EHR Can Make the Paper Problem Worse

Once a persons record has gone electronic, it really should never go back.

A paper printout of an Electronic Health Record is often huge and unwieldy. If it is printed out or faxed it creates something so huge that it is pretty impossible to be useful in a paper record.

This is the reason why need electronic interoperability solutions like the Direct Project. Without it, when a patient leaves one doctor, they have to print out an electronic record, take it to the next doctor, and then have that doctor scan the record in.

That doesn’t sound too bad until you realize that a patients printed EHR record often looks like this:

This image was provided to me by Jodi Sperber and Dr. Eliza Shulman, who generously agreed to share the photo under a Creative Commons license. Here is the full description from Flickr, which provides greater context.

An example of why interoperability is as important as the electronic health record itself.

The story behind this photo: This is a printout of a patient’s medical record, sent from one office to another as the patient was changing primary care providers. An EHR was in place in both offices. Additionally, the EHR in both offices was created by the same vendor (a major vendor); each health organization had a customized version. Without base standards the systems are incompatible. Instead, the printouts had to be scanned into the new record, making them less searchable and less useful.

Note that this was not the entirety of the patient’s medical record… Just the first batch received.

Fred Trotter is a recognized expert in Free and Open Source medical software and security systems. He has spoken on those subjects at the SCALE DOHCS conference, LinuxWorld, DefCon and is the MC for the Open Source Health Conference. He has been quoted in multiple articles on Health Information Technology in several print and online journals, including WIRED, zdnet, Government Health IT, Modern Healthcare, Linux Journal, Free Software Magazine, NPR and LinuxMedNews.

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12 replies »

  1. http://sociedadvirtualmusic.com/?page_id=96
    ***This is a link to a blog about the EHR implementation. Its in spanish (use google translator) In resume, it concludes that the patient is going to be affected by the closed “EHR” networks that are developing, since the provider’s desicions are becoming purely economical. Althougt these networks are supposed to share the information, they purposedly make it very difficult to those outside it. Those providers such as labs and xrays facilities that are not part of the monopolistic network, will be left out from giving services to patients.

  2. I think all of the people finding the unwieldy amount of data useless might change their opinion if it were computable and perhaps used in ways they have not imagined yet. I mean Google indexes billions if not trillions of pages, but when your search is focused it’s indispensable.

  3. I thought it was more of a unwieldy, unsearchable, uncomputable format problem rather than usefulness of content. Content is content, but searching for something specific in electronic data is way easier than paper.

  4. It’s in part intrinsic to an EHR as EHR printouts contain info that normally would not appear on a provider document.

    Also, templates become a problem if they are not individualized to a specific provider and/or specialty.

    Documentation is only of secondary importance for physicians. There is a dynamic that is little unproductive: EHR leaders (programmers, physicians, usually PC, and maybe administrators) buy programs and do some adjustment, often with very little input by the majority of actual users. No wonder if templates or other features are not used well.

    Not that I like the pre EHR era that much, but doctor’s notes were fairly concise documents. The EHR changed that.

  5. It’s probably time to start noticing that ‘garbage” is not intrinsic to an EHR, but is usually the result of sloppy template creation or usage.

  6. I am not in health informatics, but my superficial reading on THCB and elsewhere, as well as discussions with people involved in one of the major EHR indicate that no one recognizes the major problem:
    that EHR of active patients, over the years, turn into huge piles of poorly structured information, with a lot of distracting and/or even outright irrelevant info hiding what you are looking for. Paper notes are usually concise, while electronic notes tend to add autmated info that is often irrelevant …

    I am sure there will be lawsuits with the plaintiff’s lawyer pointing out that some piece of relevant info was “right at the (defending) doctor’s hand”, even though it may be buried in a huge pile of garbage.
    Storing information is one easy thing, organizing and making it accessible to the user another.
    … and the more important issues is the one of document organization. I noted that powerchart has an excellent oragnization of past notes, that, with one or 2 intuitive clicks, you can search very easily. With Epic, you have to either screen a whole barrage of notes, or you have to set up filters, which is cumbersome and error prone (for instance, if a system is set up to make the mistake of filing the same note type as “cardiology” or “adult cardiology”

  7. It shouldn’t. There is usually a button somewhere that says export CCD (like Bobby describes above). There may be a selection, or configuration, somewhere to choose how far back you want to go with, say, lab results, if included. It differs in various software products.
    To print out the entire chart is very easy. There is a button for that too – export to PDF. May take a while to complete…..

  8. I am not saying that EMR vendors are not to blame… HOWEVER 🙂

    Is it fair to blame a billing/documentation database (which is what an EMR is in essence) for dumping out everything it has on that patient – if that is what the hospital asked it to do?

    To further what Margalit is talking about…
    It will be a good poll to the PCPs/Hospitalists on this list – how often do you read the copious patient notes from prior hospital stays (assuming you do get access to it)? If not that often, then what do you find most useful? I am guessing a discharge summary…


  9. Fred,
    Electronic interoperability, as in the Direct Project, and what shows in that picture are not equivalent or interchangeable.
    If you want the whole enchilada, it will have the same exact size in paper and in bits and bytes. If you find it daunting on paper, I hope you are not expecting any physician at the receiving end to read the electronic version. Maybe we should have an EHR reader for the Kindle.
    If you just want a summary, like Bobby mentions above, you can move it across the network with Direct, other means like eCW has, or print a human readable version, which will measure in microns on your ruler above.

  10. From the Wiki:

    “The CCR standard is a patient health summary standard. It is a way to create flexible documents that contain the most relevant and timely core health information about a patient, and to send these electronically from one caregiver to another. It contains various sections such as patient demographics, insurance information, diagnosis and problem list, medications, allergies and care plan. These represent a “snapshot” of a patient’s health data that can be useful or possibly lifesaving, if available at the time of clinical encounter. The ASTM CCR standard is designed to permit easy creation by a physician using an electronic health record (EHR) system at the end of an encounter.

    Because it is expressed in the standard data interchange language known as XML, a CCR can potentially be created, read and interpreted by any EHR or EMR software application. A CCR can also be exported in other formats, such as PDF and Office Open XML (Microsoft Word 2007 format).

    Continuity of Care Document (CCD) r1 is a HL7 CDA implementation of the Continuity of Care Record (CCR)…”

    I’m sitting here right now with eClinicalWorks 9.0 open via a remote desktop login. It has a top drop-down menu item labeled “CCD” via which you can export, import, encrypt/decrypt a patient record export/import.

  11. Aren’t EMRs just wonderful? *his voice dripping with sarcasm*