Are We Finally Ready to Cut the Paper out of Doctors' Paperwork?

As physicians trade in their patients' file folders for electronic medical records, Case Western Reserve University experts discuss the promises and pitfalls that lie at the intersection of technology and health care.

In an increasingly paperless world, it's almost quaint to visit your local physician and see your medical chart among the rows of file folders worn from years of rubbing elbows with the medical histories of two strangers with alphabetically similar last names.

Many doctors' offices today devote entire rooms to housing these files. But soon the folders-thick with documentation of every sneeze and surgery—will be replaced.

New federal guidelines state that by 2015 physicians and hospitals around the country must either digitize their patients' health information or face financial penalties. The idea is that electronic medical records (EMRs) will improve patient care and lower health-care costs.

As practitioners around the country work to trade paper for pixels, two Case Western Reserve University health-care experts met with Think to discuss the potential of EMRs, and the possible risks associated with the technology.

Pamela B. Davis, MD, PhD, is dean of the School of Medicine and vice president for medical affairs, and is leading the school's efforts to help physicians implement EMR systems.

Sharona Hoffman, JD, is a health law expert at the School of Law. Her research addressing security and privacy issues surrounding EMRs has been widely published.

Think: Of course, much in the world is going electronic. What are the benefits of digitizing health information-beyond cutting down on paper?

Pamela B. Davis: The hope is that EMRs will improve quality and reduce cost.

For example, if you come to the emergency room and get X-rays and blood work and then go see your doctor four days later, all of that on an electronic health record would be available to your physician relatively expeditiously. The physician doesn't have to repeat things at duplicate cost.

The other potential cost savings come from avoiding errors in administering medications. EMR systems identify drug interactions and maintain a list of the patient's allergies so that you're not giving a sulfa drug to someone who's allergic to sulfa.

The system also contains dosing information. So, if you prescribe doses outside of the appropriate range, it should at least ask you if that's really what you want to do.

Think: Why, then, didn't the medical community put EMRs into effect 10 years ago? Are there reasons that some doctors might want to hold on to their antiquated files?

Sharona Hoffman: When you have a computerized system, you have some likelihood of things going wrong. There are significant risks of malpractice and risks to patient safety.

You have the potential for information overload. In malpractice cases, doctors may well be held responsible for every detail in the record. They will no longer be able to say, "Oh, I just didn't know about this thing that happened in childhood that might affect what's going on today because the patient didn't tell me." It's going to be a few clicks away on the computer. The doctor is not going to be able to claim ignorance, even if she never saw it because the record is enormously long.

Davis: I think the malpractice issue is interesting. In some ways, it does expose you to more liability. On the other hand, if you believe that many malpractice cases are settled for lack of adequate documentation, then EMRs will help on that score.

Hoffman: True. EMRs are a little bit like a black box in an airplane. The idea is that the EMR will report every intervention, every patient encounter and everything that the computer itself did, so if somebody went in and changed the record you'll actually have an indication of that through audit trails. That's very important. So, it could certainly help doctors. It could also help plaintiffs.

Davis: I think those of us who feel like we practice good medicine would consider full documentation an advantage. I'm not afraid of people knowing what I did and when I did it.

Think: But if the system sends alerts when doctors do things like prescribe doses outside of the appropriate range, as Dean Davis said, wouldn't EMRs make doctors less likely to make some of the mistakes that get them sued for malpractice in the first place?

Hoffman: The alerts signal to doctors adverse reactions to drugs, risks and so on, but clinicians have been complaining that they are absolutely inundated with these alerts. They're not only distracting, they may be irrelevant to a patient because she's been taking the drug and tolerating it well for years. Or they may be misleading because this patient has complicating factors and so this particular alert is actually wrong. At the very least, they take time away from other things the doctor should be doing.

So, doctors sometimes turn them off, but then they're going to miss the warnings, and again, that can lead to liability.

Davis: I'll give you an example from my own practice. I work with patients with cystic fibrosis. They don't handle antibiotics like other patients. The doses that I need to give are sky high, but there is a huge body of literature that shows you that if I were treating you with tobramycin, I would start with 3 mg per kilogram per day. With a cystic fibrosis patient I never start with less than 10 mg.

I can override the electronic medical record and say that patient has cystic fibrosis and drug distribution, metabolism and excretion are different from a normal patient.

Hoffman: But I'm told that having to do all that documentation in the record is enormously time-consuming. Doctors complain it takes them hours and hours. It takes time away from actually examining the patient, listening to the patient, figuring out what's going on.

Or they say they stay in the office until 10 at night because they have to explain everything to the computer.

There's a range of quality right now in EMR systems. There's some effort now to have certification and more uniformity, but we're not there yet.

Think: What about the relationship between the doctor and the patient? If doctors are spending their time navigating through the EMR, what effect will that have on the patient's visit?

Davis: We are coming up with a whole generation of young people who text at dinner. Their lives are contained on a small screen. If you put an electronic record and a patient in front of a doctor like that, they're likely to pay attention to the electronic record and not to the patient. This worries us, particularly at Case Western Reserve where we have a reputation for training doctors who find out most stuff by talking to and examining the patient. We turn out excellent medical historians and excellent physical diagnosticians here. We don't want you staring at the computer screen.

So, we have the Mount Sinai Skills and Simulation Center, where we do a lot of patient simulations. We teach students to interview patients and to give bad news.

We're also opening a module of teaching students how to interact with a patient in spite of the electronic medical record.

Hoffman: From a litigation perspective, I have heard patients complain bitterly that "now my doctor couldn't care less about me. He pays all his attention to the computer." Patients who are unhappy with the doctor-patient relationship are much more likely to sue. So, that's a real danger for doctors. If they seem uncaring, if they seem obsessed with clicking and entering data into the computer rather than paying attention to the patient, that is dangerous.

Think: With computer-related stuff there always seem to be concerns about privacy, as well. Are EMRs immune to these kinds of threats?

Hoffman: When you have computerized records, you have to worry about hacking, of course. You have to worry about lost laptops, stolen laptops, as well as accidental disclosures by employees or malicious disclosures and various other things that can go wrong. The doctor emails somebody, but the automated completion sends it to somebody else, or the doctors email information to themselves in order to work on records at home and that goes to some third party or is hacked.

So there are lots of opportunities for privacy to be compromised. We do have the HIPAA Privacy Rule, which restricts the people who can have access to the records without patient authorization. Doctors can only disclose information for purposes of treatment, payment or health-care operations. Otherwise, they have to get specific authorization from patients. The rule also imposes security safeguards on those who store information electronically.

Those regulations are fairly extensive. They're imperfect, but they do exist. If people comply with them, then we're certainly moving in the right direction.

Davis: EMR systems are going to have to rise to the level of being relatively hacker-proof. I suppose you can say you can hack into the air traffic control system, but we haven't crashed a whole lot of planes.

There are systems that allow you to preserve the integrity of the system against hackers and power outages. We need to just make sure that the electronic health record is in that category because there is real promise in EMRs. Think of the promise of having the doctor who takes care of you be able to access critical information you may not report because you're anxious—or because you're unconscious.

EMRs will also help academic physicians understand very quickly with large numbers of patients what comparative effectiveness really is for various disorders. And doctors in individual practices will be able to look at their information and say, "We need to improve in this area. We're not meeting standards in that area."

Machines are imperfect. I think that every system needs to be improved and monitored. So, since we know the electronic record is coming, I think the imperative is to figure out how to avoid these pitfalls.