Clipped Wings

Today, I had my first real intimate look at one of the electronic medical record systems used by one of the hospitals in which I will rotate during my third and fourth years of medical school. Although I am generally in favor of the idea of digitizing medical records, I was thoroughly unimpressed by the system for which I received training today. A few points made by many medical writers before me with a few of my thoughts interspersed:

1. Many electronic medical record systems are very poorly designed from the perspective of those who use them. – This is a common complaint of doctors and nurses. EMR systems are generally not designed with the user in mind: they are designed solely toward achieving the goal of preventing errors. As such, they are sometimes built in ways that impede the ability to search for and access information in an intuitive manner. Why isn’t there a national standard EMR designed with a joint consortium of physicians, nurses, programmers, and legal consultants? Instead, we have dozens of expensive, cumbersome and antiquated systems that do not cross-talk and sometimes cause more medical errors.

2. Information technology administrators hate medical students. – At least, they seem to want to make our lives as difficult as possible. This is perhaps an unfair way of putting it, but I was left with the distinct impression that some information systems administrators see medical students only in their capacity to screw things up. It might have had something to do with the administrators repetitive statements of “This measure is put in place so that you cannot screw up the system” and “You are at the bottom of the food chain, so you don’t have access to this.”

A few questions I have:

Q1: What sense does it make for medical students to not have access to the radiology records (e.g. x-rays, CT scans, MRIs, etc.)?

My preceptor (e.g. attending physician) specifically told my team that a good medical student might improve his or her skills and demonstrate the desire to learn by evaluating the imaging studies on his or her patients and then reviewing them with the intern or resident on the team. How can a student effectively learn without having to bother his or her team members for access?

Q2: What sense does it make for a medical student to not have the ability to access records outside his or her assigned service?

For example, a medical student on a Medicine rotation cannot access information on a patient coming from the Emergency Room to the medicine ward until someone else enters a digital request for a consult for the patient. Considering that medical students in our system cannot edit or modify electronic medical records at all, what is the purpose of this “safety measure?”

Thoughts for later consideration:

In the midst of my Shelf exam and USMLE Step 1 preparation, I have looked toward the third year of medical school with excitement and anticipation: at last, my classmates and I might have the opportunity to have some responsibility, however small. Through the inspiring teachings of clinician-educators such as Dr. Jeff Wiese, I have discovered that many academic physicians see medical students as viable and integral members of a medical team: we are the ones who spend the most time with our patients and can truly become “experts” on the patient’s story, if not the patient’s medical condition and management. The patient’s history and story/context are extremely valuable pieces of information, usually providing up to 90-95% of the information needed to obtain the correct diagnosis (according to Dr. Wiese). Furthermore, medical students play an important role in building relationships with patients and helping them adjust to their stay in the hospital. Medical students also keep the rest of the team on their toes: for example, asking questions about clinical, laboratory, or imaging findings (which might not be as feasible with restrictions on imaging access). If anything, it seems that many attendings and their teams of residents and interns would prefer to give more responsibility to medical students: they want to see us demonstrate our mettle, very much in the tradition of a mentor passing on duties to a rapidly learning apprentice with guidance and supervision.

However, there is an opposing force: the system of administrators and “safety experts” whose concern is not with the medical student but with the patient. Their objective is to keep patients safe, not to help medical students learn. If anything, these administrators most likely see medical students as walking liabilities. I wonder if this opposing force (and the medical teams that make little use of their eager medical students) are doing a disservice to medicine and healthcare by stunting the growth of medical learning on the part of third year medical students and constantly fencing them into an “observing” role. Notably, the learning curve during the third year of medical school is very steep, and there have been a number of studies that show that physical examination skills are rarely improved after the learning taking place during the third year (e.g. listening to and identifying heart murmurs, differentiating between various diseases showing findings on a chest x-ray). Don’t misunderstand: I personally believe the role of safety experts is extremely important. Nonetheless, how do you balance the need for safety with the need to train physicians as well as possible?

My concern is that there is too much focus on methods of “correction” (and punishment) rather than methods of “improving performance” (and providing incentives for better performance). Perhaps if the safety systems (such as those impairing the usability of electronic medical records) were built in a smarter manner with a concomitant improvement in mechanisms to encourage better performance (on the parts of medical teams), electronic medical records would be more readily welcomed by physicians.

  1. John Roger Bell said:

    Just to clarify some of my comments today. I am absolutely in favor of digitized medical records. I think it is in everyone’s best interest. I am just not in favor of automated medicine where people no long need to communicate outside of a computer system that tries to automate everything. The ability to access for oneself and share information with colleagues is much easier with digitized records. They are less likely to be lost this way as well. In addition, digitized imaging is great for patient education. It is very helpful to be able to pull up a CT scan on your computer and say, this is where we see the tumor. Especially for symptomless diseases it really helps it hit home with the patient so they take their care seriously.

    I wonder why we can’t just have a simple computer program like a word processor + spreadsheet combo that would allow us to type up orders and notes just like we do on paper and record lab values in the spreadsheet. It seems so simple and so much better for everyone to use.

    Obviously for billing and record purposes there would need to be some items entered into boxes such as diagnosis and procedure codes, medical record numbers of patients…etc.

    Just my thoughts.

  2. Apollo said:

    Agreed on all points. I suspect that to some degree there might be less resistance from the medical community to EMRs as older doctors retire and younger doctors (more familiar with computer tech) emerge. However, the same (debilitating) problems might remain in the system without any input of doctors and nurses into the design of these systems.

  3. Ben said:

    This answer won’t satisfy anyone — but an IT system that can handle medical records is at best similar to an IT system that a typical enterprise has to run and, at worse much more difficult to administer and handle.

    And, despite there being BILLIONS of dollars poured into corporate IT infrastructures (think Oracle and SAP) — despite the constant complaint by management to make IT “easier to use”, the sheer complexity of the infrastructure and the code, the constantly changing and evolving demands on said infrastructure, and the need for multiple systems from different vendors to integrate makes it an almost intractable problem.

    So, I can definitely empathize with you on that one, Lester — and don’t get me wrong, I think that there is definitely room for improvement (it was a startup idea of mine after I worked with some medical records the summer after my Freshman year in college) — but this is not nearly as simple as “why doesn’t someone iPod-ify electronic medical records?”

  4. Apollo said:

    I hear ye, and I agree. My last statement is simply what I think should happen in broad strokes: more input from the users, and more focus on improving performance rather than preventing mistakes. It certainly isn’t a simple problem, but I hope that more people with the right talents can spearhead reforms in this area (e.g. physicians and nurses with IT backgrounds).

    I remember reading at least one national news article a few years back about a physician who essentially served as the IT chief/czar at his hospital, and their EMR and error-reporting system seemed to be working well and was well-received by the staff using the software (according to the article). In this case, there is someone who is responsible for making the system work, which isn’t always the case. John Roger and I were discussing yesterday that in many cases, the errors and problems produced by these EMR systems are often difficult to attribute to anyone who can do anything about it: the doctors identify the problems, the IT people say they didn’t write the software and can only work with what they have, and the nurses say they were just following what the computer screen said. As JR pointed out, these “system errors” sometimes end up getting blamed on the doctors (in court), when the major problem lies in the lack of clear communication between the parties involved. With respect to EMRs, I think it is the same issue on a larger scale: the people who need to talk aren’t talking to each other (whether for lack of time, financial incentive, interest, etc.).

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