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EMR use improves primary care: new study

There seems to be a lot of buzz in the news lately around the question of whether electronic medical record documentation can lead to a higher quality of care.  Last year, a study came out suggesting that this might be true for diabetes care.  More recently, my attention came to an article published in the Journal of the American medical informatics Association in May 2012, Method of electronic health record documentation and quality of primary care.

A group of researchers led by Dr. Jeffrey Linder at Harvard University’s Brigham and Women’s Hospital studied primary care physicians taking care of 7000 patients with coronary artery disease and diabetes over nine months. The study authors assessed 15 quality measures, three of which were found to be performed significantly less by physicians using a typical dictation system for record-keeping as opposed to those keeping records by electronic medical records systems.  Two of the three standards of care measures that dictating physicians were less likely to provide were tobacco use documentation and diabetic eye examinations.
This parallels my own findings as an endocrinologist using electronic medical records. During the period of my early years before I instituted widespread use of templating, I was much less likely to hit all of the quality care measure marks compared with after instituting templates.  It’s actually quite commonsensical that a medical provider can hit all of the marks if they are prompted by the computer.  In a sense, the care goes on autopilot.  No matter how chaotic a given point in the day of a busy doctor might be, it becomes impossible to complete a note without performing all of the prompts unless doing so deliberately.

There has been at least one or two studies that I’m aware of that have doubted or not found the conclusion that electronic medical records improve the quality of care patients receive.  I think that most likely these studies did not find a significant association because they were not properly designed.  When one considers the volume of quality measures pertinent to a typical patient visit with diabetes or coronary artery disease, there are so many measures that unless every physician has the measures memorized and never forgets anything, gets flustered or has to hurry through the visit, there will almost be a guarantee that not all measures will be addressed at a visit.  I’ll take that bet and win every time.

The fact that there are now at least two studies showing a positive relationship between the quality of care given to diabetic patients in the use of electronic medical records documentation is even stronger evidence that this is a real phenomenon.  Personally, I can’t believe that anybody would think that electronic medical records don’t lead to better care, regardless of the degree of such improvement.  That is, unless they’re not using the templating advantage.

October 21, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

Meaningful Use Is Not For Specialists

You know, I’ve been thinking a lot about Meaningful Use lately. I previously I’ve had pretty negative opinions of it, and my thoughts seem to be echoed by a lot of doctors currently in practice.

Rob Lamberts, MD, wrote an interesting post titled Ten Ways to Make the EMR Meaningful and Useful. I have to admit, his suggestions made an awful lot of sense. They started me thinking about how useless much of my own documentation is because of its origination in archaic rules for receiving insurance reimbursement money. Unfortunately, it seems that a lot of these rules stem from the medical profession itself rather than have been having been thought of exclusively by insurance moguls. For example, the family history is usually almost entirely irrelevant to what my scope of practice generally entails. The Review of Systems (ROS), which is the part of the exam where we as doctors ask the patient a myriad of questions regarding their symptoms, is typically exhaustive, unproductive and usually despised by most practicing physicians. Patients are generally very forthcoming about any active symptoms that they are currently experiencing, and a few additional questions around their symptoms typically suffices for a doctor’s purposes.

The majority of old medical records that I get from previous practices in which the patient has been involved are usually either illegible, irrelevant, or not directly related to the reason the patient is coming in to see me. If I am seeing them for the same purpose and they are just transferring their care to me, I generally will ask much of the same questions that have been asked before, rendering the review of records of even more limited value.

I think that getting meaningful use out of our own individual records could be greatly helped by an overhaul of the medical profession’s recommendations to insurance companies on the types of information that needs to be included in medical office notes for the purposes of providing excellent healthcare. In the increasingly complex and technologically-advanced society in which we live, information “noise” really should be kept at a minimum, especially in providing appropriate healthcare recommendations to patients. Medical records should not be in a habit of containing information that does not change or impact the medical management of the patient. We really need to revisit the idea of “gee whiz” type of data and cut out any extraneous documentation.

This would, of course, require that meaningful use become much more personalized and individualized to specific doctors and their specialties. The current state of meaningful use is actually fairly limited in that it applies mostly to primary care providers making recommendations for preventive health care. Preventive health care, unfortunately, is almost never the reason why patients seek the advanced medical knowledge of specialists and subspecialists in specific areas of medicine.

In summary, I agree with Dr. Lamberts that we need to overhaul meaningful use into something that is much more meaningful and usable.

October 1, 2012 I Written By

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.