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IN PRACTICE

The doctor is in and logged on

E-mail can be as useful as a stethoscope in diagnosing, and electronic medical records are for the better.

July 20, 2009|Rahul Parikh

Wow. I've just taken care of three patients in 12 minutes, and I didn't do it by "churning" them through my office as if it's some sort of factory assembly line. Rather, those patients (their parents, more specifically -- I'm a pediatrician), e-mailed me over a secure network with questions and descriptions of signs and symptoms.

One mother attached a digital photo of a rash on her 3-month-old daughter's face; it turned out be nothing more serious than baby acne (it'll go away in a month or so). Another mom had noticed that her son was missing one of his pre-kindergarten immunizations (she had pulled up his shot records online) and requested that I order it. And the father of a 5-month-old boy told me that his son has been constipated off and on for the last month. I e-mailed him a questionnaire so I could determine whether the family should try something at home or bring the child to the office.

In the past, these parents would have left a phone message and we probably would have spent the better part of a day or two playing phone tag. Or they would have had to make an appointment, strap their children into car seats, pack diaper bags and snacks and sit in a waiting room full of sick children -- only to spend 5 to 10 minutes with me while I told them everything was fine. Instead, we fixed the issues by e-mail, allowing parents to stay in their lives at home and at work.

Such interactions are no longer a pipe dream for the future of medicine. This is how I (and several thousand of my colleagues at Kaiser Permanente in Northern California) practice medicine every day. In 2006, we implemented an electronic medical record system and haven't looked back.

The advantages

Medicine is a multi-trillion-dollar-a-year business, yet most doctors still run it like middle-school students passing notes in a classroom: A doctor scribbles something on paper and passes it to a nurse or another doctor, who then scribbles something back. Later, somewhere on those same sheets of paper, another doctor will write something else that's barely legible. It's a primitive, fragmented and unreliable way to do business.

In my pre-electronic days, it wasn't unusual to get an incomplete medical record because various parts were stuck in storage or older pages had simply fallen out.

Electronic medical records eliminate many of those fundamental problems -- notes, orders and prescriptions are clear and contiguous. There's no waiting for paperwork. And if a patient of mine shows up in another office across town (remember, Kaiser is an integrated system -- we all share the same computer network), a doctor whom I have never met can see what I've written, my patient's list of problems and what I've done for the patient in the past before he or she even sets foot in the room to talk to the patient.

Such record systems can alert us to possible medication errors or dangerous drug interactions. They can continuously be updated to identify best practices. And they talk to patients as well, allowing them to access past-visit information and immunization records and to make appointments and send e-mails to their doctor.

Finally, they help better integrate care. When a woman came to a routine eye appointment in our medical group, the nurse noticed a "preventive health prompt" in the patient's medical record saying that she was overdue for a mammogram. The nurse booked her for a mammogram and, when the woman had it done a short time later, her doctors discovered early breast cancer. She was treated and remains well today.

Valid criticisms

All of this being said, electronic medical records have their critics.

In March, as President Obama was announcing his plans for healthcare reform, Harvard doctors Jerome Groopman and Pamela Hartzband wrote an op-ed in the Wall Street Journal questioning some of the records' purported benefits. They wrote: "A study of orthopedic surgeons, comparing hand-held PDA electronic records to paper records, showed an increase in wrong and redundant diagnoses using the computer -- 48 compared to seven in the paper-based cohort. But the propagation of mistakes is not restricted to misdiagnoses. Once data are keyed in, they are rarely rechecked with respect to accuracy. For example, entering a patient's weight incorrectly will result in a drug dose that is too low or too high, and the computer has no way to respond to such human error."

That's a valid criticism, but these are data entry and vigilance errors by health professionals taking care of patients, the kind that can be remedied by holding doctors and others accountable for the accuracy of their documentation.

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