Physicians

From the Case Files of the Robert Wood Johnson University Hospital, Dec 2015

May 30-8:12pm: 27 yo teacher, Pam S., is out for her evening run. The delicious evening air fills her nose and lungs. She feels strong, healthy, and alive.

May 30-8:13pm: Pam pushes up a gentle hill. She feels sudden and severe pain, as if stabbed deep by a flaming splinter.  Pam stops, almost falling.  She struggles the mile home. The searing throb begins to fade. A long hot shower gives some relief.

June 3-5:45am: The torment progressed through the weekend and curled around pillows, drenched in sweat, she has not slept all night.  As traces of sunrise light frame her bedroom window, she decides to get medical care.

June 3-9:22am: Pam tells her story to her Primary Medical Doctor (PMD) and is examined.  Her pain is intense with any movement and he is worried. He orders blood work, pain medication and calls an orthopedic surgeon. The PMD completes his history and physical report, as well as his differential, in his Electronic Medical Record (EMR).  The note is transmitted instantly to the surgeon.

June 3-9:59am: STAT blood work is drawn at a lab down the street.

June 3-10:37am: Pam picks up the pain medication.

June 3-11:25am: The orthopedic surgeon reads the PMD’s note, listens to Pam’s story and examines her.  He orders an emergency MRI.

June 3-11:51am: The MRI is performed on the scanner in the surgeon’s office. The images are simultaneously sent to his desktop and to a radiologist, 85 miles away.

June 3-12:28pm: The surgeon is concerned about a possible mass on the scan. The radiologist calls the surgeon and confirms the presence of the lesion, and notes three others. The surgeon meets with Pam and explains the possible diagnosis. He also calls an oncologist, me, who agrees to see the patient that afternoon. The orthopod documents his findings in his EMR.

June 3-3:00pm: Even though Pam feels somewhat better from the pain med, she is frightened. She arrives at my office, carrying only the DVD of the MRI.  The electronic notes of the PMD, the surgeon, and the radiologist have been downloaded into our database.

June 3-3:51pm: After reviewing the records and doing a careful examination, I confirm the likelihood of cancer.  I am concerned about the apparent rapid progression of the disease and even though it is likely the illness can be cured, right now she is in danger. I recommend immediate hospitalization.

June 3-4:05pm: Understanding she may need complex therapy, and possibly urgent surgery, Pam requests that she be admitted to a hospital near her family in northern New Jersey, 47 miles away.  It takes 45 seconds to contact one of my partners in Regional Cancer Care Associates (RCCA), who works at that hospital. He accepts Pam as a patient and agrees to meet her in the emergency room, when she arrives.

June 3-5:27pm: Pam is at the hospital. Even though she has not yet checked in, the electronic notes of the PMD, the surgeon, the radiologist, the lab test results, the MRI images, as well as my evaluation with recommendations, are already in the ER, forming the base of her hospital medical record.

June 3-5:50pm: The curtain opens and her Oncologist, who has reviewed the day’s findings, greets Pam. She begins the road to recovery.

James C. Salwitz, MD is a Medical Oncologist in private practice for 25 years, and a Clinical Professor at Robert Wood Johnson Medical School. He frequently lectures at the Medical School and in the community on topics related to cancer care, Hospice and Palliative Medicine. Dr. Salwitz blogs at Sunrise Rounds in order to help provide an understanding of cancer.

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16 replies »

  1. Thanks… I believe that if physicians are going to control the future of healthcare they must seize IT technology. From my standpoint if someone walked into my office today and said, “great news, we are returning to paper charts, can I get you a pen?”, the only thing I would sign would be my resignation.

    jcs

  2. Dr. Salwitz, In the time I read your reply, I dictated a brief office note on dragon and faxed it(on a fax/server) to a colleague paperlessly. As a matter of fact i can do the same thing on my cell phone! I dont need an emr to do that! My smart phone has better software than my emr!
    So let me get this straight, as you see it, my group payed hundreds of thousands of dollars for am emr system that slows work flow, does not allow me to see as many patients in a day as when I used paper and has the “POTENTIAL” to do good things. I guess I want to know is why I was forced to buy and implement a product that has “potential” as opposed to waiting until it realized that potential. Until then, I will keep paying my licensing fees and dreaming of that “potential” and the flying car we are all supposed to get(at least they won’t make me pay for that in advance).

  3. Rob,
    Note there is a critical difference between faxing and using a fax/server, the direct downloading of information, even if it is still not raw data. I would be amazed if six different providers (PMD,ortho,onc, radiolology, lab, ER) could exchange information by dictating and paper faxing in the “real time” nature of this case, without much more cost (i.e. transcription service & staff) at each site. As per my first comment we will not achieve the full potential of EMRs until we are all working off a single universal national EMR (i.e. air travel or banking) and fix problems such as data input. However, having done it both ways, this is an astonishing improvement and shows the potential.
    jcs

  4. The expensive EMR you have, which cost tens of thousands of dollars “faxed” the data to another provider. Thats progress? I can dictate and fax that copy paperlessly WITHOUT an EMR. The reason I am so strident about this issue is that with all due respect, I think your article misleads the uninformed reader into thinking that providers today are exchanging digital information with the use of these mandated EMR’s. Well you and they are not. Although you pointed out the potential of these systems you conveniently or should I say unobjectively left out the shortcomings, leaving the uninitiated with a false sense of what these systems are capable in todays world. Articles like this grossly undercut the ability of users of this technology to voice credible appraisal because the opinion of the general public has been shaped by articles like this one, that offer an unrealistic, unbalanced and misleading version of what emr’s are presently capable of performing. We dont need more cheerleaders for adoption, we need unbiased criticism and indignation among both providers and health care consumers that will hold these software companies accountable for reaping enormous profits(at my and the taxpayers expense) while providing a product that does not live up to its hype or its promises.

