Saturday, April 24, 2010

More on the Electronic Monster

We like to bicker about Electronic Medical Records here at Shrink Rap. They give Roy's life meaning. Clink and I are more ambivalent.

In An Unforeseen Complication of Electronic Medical Records, Dr. Paul Chen (NY Times, April 22nd) writes about trying to pay attention to the patient and the computer at the same time:

“EMRs are a phenomenal contribution to care,” said Dr. Ann S. O’Malley, lead author of the study and a senior researcher at the center. But there is often so much information available — some of which requires a direct and immediate response from the physician — that “some doctors liken the presence of EMR to having a 2-year-old in the exam room.”

As all parents can attest, while a 2-year-old can create chaos in any situation, a setting that is as delicately balanced as the clinical one runs the risk of falling into complete disarray. Doctors often must consider several issues simultaneously when seeing a single patient — all the potential diagnoses and possible treatments, the patient’s history and list of medications, any possible adverse effects or interactions, the limits of that patient’s health care coverage and numerous preventive health issues, to name just a few of those considerations. The addition of an electronic records system can push some doctors into what one EMR expert refers to as “cognitive overload.”

“The whole point of EMR is to simplify the process and to enhance and facilitate communication,” Dr. O’Malley said. “But in order for that to happen, EMR needs to be more user-friendly and more responsive to the clinical needs of patients and clinicians.”


Anonymous said...

I've seen three doctors who use EMR. One dealt with me as usual, then entered info when I left. I liked that, but since she didn't take notes, I wondered if she was forgetting anything. Another uses it relatively easily, although our conversations can be stilted as I wait for her to enter things. It gets awkward. And the third never looked at me, just the screen, so I left that practice.
I think EMR can be great, but they have to be used with the realization that the interaction with the patient can't be compromised. Doctoring is not all about data entry.

Unknown said...

EMR can be great - a patient's history is right there and changes easily inputted (assuming the doctor is comfortable with it). The downside to me (as a patient)? Doctors can be terribly paternalistic, and sometimes I don't want to share all information with all doctors - I want to make my own choices, even if it may be against the medical advice of some conservative doctors worried about a lawsuit.

Anonymous said...

Yeah, major problem! I guess this is a case where the iPad might actually help. It's easier to hold a tablet and look past it to your patient like with a paper chart, whereas with a desktop you have to turn around away from the wall to look at your patient. One physician at a large practice that uses EMR still writes on paper -- I guess he has his assistant enter the info later? Another two I've seen spend the majority of their time staring at the screen entering data. Also, in the old days of paper charts, it was possible to take a minute and look at the chart before entering the room, so the physician could have already refreshed her/his memory before focusing on the patient. If you stare at the computer, you can miss a lot of information your patient might not be quite saying verbally. It's nice to be able to look at test results from home, and for doctors to graph trends on the fly. But I fail to be convinced that it actually helps patient care.

Anonymous said...

I think the EMR is definitely something patients should think about when sharing very personal information. With an electronic medical record there is easier access, and while it may seem like what you said is just between you and the psychiatrist when it comes to an EMR it's likely between you, the psychiatrist, and every other physician, nurse, speech pathologist, physical therapist, nutritionist, etc who accesses your chart. I think many people would think twice about sharing some of what they do if they realized the EMR is open to so many other people and is so easy to read. Psych records should stay in the psych dept unless the patient understands and agrees to their release.

Things to think about if you are seeing a shrink who is part of a hospital/university who utilizes an EMR that's open to other health care professionals. Are you okay with your dermatologist knowing you're a victim of incest? Are you okay with the nurse in the cardiology department knowing you questioned your sexual identity? Or that your husband cheated on you? Or that you cheated on your husband? Or that your parents are divorced? Is it relevant? I say it's not, unless the patient says otherwise. However, the way the EMR is set up in many hospitals is that they believe it's all relevant so in many cases they give access to this juicy information to whoever looks at your chart. Be prepared for that. Privacy is much more of a problem, in my opinion, with an EMR.

I would not see a psychiatrist or other mental health professional who used one unless I knew for a fact that it was not open to other health care professionals.

Anonymous said...

