A Doctor's Problem With Electronic Records

Paper medical records cause harm:  They are easily lost and damaged, they disappear during emergencies, and they are often incomplete.  With incorrect or missing information, doctors end up duplicating tests, making uninformed decisions and delaying care.  Patients deserve better.  But are electronic charts really any better?

My first encounter with electronic medical records came when I was a resident just out of medical school.  Our emergency room switched over from paper.  I found paper charts quick and easy to use, and hoped the electronic system would work the same way, but be more reliable.  But the new charts made care more complicated.  Each patient note involved a maze of checkboxes, diagnosis codes, and irrelevant questions.  While my paper notes spelled out whether a patient concerned me medically, the electronic notes garbled the message and hid important information in unexpected places.

The new computer system also drew my attention from the patient.  I often stood turned away, typing on the computer mounted against the wall, occasionally turning my head over my shoulder to make eye contact.  I used a pre-emptive apology -- "I'm sorry. I apologize for having my back to you" -- but knew the excuses didn't make up for the rudeness.  A patient in pain or worried about her pregnancy deserves attention.


My guilt over my poor bedside manner paled compared to the anxiety I felt when some of the outlying clinics switched over to electronic records.  A prenatal record might be five or six pages in handwritten form. The electronic records stretched for twenty pages, sometimes longer.  Laboratory results by themselves ran pages.  Each chart required important information to be painstakingly sorted out and reassembled in a meaningful way.

It's not just me. Looking for relevant information in an electronic medical record is like reading "Where's Waldo," a doctor recently said in the New England Journal of Medicine. He's now taking notes on index cards so that he can refer to them at the patient's bedside. These sorts of stories are particularly worrying given the federal government's plan to pay tens of billions of dollars in incentives to encourage doctors and hospitals to start using electronic medical records.

The problem with the technology is simple: Doctors and nurses use it to communicate with insurers, not with each other.  A traditional note in a paper chart described the patient, what was wrong with him, and what needed to be done.  The new electronic notes tell the insurer a doctor fulfilled criteria to bill for a service. Reimbursements are important; getting paid keeps the doors open at hospitals and private practices.  But thorough, efficient billing doesn't translate to better care.

Several studies show electronic records failed to improve health outcomes, but one exception deserves special attention because it offers hope.  Fifteen years ago the Veterans Affairs healthcare system faced an existential crisis.  A disastrous mix of poor management, unclear goals, and misallocated resources left the future of the VA in doubt.  In just a few short years, the VA underwent a radical transformation that made it a model for quality, affordable care.

The VA worked to improve accountability, integrate services, and improve patient safety. It tracked successes and failures.   A study in The New England Journal of Medicine in 2003 reviewed the VA's dramatic progress.  The VA excelled at doing the little things right: getting patients the right vaccines and cancer screening, providing beta blockers and aspirin after heart attacks.  These inexpensive, easy-to-perform interventions kept costs down, prevented hospitalizations, and saved lives. Along several measures, the VA outperformed Medicare.

Underlying all of this change was an advanced electronic health record system that some experts described as the best in the world.  The system tracked results, improved quality of care, and increased productivity.  A dramatic example of the system's excellence came years later, when Hurricane Katrina hit the Gulf Coast.  The VA Medical Center in New Orleans was evacuated and the one in Gulfport was destroyed.  Veterans from the area who fled almost instantly had their medical records available at other VA hospitals.  They could fill a prescription, see a doctor with access to their records, and resume medical care anywhere else in the country.

The VA's system has had its share of problems. A flawed software upgrade, for example, led to patients' information being displayed under the wrong name  in certain circumstances. (The problem was later fixed with a software patch.) But, to a significant degree, electronic health records fixed problems in the VA that plague our disorganized, fractured health care system. 

If electronic records are only used to optimize billing and improve chart audits, patients will see little benefit.  I doubt my patients received better care from the change.  Electronic records can only play a supporting role in a broader effort to change our troubled system.  Until our health care system imagines patients as more than grist for billing, I will happily take my chances with a colleague's inscrutable scrawl over a phone-book-sized stack of computer printouts.

Alexander Friedman, M.D., is a fellow in maternal-fetal medicine at the University of Pennsylvania. Write to him at Alexander.Friedman@gmail.com

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