The Electronic Patient Record
Probably nothing of modern progression in medicine makes a physician’s eyes glaze over as much as the introduction of the electronic patient record. And it may well be that nothing has helped medical care as much while seeming to interfere with that care so greatly.
You will be hard pressed to find a physician who likes the EPR, and even patients would complain about the changes it produces, if they knew the connection.
I am an exception, but I have to be. One of my current jobs is to teach other physicians how to use our EPR, and I am currently writing a physician guide for changes that are soon occurring in our cancer center.
What is a patient record?
The repository of patient information used to reside in the doctor’s chart, paper based, in as many offices as there were doctors involved in the care. Usually it was the GP, the primary care physician, the Family Doctor. They would keep hand-written notes supplemented by reports of x-rays and laboratory tests, and possibly also Consultation notes from specialists to whom the patient was sent. The organization varied, chronological, reverse chronological, labs at the back, problem sheet at the front, demographics in the inside front file folder. There are almost as many ways as there are doctors, to tell the truth.
Over twenty years ago, the law, in Ontario at least, became clear. The physical chart belonged to the physician, or group, or hospital, or clinic, but the content belonged to the patient. The individual holding the record had the right to charge the patient for copying and explaining the chart, but has no right to withhold the contents from a mentally competent patient, or patient’s legal representative.
By law, the chart must remain intact for a period of time after the last known entry, and that time varies with institution, but is usually at least ten years. By standard, the contents should tell a story that any adequately trained health care worker can interpret, and in particular, physicians were cautioned to create a chart that any of their colleagues covering for them would be able to decipher.
What is an electronic patient record?
Well, it’s the same thing, except it is made of totally recyclable electrons. It is basically information, and again, the structure on which it is maintained and displayed may belong to the health care worker or institution, but the content belongs to the patient. This conceptualization has a lot of subtle results: to give just one, the physician cannot simply go and use the information of any old reason, without the permission of the patient. For example, there is a PET scan on this blog of a real but anonymized patient. I received that patient’s permission before using it in this fashion, even though it is doubtful that anyone could know who that patient is.
What are the advantages of an EPR?
Well, it’s just huge; and it is hard to know where to start.
The EPR can, and does, exist at many different places at the same time. I can be entering orders on my patient while another physician is looking up results, a nurse is reconciling administered medications and a radiology department is reviewing bookings for the patient’s upcoming tests. There is no longer a single binder with the patient’s chart.
Old charts are readily available, and copies of all or part of the chart may be available to anyone with appropriate access, even in other jurisdictions. Searching for and storing old records are a thing of the past.
I can access my patients’ charts (from my institution, and from several others) from virtually anywhere; I have been known to follow results and enter orders on a patient from the comfort of my cottage by the lake, four hundred miles away from my place of work.
Results on my patients can be organized and sent to me according to specified criteria: abnormal results can be highlighted, and no result will go away until I sign off on them. Order entry captures allergies and drug reactions that may interfere with care, and information about the drugs are at my finger tips on my screen whenever I request it.
Complicated protocols, like large chemotherapy treatments (an example in the picture above), are a few clicks away, and are always accurate.
Prescriptions handed to the patient are automatically recorded, and easily repeated. Graphic displays of laboratory results are easy to produce, and diagnostic imaging is immediately available without the long walk down to the radiology department.
Searching for Nimo
Over the last fifteen years that I have been at London, we have had to search old charts for patients on specific treatments, as new information suggested improvements or additions. This included patients who had been discharged from our center, who needed to be called to back because of some development.
Now, years ago, I had a secretary in my private practice who remembered everything.
“Who was that patient with the discolored skin on his leg from taking an anti-biotic and receiving an injury to the area? I saw him three years ago. Who was that?” I would ask.
“Give me a minute,” she would say. Such secretaries (like Lynne, if you are out there) are invaluable, but rare.
Searches to enhance patent care, searches to promote medical research, searches to facilitate medical education. Without computerization it is very difficult.
What are the disadvantages of the EPR?
There is nothing you can hold. Although available almost everywhere, you cannot easily carry it with you. After all, fixed copies are out of date within minutes, or can be.
It’s hard to scribble on an EPR: underline, circle, highlight. With paper copies we physicians do this all the time. When you do it on a computer monitor, it can get you in a lot of trouble.
It deviates focus. The doctor in the exam room with the patient is no longer looking at the patient; he is looking at the computer. What I find truly fascinating about this is that patients are learning: at first they were irritated by this, by the doctor constantly peering at the computer screen … like a teenager texting while you are talking to them, it was obnoxious.
But patients, I recognize, have learned already. Many quietly wait, almost holding their breath in order not to disturb me, while I look something up, because they have learned it is them I am focused on even though I am facing the screen.
