From EHR to Paper to EHR .. to Paper??

I can’t help myself from telling patients how things really work in health care. But I feel they have a right to know.

When I see new patients their jaw usually drops when I sit down with them next to the computer with a stack of papers held together with a rubber band or a gigantic clamp and with yellow sticky notes protruding here and there with words like LAB, ER and X-RAY.

Patients always assume that medical records transfer seamlessly between practices. They don’t, even between clinics that use the same EMR vendor. The stack of papers gets scanned in, as images or PDFs, but they don’t appear in searchable, tabular or report-compatible form. Often, they don’t each get labeled, but are clumped together under headings like “Radiology 2010-2017”.

In one of the clinics I work in, a Registered Nurse enters patients’ medical history in the EMR before each new patient’s first appointment. In the other, it is my job. In both cases, only a fraction of he information is usually carried over from one EMR to the other, and the patient’s life story risks getting diluted, even distorted.

It doesn’t take much imagination to understand why things work this way:

Once upon a time, the Rulers of a great country handed out money to all the medicine men so they could start using computers to document what they did (and what they charged for, which was the real reason the Rulers handed out money the way they did).

This was a gift, not only to the medicine men but also to a lot of computer companies, who quickly geared up and made EMRs that the medicine men needed to buy before the deadline the Rulers had imposed.

Soon the medicine men gave all their newfound money to the computer makers. One of the things they thought they remembered hearing about was “interoperability”, but the computer makers were no fools. By making it just about impossible to transfer data between EMRs, the computer companies figured they could keep their respective customers hostage, because no matter how much they hated the slapped-together systems, it would be too costly to start over with another system.

Eventually, each vendor secretly hoped they would end up with the most users and thereby becoming the industry standard when the medicine men and the Rulers caught on to the lack of interoperability.

That, I explain to those of my patients who were around for it, is like the early days of VCRs – Betamax or VHS – more than 100 times over or, think about it, 100 times worse.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine.

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10 replies »

  1. In my opinion, EHR development and computerization of medical data have many benefits for patients and medical providers. I suggest you should take a look at this to find out more about its potential in detail.

  2. Digitization in healthcare is growing exponentially and this journey towards smart health will help solve major challenges. Solutions like patient referral management, chronic care management, and care management will help solve many challenges. These solutions can easily integrate with the providers current EMR/EHR and seamlessly help share patient information. Help providers give better care to their patients and see better patient outcomes. Learn more about HealthViewX solution. To know more please check http://www.healthviewx.com

  3. Do you know that what is the biggest catch is technologies like healthcare IT that has made and evolved EMR/EHR? No matter how stubborn the technology is, it has a track record that it can solve the problems that it creates by itself. No matter how capable and genius man becomes, in the end machines win. It is like that since time immemorial. So, it is useless to cry over spilt milk for now.

  4. I hate EHRs that get printed and faxed to me. Endless pages with boxes checked about sunscreen usage, the flu shot, wearing seatbelts..IN EVERY ENCOUNTER. The data is such a jumbles mash, you can’t find one document that can be printed and succintly summarizes med problems, surgeries, exam findings. There is no interoperability. I’ve stopped asking for medical records and I just interview the patient and try to to get drug info corroborated by a phone call to the pharmacies. Yes, this is where I’m at. I’m back on paper. Done done done.

  5. In fact, interoperability might give us worse outcomes because we might be relying too much on spurious and error-ridden records from other providers.

  6. You’re a retired chess expert. You wander about central park on warm summer afternoons and kibbutz and chat with all the amateur players. As you size up their games, you don’t need to know all their previous moves, you only need to know the present state of the board…the contemporary architecture is all that is needed. Its history and how the board got to that state is immaterial to your advice.

    Almost all patients present pictures that give you enough to go on to allow you to do a good job. This is because the status of “health” is always changing anyway, new knowledge is constantly entering this discipline, and many tests and procedures and input data need to be repeated and updated simply because there are normal human errors in all the data presented in the patients’ record.

    We see a dynamic fluid picture and exactly how the patient got that way is not THAT important. Interoperability seems thus a need arising from some other stakeholder, not the doctor or patient.

    I admit that rarely this assessment is not correct and we do need historical records. But, really…how common is that?

  7. I have to work in real time quite a bit. Only have a couple of hours to get records a lot of the time. If the patient had been cared for in my hospital in the past, things were usually pretty good, but anything that came from another system we just couldn’t get as a rule. Then I was constantly put in the position of having most of what I needed come with a patient for a totally elective procedure, then having to decide if I should cancel and wait for that last 10% of information, or go ahead because it probably wouldn’t change things.

    Now, I have the choice of reading terrible EHR records from other places, or paper records that just say stuff like “Echo OK”, meaning the EF was 20% but not changed from an old one (which I don’t find out until we are intra op and struggling with BP and have to drop a probe) or, my personal favorite, forgetting to mention that severe pulmonary HTN. Or maybe my favorite is forgetting to note that odd syndrome/genetic abnormality my 2 year old has. So hard to choose. So maybe as an outpatient guy, this isn’t much of an issue, but as an inpatient guy, it looks to me as though paper records have/had problems too, just maybe different. That, plus I actually find it useful to pull up an actual echo and run it through and see for myself or look at old films, which I can do in the middle of a procedure, or from anywhere in the hospital or even at home. Couldn’t do that with paper.


  8. We’re on paper (out-patient medicine) and it’s a non-issue – a well-trained staff is easily able to get everything we need before seeing the patient.

    For the vast majority of physicians, interoperability is a red herring. Who has the time or interest or the need to review terrible EHR records from other institutions?

  9. It would be nice if the different EMRs talked with each other, but then let’s remember wha tit was like when everything was on paper and you couldn’t obtain any information at all from another hospital without lots of lead time, and even then with a lot of trouble.