By Mary Jane Minkin, MDClinical Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine; and Obstetrics, Gynecology and Menopause Physician, PC, New Haven, CT.
I knew that I would have problems with our new electronic medical record (EMR) system on the first day of training. The initial training was conducted by a programmatic, not medically trained “yuppette” from the IT Department, who extolled to a 60-year-old Mac user the wonders of the EMR system: you should right click here, single click there (oops, don’t double click!), and then enter some esoteric bit of medical history.
The next session was a breakout session for ObGyns. Among the first wonders they pointed out was the streamlined ObGyn order set. What were the first items I noted? An order for Bence-Jones proteins and “AFB blood.” When I pointed out that I hadn’t ordered Bence-Jones proteins since my medical internship 36 years ago, they were astounded. (Not that these technocrats had any idea of what I was talking about.) I then pointed out that even infectious disease internists never order “AFB blood.” (I am the ObGyn representative to the hospital Antibiotic Drug Utilization subcommittee.) This was also amazing and astounding to them.
I then “learned” how to abstract charts. I have patients whom I have followed since 1979. How do I abstract all the relevant information accrued from taking care of my patients for 32 years? If I have had someone on a bisphosphonate for 7 years, and I am now considering a drug holiday, wouldn’t I need a lot of information to make that decision? Do I enter the result of every bone density and every chart note into the EMR? For my patients who have had different reactions to different oral contraceptives, do I need to enter every problem they had with each different pill? Do I need to enter the details about their preeclampsia from their pregnancy 20 years ago, to help me follow their incipient hypertension? To really do justice to my patients’ records, it would take me probably at least half an hour to an hour to abstract each chart correctly to create an EMR. Who is reimbursing me for my time? Certainly not any regular insurance plan, and certainly not Medicare, which reimburses us a quarter of what previous insurers did for a clinic visit. Do I spend the hour to do things properly, of my own time?
Not having this time, do I then ask my medical assistants to abstract my charts, as most practices are doing? They are lovely folks, but they certainly do not have the experience to know what records are really relevant and which aren’t. I have tried this, but I have already seen two instances where my assistants recorded in the EMR that a patient had osteoporosis when she had a totally normal bone density. (What happened was that they read some code as “screening for osteoporosis” but entered “osteoporosis,” instead of the negative result. So then if I am to be thorough, I need to review every entry from their abstraction, before I click “mark as reviewed.” Guess what? No one is doing this.
Then, when a patient with an incorrect EMR decides to sue us for something years later, and I have clicked “marked as reviewed” on some statement that isn’t totally accurate, will I be held accountable? I think so, do you?