番茄社区

Could there actually be an opportunity here?

This weekend, in the darkness of the early hours on Saturday morning, our institution went live with a unified electronic medical record (EMR) across our entire network.

All of our hospitals, all of the practices, inpatient and outpatient, from the primary care clinics to the emergency department to the ICU's to the PACU's to the OR's.

Suddenly, for the first time since the days when we all used to do it on paper in stiff cardboard folders, everyone across the spectrum of healthcare here will be using the same system to document the care of our patients, and in fact gain the advantages that should, by necessity and previously missed opportunities, come with consolidation and unification.

Our colleagues across town and at satellite clinics throughout the city and beyond can see all the care provided to any patient no matter the context -- their medications, their past medical history, their test results, their allergies, their blood pressure when they were seen in a dental clinic, all of it.

Perhaps this is an opportunity to rethink how the care we provide is documented in an electronic medical record, and rethink how this affects the way we may be able to take care of patients in potentially much better ways. If we all work together and cooperate and allow the electronic medical record to become a true reflection of the patient's care within our institution, then perhaps we can avoid all the duplication, defensive medicine, and over-documenting that has come about as electronic medical records have taken over our lives and, in many ways, interfered with patient care.

Under the previous systems we used, we've far too many times seen useless boxes that get clicked, that things get confirmed as being true when they're just not so, that body parts are listed as being examined when they aren't owned by a patient, that we said things and they said things that just weren't true. Clicking a box that confirms someone's outpatient medications, when this only reflects the list that you have from the last time they were there and not what they're really taking, really doesn't help anybody.

Performing a surgical operation or a procedure on a patient, but then not adding it to their past surgical history in the medical record, either right after they emerge from the operating room, or during any one of the several postoperative visits they have in your office, should not only be bad practice, but should not be possible.

Think of the savings in terms of forms and faxes and certifying and pre-authorizing that we all need to do, that consumes our days. After a patient is seen for preoperative evaluation, as long as everything is within our institution, no one should be asking us to fax over a copy of our note to someone who shares the selfsame electronic medical record with us.

And if a general care plan could just be created within the system, and we all agree on it, then we as the primary care providers would save thousands of hours a year filling out and signing endless forms and bureaucratic nonsense, often for things about our patients that we have no knowledge of (e.g. how frequently should that post-op dressing be changed, and what size Foley should the homecare nurse place?). That would free us up to do some actual doctoring, practicing up to our licenses.

Building a true past medical history, and an accurate active problem list, may allow us an opportunity for truly shared decision-making with our patients about what has happened in their lives and what is going to happen next; this could potentially come out of having all of us who are working to take care of them on the same system, on the same page.

The opportunity is here, but we need to think carefully about it, to plan for it, and find ways to help bring it to fruition. More than likely, many people are not going to want to change. They are going to keep doing things the same way they always have, getting those results that the systems that we've allowed to be built up around us are perfectly designed to achieve. But if we take this time to pause, to rethink how and why we're doing all of this, then maybe our jobs can become less about clicking boxes, and more about taking care of our patients, and having this behemoth of an electronic system work for us, instead of us working for it.

So, in the days and weeks ahead, let's work towards rethinking how we think about our electronic medical record, and figure out more ways for it to serve us and our patients, to make our lives easier, and to improve the health of our patients as they move across our healthcare system. And perhaps this can become a model for finally creating and allowing a unified system across our entire society, ensuring access and high-quality care for all of our patients, regardless of which vendor sells us their latest newfangled product.

This is the dream for electronic medical records, the vision that it could answer, the hope that it can provide for our patients and the healthcare system of this country.

, of Weill Cornell Internal Medicine Associates and weekly blogger for 番茄社区, follows what's going on in the world of primary care medicine from the perspective of his own practice.

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