Electronic Medical Records

A lot of discussion has gone on recently by the proponents of electronic medical records, including the current administration. I have discussed them before but wanted to take another look, including the views of a user. The military has already implemented an electronic system which was originally called CHCS (Composite Health Care System). When it was first introduced, it provided some valuable services despite its user unfriendliness. It allowed students and physicians to access laboratory results and radiology results without having to trek down to each department and go through a log book to retrieve them. When I was first training in medicine, that is exactly what we had to do each morning and evening. From that stand point, CHCS was a boon to efficiency. Those same tests could be ordered in the system although there was a learning curve as the names of the tests were not very intuitive. There were a lot of problems with the system. For example, if a laboratory technician entered an order from a drop down menu under the incorrect physician’s name, the results of the test would be returned to that physician and that physician would be asked to electronically sign the order. There was no way to correct the mistake. Even the administrators of the system could not fix them. Physicians were constantly receiving results and signing orders on patients they had never met. Rather than quibble on the other inconsistencies and problems with that system, let us move on.

The next iteration of the system was originally CHCS II, but has subsequently been renamed AHLTA (Armed Forces Health Longitudinal Technology Application). The AHLTA system has many of the same advantages in that no matter where you go (in theory) your drug allergies, medications, past medical history, etc. are available to a new physician to whom you present for care. That is not entirely true as I have been deployed eight times in the past five years and have never had access to the AHLTA system on any deployment. While the AHLTA folks consistently crow about the advantages of the system, they never discuss what it is like to use it. Let’s look at some of the results:

The Navy has decided that in order to improve efficiency, they want the physicians to see seventy five per cent of the productivity of major Health Maintenance Organizations (HMOs). Part of the reason is to lower costs, and part of the reason is that they are having trouble keeping enough people in the Navy to serve the patient population. In the brick and mortar hospitals, the current requirement for a General Surgeon is to see forty five clinic patients a week (based on HMO productivity). If that is only seventy five percent of what an HMO doctor sees, why should that be a problem? First, the average physician in civilian practice averages four support personnel per physician. The civilian practices know that the only person in a surgery office that makes a dime for the practice is the surgeon. Therefore, people are hired to keep the surgeon from doing anything which is not billable. Record keeping, billing, coding, telephones, communication, cleaning, education, etc. are all handled by trained assistants, freeing up the surgeon to do surgery and outpatient care for which billing can be generated. In the Navy, there are four physicians for each support person. Those people are Civil Service and we all know how much incentive the Civil Service has to work hard: none. Therefore, Navy physicians type their own notes, write their own consults, fill out their own preoperative and post operative packages, make phones call, schedule procedures, etc. I forgot to mention above that those forty five patients have to be seen in only two clinic days a week. Broken down evenly, this means twenty two patients on one clinic day and twenty three on the other.

Meanwhile back at the AHLTA system: Even after the training required to use the system, it is so cumbersome that trying to find your way through it is very time consuming and frustrating. I know how bad it is for surgeons. I can’t imagine how bad it is for primary care physicians who see such a wide variety of diagnoses. There are templates which can be customized for a specialty, which can save time but any unusual case will take a lot time to do the note. Additionally, the system can not keep up with the amount of usage so it is slow and crashes regularly. I have found the average AHLTA note to take between ten and twenty minutes to do even with a template. Therefore, twenty two times fifteen minutes equals three hundred thirty minutes. That is five and one half hours a day entering notes into AHLTA. If a surgical appointment is 20 minutes long, that means four hundred and forty minutes, or seven hours and twenty minutes a day talking to and examining patients. So far, we are up to twelve hours and fifty minutes each clinic day. Why do patients go to see a surgeon? Because they might need an operation. Assuming that only half of the patients need surgery, that means eleven preoperative packages (preoperative orders, admission paperwork, consent forms, notice to parent command, history and physical examination, etc.) need to be completed in addition to the AHLTA note for those eleven patients. Just for argument, let’s say that they only take fifteen minutes each (not realistic). That is another three hours and forty five minutes a clinic day. Now we are up to fifteen hours and thirty five minutes each clinic day. That is assuming that the physician never goes to the rest room, eats, or takes a break from paperwork. Additionally, the physician needs to round and care for inpatients which requires going to the ward or intensive care unit. Does anyone wonder why people leave for increased salaries and lots of administrative support?

Another phenomenon of the electronic record in the military is that performance evaluations have become partly based on the amount of relative value units (RVUs) billed as interpreted by the coding of each visit by the system. Subsequently, the smart physicians have learned to “game” the system and turn every visit into a coding bonanza with their templates. The coding is not based on what you do, it is based on what you write. Therefore, the smart ones learn to produce templates that over code visits by entering extraneous and unnecessary data into the AHLTA system. If you do what is considered a normal work up on a patient, you will fall way behind the coding curve. Since everyone is now forced to play the competitive coding game for advancement, even more time is spent on the computer entering redundant and irrelevant information.

Another interesting thing about the AHLTA system which has not been improved is that information, once entered is almost impossible to remove. Errors and diagnoses follow the patient around like a bad tattoo.

I wonder about the wisdom of a central repository of private medical information. I can see not only hackers but the Orwellian use of that repository for behavior modification and other abuses. It will not be hard for advocates to argue that anyone with a risky hobby (e.g., surfing or skiing) or diet should pay more for insurance or might not be looked on as favorably for employment. The proponents will argue that the privacy of the system will be guaranteed but if it is available to any physician (as it has to be to provide medical safety), it will be available to nearly anyone eventually. I believe a better alternative is for the government to establish standards for the format of electronic medical records and have them stored locally at physician offices or hospital records facilities. If records are required in another location, a secure and verified request can be made for those records and they can be instantly electronically transmitted to the requesting location. That system would also allow tracking of who requested records and for what reason. That should reduce the incentive for anyone to pry unnecessarily and would increase privacy.

Proponents of the electronic medical record argue that they will reduce medical errors by having allergies and medications available. That is intuitively true. I wonder how many errors will be produced by the lack of time to talk to and examine patients caused by the increased requirement for computer time to input data. If you want to reduce errors and provide better care, get some support personnel for the physicians so they can spend time taking care of patients and have some “scribes” enter the data into computers.