It is confusing and new. It is indeed. And physicians who fail to embrace the EPR suffer greatly. They complain about the ‘extra clicks’, about being unable to find things, about the ‘trickiness’ of the programming. They complain that it takes longer, that productivity is reduced, that mistakes are easy to make.
Doctors complain that they are being turned into scribes.
One of the controversial areas is something called CPOE, Computerized Physician Order Entry. In our institution, physicians are learning to put orders directly into the computer, rather than writing them out on paper and having them transcribed, a time honored tradition that involved multiple clerical staff … and, of course, like the children’s game Telephone, prompted untold numbers of errors, as when trying to decipher if the handwriting suggested Losec or Lasix.
Or whether OD meant once a day, or right eye: “Do you really want to put the enema in the right eye, doctor?” Yes, I got that telephone call once.
Where the complaints don’t hold water.
I have been involved in computerization of medicine for a long time. As I tell my students, the first computer I programmed was in 1967. My students don’t know anybody was alive back then, let alone programming computers.
One thing that is universal is that physicians … and probably everybody else … always complain about the computer. Like the weather.
It slows me down!
No, it doesn’t. Not if you embrace it. (I’m going to get hate mail now).
A whole page and a half of admission orders can be entered in ten seconds or less.
A complicated chemotherapy treatment protocol that you would normally have to look up takes maybe twenty seconds, if that, and calculates the body surface area, drug dosage and adjusts for renal function in certain circumstances.
The radiology images take too long to load!
You used to have to hand in a list of x-rays at the beginning of the day and pick them up later that afternoon. Then you had to arrange them on a light box. Now you can look at them from the comfort of your office, your home, your cottage for heaven’s sake.
It takes me ten clicks to enter a Tylenol order!
It takes eleven strokes of a pen, after you rummage around finding the prescription pad. And then you have to sign it. And put in the patient’s name. And age. And address. And then you have to record that all again in the chart.
If you have set up your favorite orders properly, they are barely a few clicks away, too.
I sit and wait for the chart to open!
Yes, you do. And sometimes it actually takes twenty seconds. And you don’t have to go looking for the chart down the hall. And search through the chart to find the progress notes, or the labs, or the radiology. And of course, the chart does have the actual images if you just click on something and wait ten seconds.
This is worth a word. A clever hacker might be able to look at the chart. Yes, it’s true. And probably almost any physician can look in any chart. But years ago, in the paper era, our charts were being stolen by some nefarious characters, in order to get prescriptions out of them that had not yet been filled out. Twenty years ago, almost anybody with the nerve could walk into a nursing station, pick up a chart and read it, so long as they kept the air and appearance of a physician. In fact, put a white coat on them, and nobody would question it.
A few years ago, I had my wrist verbally slapped by the VP Medicine (bless her heart … she was very nice about it) because I had been looking at my own chart. I dare say lots of physicians do this now, and I had actually asked my family doctor permission to do this, which she gave after a few minutes of consternation. The information technology people had been looking at administrators’ charts (I was an acting VP then, I think) to ensure privacy was being maintained. They decided to check access to some visible leaders. Well, I was caught looking, and learned quickly this was against hospital policy.
Now, I still don’t agree, although I do comply. I know, for example, that the information in my chart legally belongs to me, and I think the hospital is wrong to prevent me from looking at it. In fact, I strongly believe, and have so advocated, that patients should be allowed to look into their own charts. I think this could be the next major Quality Assurance improvement.
After all, who is going to be most motivated to make sure things are accurate. Or that results are being addressed. The easiest patient to take care of is the informed patient, much to the disagreement of some physicians. I want my patient to know what their PSA is, or their INR, or their Absolute Neutrophil Count. They will tell me when something is wrong, and the only thing worse than being embarrassed by a patient that their counts are bad … is not being informed at all!
Science Fiction and Medicine
What has this got to do with science fiction? Well, a lot of this was science fiction forty years ago, though many of us saw it coming. Computer assisted diagnosis is already in its infancy. Point of care information is here, with the advent of the EPR. When I order a drug or a lab test, or even a treatment protocol, information is right there to guide me and make my life easier. Right now I can click on ‘Reference Information’ in a drop-down menu when I order an anti-biotic, and preexistent order sets are available for a variety of tests when I am not always sure I remember what is best.
However, one can also see clever nefarious ways of using the EPR to commit a crime, and a nasty one at that. But to see a good example, you may have to wait for my next book Trojan: Nefra Attack, which will be out next year at ebook distributors near you … like the EPR, they’re all near you … wherever you have a computer. And of course, if you’re just looking for Medicine in Science Fiction, the books I have reviewed on this blog contain varying levels, as does my second book Trojan: Hollow Moon of Jupiter, available at Smashwords and all its distributed sites, or at Amazon.