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FAQ > Electronic Medical Records > Are there any other reasons you don't like EHR systems?

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Are there any other reasons you don't like EHR systems?

I believe that EHR's pose a great risk to atrophy the intellectual skills physicians learned during the process of their medical education and training.  The early years of medical education involve the acquisition of a large number of facts -- the normal anatomy and normal function of the human body, abnormal anatomy and abnormal function of the body in various disease states, and the armamentarium of treatments.  The next few years of medical education are devoted to developing analytical skills.  The medical student must learn to acquire as much information about a patient as possible, to analyze that information in order to distinguish the important facts from the irrelevant, and then to formulate an analysis of the patient's problem as well as a coherent plan to deal with the problem.  This process requires years of practice and refinement.

When a second year medical student is sent to interview a patient, the student's professor expects the student to ask every question from the top to the bottom of a long list and to record all of the patient's positive and negative answers.  The purpose of this exercise is to teach the student all of the questions which must be asked.  After a year or two of this exercise, the student is permitted to record only the pertinent positive answers and the pertinent negatives.  By then the student has a good understanding of the important questions to ask, and the professor trusts that the student has not missed important questions.  A beginning medical student's note may be 8 pages long.  A senior medical student's note may be two pages long.  An intern's note may be 1 page long, and a resident's note will be a summary note 1/2 page long.  In the traditional medical education, the professor's note or the private physician's note may be a 1/2 page statement of the problem and what must be done about it.  The student at every step of the way learns that compiling an adequate amount of information, focusing on the important, and being progressively more concise at each higher level of education and experience are important skills that must be mastered.  The entire process of medical education is one of distilling information to its essential essence.  If you can't summarize a patient's problem and the plan for dealing with it in a few well chosen sentences, you don't know what the problem is or you don't understand it.

In the 1990's the medical profession permitted the Federal government and commercial insurance companies to define levels of physician effort by the length of the written or dictated note; those definitions permitted the insurers to develop computer billing codes to describe different levels of effort on the part of the doctor's work for each service performed.  Doctors were paid more for writing or dictating longer notes and less for being sharp, concise, and focused.  Insurers and the Federal government equated quantity with quality when, in fact, the opposite is more likely to be true.  Creating financial incentives for being verbose is the antithesis of the skill to be selective and focused in one's thinking and writing.  In reality, it takes a lesser intellect to record everything and a greater intellect to be concise.  EHR's are set up on the belief that more verbiage is always better than less.  Computers are great storage devices, but cannot weigh the relative importance of the facts gathered and how they fit into the puzzle of the patient's problem or the solution to the problem.  Electronic records create massive documents so that it is difficult to find the essential elements of a case history because it is buried in mounds of irrelevant detail.

Over-documentation is a concept that physicians understand but bureaucrats do not.  In that sense, the EHR can actually impede communication among medical professionals.  In a nearby town, I know a physician who has the ultimate EHR which acts like an electronic shovel for miniscule detail -- a bulldozer is more like it, upon further reflection.  When I see one of his patients in consultation, the patient tells me the doctor spent 10 minutes in a cursory interview, but the doctor's computer generated a ten page single spaced report with tiny printing.  I find myself spending 10 minutes wading through all of this verbosity to find the key one sentence which tells me why the physician is sending me the patient and what he expects from me.

There is an old adage that "if you don't use it, you lose it".  Given a decade or two with most doctors repetitively following the EHR scripts rather than thinking for themselves, I fear that the doctors who will be taking care of me in my dotage will not know how to think or to analyze.  If physicians let the computers guide them through long "to do" lists rather than thinking on their own, they will lose the ability to think and to analyze.