How Honest Is the EMR?

Rebecca Bechhold, MD

Have you ever read someone’s note in the EMR and noticed it says “normal” in every section under physical exam, when in fact, the patient has had a mastectomy, a markedly enlarged liver, 3+ edema, or (horrors!) an amputation that goes undocumented? Not because the clinician didn’t know, but because it is tedious to go through the template in the EMR and enter in all the findings. Worse, the note then gets “copied” and the error lives in perpetuity.

I find it annoying that so many doctors set up their template to include everything in the record-all meds, all lab, all imaging results, etc. It makes the note ridiculously long and difficult to get to what I really want to see, which is what is going on with this patient? If they are the consultant, I want to know what they think and what they recommend. If I am asked to be the consultant, I want to know what the question is for me.

My colleagues insist that the reason for this format is to “prove” that they reviewed all the data in case of litigation. Honestly, having the data printed in the note does not mean you reviewed it. Auto population of a field is just that. IT can track your every keystroke, so they know if you went to the results page, how long you spent there, and even if you actually scrolled through all of the results listed. Having data automatically listed in a note does not prove you interpreted it and used it appropriately to treat the patient.

There are some great things about the EMR-I love the dashboard feature where you can get a graphic summary of data that you can actually read and see a trend. A drastic improvement from reading hand-drawn numbers, lines, and dots. I no longer have to try and decipher doctors’ handwriting, and I read the entire nurses’, social worker’s, and chaplain’s notes, which can be incredibly helpful.

In our region, everyone is not on the same system and they do not all talk to one another, so we still get some records faxed or hand-carried. Have you experienced the single lab result that takes four full pages to print? Even the records you can view on a computer are often page after page of predetermined queries and stock answers that are repetitive and irrelevant after the first visit, but they take up space and once again make it difficult to actually drill down to the problem at hand.

Personally, the hardest part about having boxes to check and smart phrases to choose from is that it makes it impossible to express nuance, feeling, and instinct about the person. There is a limited allowance for free text in some EMR, but I see few clinicians utilize it for the personal details I find enlightening when treating someone. At this time, our office is still using dictation to supplement our EMR and I need it. My patients with long, involved histories are not easily summarized. I also value documenting my decision-making process and how the patient, family, and I came to our decision. It can be helpful to look back at that for myself but also for a covering physician if necessary.

The EMR is for data collection, and I get that and I support it for standardization, guideline management, and cost control. But you cannot express the emotion and anxiety that is part of oncology care in a prepackaged document. We still do not have an optimum tool specifically designed and supported for oncology. Our practice has used three different chemotherapy ordering systems as well, and that is yet another tool that has not been optimized.

With the lust by payers and the government to get raw data, I am confident that the EMR for oncology, the most expensive specialty, will continue to evolve and improve, but as it does, I hope it does not abandon the most important detail-the person that data represents.