March 25, 2018, Medical Economics published an opinion piece by a Texas physician criticizing the use of electronic medical records.  The piece lamented the following:

• Physician losing control of healthcare with the suggestion that not electronic records would restore that
• Administrators being in charge of physicians with the suggestion that the elimination of  practice transformation would correct that.
• Innovations coming from administrators
• Quality and improved outcomes being the focus of patient care manacled physician.
• Lamenting the loss of SOAP (Subjective, Objective, Assessment, Plan) notes.
• The once thoughtful and educational consult note is now “pages of worthless computer-generated gibberish.”
• The loss of differential diagnoses and physician decision making process.

The author of the piece laid fault for all of this at the feet of the adoption of electronic patient records.  March, 2018, Southeast Texas Medical Associates, (SETMA), celebrates twenty years since the decision to adopt EMR was translated into the purchase and development of an EMR.  Everything the above reference article asserted is contradicted by SETMA’s history.

Fifteen years ago, a physician joined SETMA who agreed with all of the complaints about the use of the EMR.  He was vociferous and occasional profane in his objection to the EMR.   Six months after joining SETMA, that physician announced, “I now realized that my records were totally inadequate and if I had been audited before using the EMR, I would have been arrested and jailed.”  While that may have been an exaggeration, his perception of the ability to produce quality records and to practice excellent medicine with the EMR was real.

No doubt the transition from dictated and transcribed medical records was difficult.  I remember the first day we used the EMR. It was a Tuesday in January, 1999.  It was the worst day of my life but after four days all patients were seen with an electronically created record.  No doubt, in the beginning the “clicks” were  intrusive to the patient-provider relationship.  But, in time and with development (weeks not months or years), the EMR became a valuable tool in promoting excellence in care, documentation and following patients.  How?

What are the Structural Benefits of Electronic Records?

Have you ever watched a doctor flip through paper records - whether generated by hand writing, or by dictation and transcription?  It would be amusing if it where not so inefficient.  Simply, trying to compare a series of blood pressures was a daunting task where as with EMR it is done with a click of a button.  Have you ever watched a doctor look for a report in a paper records?  With an EMR, which is properly structured, the report can be found with a click of a button.  Already, we begin to see the efficiency of a “click” rather than the shuffling papers.  Trying to identify all patients in a practice on a particular medicine which was recalled was an almost impossible task. With the EMR, it can be accomplished in a few minutes, while generating letters to patients with instructions of what to do.

With electronic records and appropriate security measures such as two-factor authentication, and controlled access, no matter where the patient is being seen the record is available.  With paper records, they are available only where the records are stored.  SETMA’s providers have been in Europe and are able to review patient records and interact with patients about their care needs. 

Have you ever seen a doctor try to compare your most recent laboratory results with the pattern over the past two years?  It can be done but it is laborious and it is often not done.  And, if it is done, there is no way for the physician to prove that it was done.  With the EMR, with a button entitled, “Labs Over Time,” it can be done with the, dare I say it, “click of a button.”

The security of patient data is a serious concern.  In 1997, three SETMA partners attended a nation meeting about practice management.  The question was raised about the security of electronic records.  A professor contended with the speaker aggressively and repeatedly arguing that it was impossible to make electronic records more secure than paper records.  Knowing that was not true but unable to persuade the professor, the speaker was frustrated.  With the final blow, the professor said, “You can’t make your EMR more secure than our paper records; we can’t find out paper records, you can’t be more secure than that!”  Everyone, along with the professor laughed.

Whether you are in the hospital, nursing home, emergency department, your own home or one of our clinics, all records are always available.   Any activity on any patient’s chart in any location, is documented in the same record.  When I am in our Lumberton clinic seeing a patient and I order a blood test, patients often say, I am seeing another doctor the following week can the lab results be sent to that doctor.   When that provider is a part of SETMA, the lab results are instantly available. When that provider is not a part of SETMA, an electronic note can be sent to the laboratory to send that result to the non-SETMA physician. 

Several years ago, a patient was concerned that her sister-in-law who works for SETMA had looked at her chart.  With paper records, there is no way to know that.  Because SETMA has hardware functions which document every click, every day as to who entered that information into the EMR and as to who logged on to a chart, we were able to prove that that employee had never looked at the chart.  In an abundance of caution, we inquired of the employees in the same area with that relative as to whether a request had ever been made to open the patient’s chart and show it to the sister-in-law.  There never was a request.

The SETMA Model of Care - Impossible Without EMR

The SETMA Model of Care involves the following five steps:

1. The tracking by each provider on each patient of the provider’s performance on preventive care, screening care and quality standards for acute and chronic care. SETMA"s design is such that tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the personal provider, nurse, clerk, management, etc.
2. The auditing of performance on the same standards either of the entire practice, of each individual clinic, and of each provider on a population, or of a panel of patients. SETMA believes that this is the piece missing from most healthcare programs.
3. The statistical analyzing of the above audit-performance in order to measure improvement by practice, by clinic or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, payer class, socio-economic groupings, education, frequency of visit, frequency of testing, etc. This allows SETMA to look for leverage points through which SETMA can improve the care we provide.
4. The public reporting by provider of performance on hundreds of quality measures. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool “plans of care” and the medical-home-coordination document summarizes a patient’s state of care and encourages them to ask their provider for any preventive or screening care which has not been provided. Any such services which are not completed are clearly identified for the patient. We believe this is the best way to overcome provider and patient “treatment inertia.”
5. The design of Quality Assessment and Permanence Improvement (QAPI) Initiatives - SETMA"s initiatives have involve the elimination of all ethnic diversities of care in diabetes, hypertension and dyslipidemia.  We have designed a program for reducing preventable readmissions to the hospital. We have completed a Business Intelligence (BI) Report which allows us to analyze our hospital care carefully.  These are only a few of the capabilities that EMR has given us.

I suspect that the Texas physician who complains about the use of EMR is using one which is awkward and difficult.  SETMA’s is neither.