practices, absorb them and defenestrate unprofitable patients.
Electronic records rely on software. McLuhan's seminal "The Media Is The Message" was prescient in many ways. Data structure conforms to the interface, the interface does not conform to the data compilation requirements. All is compromise, settling for the least bad design. This changes communication modalities. I have watched it evolve from the beginning, and there is no way 'round it; software companies are not charities.
Because the business side of practice is now controlled by corporate hacks like me, the business case rules. Set aside the disingenuous tripe about "nonprofit," there would be no network expansion without accrual. The iron law of institutions obtains. Simple mechanisms like appointment telephone reminders for those not obsessively online, do not meet the business case driven by the prosperous demographic that prefers to avoid human interaction.
Scenario: you are a good surgeon working the ambulatory center of a parasitic corporation expanding its market base. Your last colorectal surgery was a delightful success, but your patient is allergic to all OTC NSAIDs but aspirin. There is only one option; celoxib. You are "strongly discouraged" from issuing a paper prescription and forbidden (or refuse) to transmit that non-scheduled medication prescription before the surgery. You dutifully transmit it while your patient is in recovery. You go home, knowing all is well.
But the prescription is never recieved by the pharmacy. Because you are in a wing of a hospital complex. You transmitted that prescription from an IP address inside a hospital, and your corporate masters instructed the IT department to route all prescriptions not previously reviewed by the predatory underwriters, into a utilization review queue reserved for inpatient dispensation. The patient is ambulatory, not admitted, and the prescription will never be received by the offsite pharmacy because of that corporate hack cost-effective IT instruction.
Your patient didn't need the narcotic for more than a few hours, but he needs that celoxib badly. He is hurting and he calls in. The on-call has no time or patience, and the patient becomes increasingly frantic because no one will do anything but push keys that do nothing. Days go by, the patient gets a message to you, a detailed message that is shortened by reception. You dutifully transmit that prescription again, but it goes nowhere.
By now, the patient is frantic after five days of nothing but a narcotic, but no one in your organization will do anything for him about that prescription, because no paper is allowed. You won't issue the paper because you have no idea what scam this guy is trying to pull. You're not an IT guy and have no idea what's happening.
Finally, the patient figures out what's happening and contacts his attorney, then forces his way via telephone to your IT guy, who is not allowed to view any patient activity, and cannot assist anyone, however much he wishes to. The IT guy can do one thing, though; he connects the patient with the hospital pharmacist, the person your gatekeepers could have spoken with, and finally gets the problem solved by making personal contact with an offsite pharmacist she knows.
The patient comes back for his follow-up and explains what happened, but you're a corporate employee and you will not step out of your lane and make any waves, because you know what happened to the last surgeon who cared enough to do something so rash as to try to defy an administrator who told him to shut up and stay in his lane.
Nothing changes, because the business case isn't compelling enough.
Digitization is automation, full stop. That's all it is and all it does. Automation selects for automatonic behavioral response.
I could go on, with example after example. You, doctor, exhibit intelligence, compassion and concern, and hence are unlikely to serve your own complacent self-interest by means of the mendacious dismissal "but that's an outlier and 'patients' are better off now."
No, you wouldn't do that because you are well aware that you are a practitioner, not a public health officer who deploys the utilitarian calculus exemplified by the classic trolley problem. You treat individuals, not aggregate statistical cohorts, abjuring the practice of hiding behind spurious correlations.
You and those like you, are increasingly becoming statistical outliers.
As a DVM our EMRs are local (ie only used in a single practice) & have been a boon to patient care. I cannot begin to describe how hard it was to find charts, let alone read them pre EMRs!
As patient, I really appreciate having my chart access to my records & those of my family.
Like so many things there are two sides to the Epic EMR coin and I can see how it could be frustrating to madening for those in human medicine.
Pros include immediate access for all caregivers (professional & non), legible, detailed info, reasonable communication path between caregiver & patient (though patients can be unreasonable), easy of sending Rxs, ease of transferring medical info...
Cons: Too many boxes to check that have little or no application to many patients, repetitive redundant entries, no master problem list that prioritizes the problems, clients can panic when reading reports before speaking with their caregivers, difficulty deleting things such as medications no longer being taken & erroneous or outdated entries (at least in my local area, it seems most staff can't simply code that the SMZ-TMP was only used once 2 years ago for a UT!)...