Posted by Bill Sandweg on 28 December 2020.
One of the requirements of federal law is that hospital records be recorded electronically. The requirement for electronic medical records (“EMR”) has a number of justifications, including portability. Patients are entitled to have a copy of their medical records. When the record was paper, that meant someone had to copy all the paper. The patient had to pay for the time of the person copying the chart and for the cost of the copies. A chart of almost any length could get quite expensive. With electronic records, the patient, who asks for a copy, is given a computer disc onto which the records have been transferred. It takes only a few minutes to make the disc and the cost, if any, is minimal.
Another reason for mandating EMR’s is that, much like the patient copy, the records are now easily transferred from institution to institution. When patients are transferred to a new hospital with a higher level of care, their chart can be put on a disc and sent in the ambulance or helicopter with them.
Other reasons offered for requiring EMR’s are cost savings, better communication, the ability of multiple practitioners to have access to the chart at the same time, ease of making entries, reduction in prescription errors, and reduction in adverse drug interactions (because the computer can flag the potential interactions). With all these wonderful things going for them, I almost feel guilty complaining about EMR’s.
EMR’s make my job as an attorney for patients injured by medical malpractice more difficult. They make the chart harder for me to read. Because information can be entered with just a quick keystroke, more information gets entered than if the nurse or doctor had to enter the information by hand. The EMR is much larger than a comparable paper chart would be.
One of the biggest failings of EMR’s, in my opinion, is that they pretty much force the person entering the information to choose from “drop down boxes.” Nurses are the providers most often faced with this problem and it makes it more difficult for them to accurately convey the condition of the patient. For example, when I review the EMR from an emergency room visit, I see the following, “The onset of the problem was ______.” The nurse has to click a box over the blank space and a number of choices will drop down. These choices are something like “slow,” “rapid,” “insidious,” or “progressive.” The nurse must choose one of these to fill in the blank, even if there are far better ways to describe how the condition began.
EMR’s naturally assume a cookie cutter appearance. The level of detail is limited by the imagination of the person who establishes the template that the nurses have to fill out for each visit. Each visit appears very similar to every other visit. If the person creating the template does not offer many choices to the nurses, they cannot do a good job charting. And because one of the goals of the charting from the point of view of the person creating the template is to encourage easy and quick charting, the tendency is to offer few choices so as not to slow down the process.
Another problem for lawyers like me is that we are at the mercy of the hospital computer people. With a paper chart, the chart is what the chart is, although there have always been a few loopholes. With the EMR, the data is in the computer and the hospital and their computer people decide what I get when I request a copy of the patient’s chart. For example, Hospital A may decide that hourly temperature checks, which are in the computer, need not be a part of the patient chart and does not include them when I ask for the chart. Hospital B may decide to include hourly temperature checks but to exclude something else. While I can see what they put in, I cannot know what they decided to leave out. I may never see information which is critically important to my client’s case and may never know that it was in the computer all the time but never produced by the hospital.
There are a number of companies that produce templates for EMR’s. Much like the old wars between videotape players, their systems are not compatible. Things will be a lot better for everyone when hospitals settle on a single format for EMR’s.
The final problem for me is one of overwhelming quantity. If the hourly temperature checks are included, they may appear in two or three different parts of the chart. It is hard to find things because the record is cluttered with information I have seen ten times before in other places. It is like trying to get a sip of water from a fire hose. Written charts that would have fit in one three ring binder, now occupy three binders. This may be good for the people that manufacture paper but not so hot for me.
Electronic Medical Records are here to stay but they can certainly be improved. I am not holding my breath. Nor should you.