I became very interested in privacy issues because of a situation where psychotherapy notes were not kept in the psychiatry department but as part of the general medical record - and ended up causing a big mess.

Several years ago a patient told a psychiatrist that a previous therapist had done something illegal which was the truth. The patient never named the therapist, but teh psychiatrist got confused and wrote in the patient's medical record that the subsequent treating therapist was the one who the pt said engaged in illegal activity. The patient was unaware of this mistake and was also unaware that the therapy notes were part of the general medical record (as she had incorrectly been told they were kept separate).

A couple of years passed, and the patient saw a dermatologist on more than one occasion, she saw residents, medical students, nurses, a primay care provider, etc for various other reasons, not realizing the therapy notes were accessible to all. One day the pt notices the medical record lying open and sees a tab marked psychiatry. It is then the patient realizes the therapy notes are not only accessible to everyone she has seen, but that they incorrectly named her subsequent treating therapist as the one who engaged in illegal activity. Imagine how this patient must have felt.

It was an honest mistake, however the therapist who did nothing wrong had her named dragged through the mud time and time again as each person accessed the medical record. What about that therapist's right to privacy? What about other cases where it's not a mistake but the patient has lied about what someone has done?Does this person get a chance to defend themselves? No, they don't.

In the case above the record was not an EMR, but it illustrates why it's a bad idea to include psychiatry notes in with the general medical record. One, the patient was harmed because of this breach of privacy and her concern for her therapist who was slandered, and two the person who was incorrectly named as engaging in illegal activities had no opportunity to defend her name. Her name was handed around to the dermatologist, the medical students, the nurses, etc, etc. If these records were kept in the psychiatry department as they should have been very few people would have seen them.

Next time it could be your name. Think about this when you put things a patient says about someone else (or things you think they said) in the medical record, and even more so when it's part of the general medical record that so many other people are accessing.

Dinah said...

I, too, worry about confidentiality issues with psychiatric records and don't believe psychotherapy notes have a place in the general medical chart.

If it's any comfort, I don't think that busy medical professionals would read psychotherapy notes (not that it's fine for them to be accessible). I know when it comes to handwritten scrawl and check marked boxes, I read as little as possible. When I read electronic records, I scroll straight to the issue of interest---if a patient complains of poor appetite and weight loss, I may look to see what his weight was six months ago. Mostly I want the diagnoses, med lists, and impression/plan.

I can't imagine a dermatologist who would want to know more than say my thought that anxiety may be exacerbating an itching problem and perhaps an ssri might help...or something along those lines. Therapy notes? Only if the dermatologist has a very boring life. Obviously just my conjecture here.

Anonymous said...

Dinah, I appreciate your comments. I hope in the case I mentioned that people did not take the time to read the psych notes too closely. It was kind of interesting that the only discipline that had it's own special tab in the chart was psychiatry. It's almost like it was a neon sign suggesting the good stuff was behind the tab. So, I did worry about that.

Unfortunately, the psychiatrist had very nice handwriting so it was quite easy to read. I do hope people didn't take the time to read it, though, because this therapist is very well loved and respected. To even think that someone might have questioned her integrity is upsetting.

When I think about this topic I tend to get pretty passionate about it because of the harm that was done, even though it was certainly unintentional. If I knew something I could do to prevent this from happening again, I would do it. We were able to makes changes at that one location, but I know that this could happen anywhere that records are combined like this.

If I were to guess most mental health professionals probably do share your opinion about keeping psychotherapy notes separate from the general medical record. I think that's why I was so surprised to actually encounter a couple of different EMR's where they're not separate. It's just so easy and quick to skim a typed page, much easier than taking the time to decipher someone's hen scratch.

Maybe, there should be a separate informed consent in cases like that so the patient is well informed and it's not buried in an ICD somewhere that they've signed. It's just such a sacred trust, and I know from personal experience that my dermatologist has been quite successful at mole removal without knowing about a disagreement I may have had with my mom back in 2002. :-)

kwkeirstead said...

I really don't understand where the notion that EMR's can be read by anyone comes from.

The usual setup is access on a strict need-to-know basis where each healthcare worker has access only to relevant portions of an EMR.

In respect of data exported from the EMR to various 'subscribers' the access restrictions go down to the individual data element level.