KevinMD writes about EMR in today’s USA Today – Why doctors still balk at electronic medical records – and then Matthew Holt criticizes him – KevinMD turns into raving socialist…
Holt is amazed that Kevin champions the VA system, and therefore accuses him of socialism (at least sarcastically.)
Now for my disclaimers – I have a 2/8 VA appointment, and thus have used the VA computer system since its introduction. I also championed the introduction of an EMR for the Huntsville Regional Medical Campus (25 faculty and 37 family medicine residents.)
In both settings, I believe that the EMR has improved patient care. We must make certain that we do our best to not change the doctor patient relationship to fit the EMR, rather we can mold the EMR to fit the doctor patient relationship.
I see several major advantages to the EMR. With an EMR we have consistent records of medical problems, medications and laboratory data. With our HRMC EMR we save money on billing – because we do not need to have billing staff hold paper, but rather the bills transfer to the billing system automatically.
We do need better, more accessible medical records for the good of patient care. We need records of all physicians, all prescriptions. We need to avoid silos.
The beauty of the VA system stems from the univerality of the records. I can read all the subspecialty notes and have access to all tests that they perform.
The VA system is not perfect, but it has improved dramatically over the 35 years since I first walked into the VA as a 3rd year student. The medical record represents a major step forward.
Now I am not a socialist, but I will profer this modest proposal. Someone (perhaps the government, perhaps private financiers) should expand the VA system with a global fee for care. We could offer this as an alternative to our current system.
How would the VA system compete with private medicine? Well wouldn’t that be an interesting experiment?
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4 Responses to Electronic medical records and the VA
Dr Dan
October 1st, 2008 at 4:14 pm
If the government adopts a universal system that competes against private medicine, we will have adopted the British system of the average citizen expected to use the NHS and its delays, shortage of specialists and GPs alike. We will have a two tiered system and through natural selection the lower quality docs will dominate the public system because of the lower incentives. The VA system may work better from a doctor’s point of view now than 35 years ago, but it still has many deficiencies: to begin with, eligibility for care is determined by the VA budget. Not all veterans can use the system, a point that ALWAYS escapes the attention of the network news reporters and obtuse politicians who marvel at it. If all veterans were made eligible for care the system would collapse under the weight of the demand. Think of the Walter Reed situation multiplied by 1000.
anonymous
October 1st, 2008 at 4:48 pm
why is an appointment 2/8 rather than 1/4? what are the other 6/8?
TerryS
October 2nd, 2008 at 1:44 pm
There problems with the VA EMR that will likely be universal.
#1 cutting and pasting- unfortunately sloppy inattention to detail gets alot of redundant and uneeded information in a record. This leads to problems when JAHCO looks at the chart and views what you cut and paste for example from the radiology report as your interpretation of the film
#2 if a note is unsigned it cant be seen. Residents have to have their notes cosigned by an attending. Until that happens no one can use that note to care for the patient. this happens alot!
#3 The patient only has one record now. That seems like this would be a good thing and it is except from a quality assessment standpoint. I often get “dinged” for BP control when the BP was fine when I saw the patient but when they go to another clinic a week later and its high i get nailed for it. Under a paper chart system I would be fine.
#4 Lack of thinking- I truly believe EMRs lead to less doctor thinking. Everything is a template and you dont have to think as much as when you had to hand write the note. Its easy to keep bringing the same ideas forward via the template or cutting/pasting.
#5 the EMR has likely greatly changed the doctor-patient relationship. More doctors now look at the computer and type and not pay attention to the patient. I suspect very few docs wrote their handwritten note while interviewing the patient. But now many type away while the patient talks. I consistently hear this from patients.
There are other problems but I think these are important. I look forward to other’s comments
TerryS
October 2nd, 2008 at 1:54 pm
Thought of one more important limitation….
Quality assessment is “limited” via EMR. No one reads a chart at the VA anymore in the quality assessment word. All they do is electronic searches that often/usually fail to find the appropriate information. We get no credit for writting 1000 words documenting every milimeter of a diabetics foot if we dont use the clinical reminder. Thus what usually gets evaluated is quality of documentation and not quality of care.