  5. Rob,
    You are partially correct regarding the data exchange methodology. Each of the notes were transitted via fax/server, which is to say they were entered directly into next EMR without going to paper, but are still complete documents, not raw data. The exception being the lab work, which down loads directly into the notes and the MRI images which were shared from the cloud. The EMRs at each site created immediate complete legible records which were transmitted without ever going to paper and were immediately sent both up and down the treatment line, so that everyone was in the loop. Very difficult to do in a short time frame using dictation or hand written notes. My point of the article was to show the potential of such systems, we all know the weaknesses (data entry, common platiform, compatability..). My own work load would be impossible without the use of an EMR.
    jcs

  6. Great article.But Then why extoll the virtues of emr instead of pointing out its myriad of shortcomings? We all know what it should be able to do. Where is the outrage from both physicians and consumers of health care that after all these years emr’s are still expensive, difficult to use, drive up medical costs and have yet to produce any tangible improvement in quality outcomes? The above article would suggest to the uninformed reader that different emr platforms have the ability to interconnect and share data. They do not. That’s a canard. Anyone can fax or email a bunch of notes to other providers. That’s not the kind of sharing of digital data we were promised, and that’s not what we got, but its what this article would have you believe.

  7. I would be wiling to bet that many of those information exchanges you describe are merely the transmission of facsimiles of other providers work and not digital data that integrates with your emr. You dont need an emr to do that or anything else you described above! I can fax a paper record or email a pdf file of my dictation to you just as easily! You dont need an electronic medical record for that! I would be impressed if you could access her primary care physicians file at 3 am when the provider is not manually sending you a copy of their note or if other providers lab values integrated into your system. I consider myself an early adopter as well, as I have been using some iteration of emr since I was an intern. I will say it again however, no industry adopts a technology on such a widespread basis unless that technology improves their efficiency, profitability and produces a superior product or outcome. My state of the art emr does none of those things. What we have been sold and wasted billions on, does not live up to its promises. I too believe in the potential of emr. Just give me a system that does any of those things and I will drink the cool aid and become a cheerleader of adoption. Until then, with all do respect I think you do a disservice by not being a little more objective, to all the physicians that can’t take care of as many patients as they had in the past, struggle with all time it diverts from direct patient contact, and bear the expense for a system that is designed to collect billing and demographic data and not improve the patient physician experience.

  8. WOW. Not a fable, fact? Wow. I’m gonna assume that every facility in the chain was on the same EMR system, ’cause that would have to be the case to have this interop fully, right?

    And boy howdy are you right in your observation that “EMR” is just a dream until, like banks, the entire system works from a single database …

  9. Ron,

    I appreciate your skepticism. This is actually a true story that happened last Monday. That is why I wrote the piece, because it shows the potential of EMR based medicine. By chance the patient moved from caregiver to caregiver who had each fully implemented electronic systems. There reality still exists that even in my community, which has a large number of early adopters (our practice has been EMR based for 13 years), this was the exception, but it is an exception that shows the potential in such systems. In the end we will not be fully “EMR” based until we, like banks, work from a single database.
    jcs

  10. You are either very naive or you have never worked with a moderm electronic medical record system. Either way, I am in pocession of a large bridge you may be interested in purchasing. Please contact me offline for the details.

  11. Not in my world it doesn’t. Offices in hospitals next door to each other cant communicate due to lack software compatibility. We have doctors here whose offices are IN the hospital, but the outpatient emr won’t communicate with the in hospital record. Put in another way, the data won’t even transfer WITHIN the same building! Even though we have the latest and greatest emr, If Dr Salwitz were to consult my group he would not be able to electronically send the record to me unless he faxed it! Hows that for cutting edge technology!

  12. Wow, I love science fiction. The dream of what tomorrow’s technology may bring us. You forgot the part where the doctor drives home in the flying car we have all been promised! I guess it would have been great to have these features and inter connectivity BEFORE emr was forced upon us. No, that type of functionality isnt important to the bean counters and those who want to mine demographic data all under the guise of the promise of improved health outcomes and diminished costs, which are surely just around the corner(just like your nuclear fusion powered home)! Im sure the preliminary data we have now demonstrating increased costs and no improvement in outcomes with emr are merely a preverecation generated by those Neandrethals who do not think the technology is sufficiently advanced to be widely adopted.Until then though, it’s not a crime to wax poetic about all the really, really neat stuff that is just around the corner. I promise!

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