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Tuesday, August 24, 2010

Electronic medical records, revisited

Last night I realized that I actually do like having a computerized medical record system.

I have had a love hate relationship with our computerized medical record system since we adopted it in January of 2007.  We decided to make all of our records and billing electronic in 2006 and tried out several systems before deciding on General Electric's Centricity product.  It was expensive, over $100,000 for our 9 physician group, not including the loss in production as we learned how to use it, and not including many of the laptops and desktops and printers and other hardware. When the system "went live" we all slowed our history taking and record keeping to a snail's pace and were hard pressed to see half as many patients as we had before the system was in place. We all stayed late and came in early. Eventually we adjusted to it, and after a year, we were not as fast, but almost as fast as we had been before. We lost 2 physicians who really couldn't deal with it and had trouble retaining a couple of newly hired physician because it was difficult to use. We kept better records, eventually. Some of the nurses and other office staff couldn't adjust and left.

Sounds bad, I guess.

But there's more. It would freeze up when we did certain things that were supposed to work, like faxing a prescription, and stay frozen for 5 minutes before resetting itself. There would be system updates which caused new bugs to appear. If one person was using a document, another person would not be able to use the document until various closing rituals were performed, and if they were performed wrong, a chart could be in a state of limbo that only the IT guy could fix. 

Now these problems are only a bad dream. There were other ones too which I thankfully can no longer remember. We are left with only the bugs that seem to be completely resistant to all attempts to treat them, and bugs that are intrinsic to the system.

There is no back button. There is no automatic spell check (though you can spell check manually). Once a document is electronically signed, it can't be changed, and it is easy to accidentally sign a document. There are no autocomplete functions. My cursor jumps, and so when I am typing, all of a sudden I am no longer creating text and I have to manually put the cursor back where it is supposed to be.  Sometimes  the jumping cursor will randomly highlight text and then when I start typing again it deletes the highlighted text. Occasionally vital signs are entered and just don't appear on the final document, but you can make them appear by re-entering any value into the form. Documents are much longer than they need to be and look awkward.  I can't look at a patient's medical record in the same window that I am using to take their history.

When I tell people this, they say, "oh, you just have a bad system." Well, yes, obviously that is true.  Nevertheless, this General Electric product is one of the most widely used medical record keeping systems, and being able to communicate with other medical offices and hospitals by way of shared software is one of the major reasons to computerize records. The obvious solution to bad electronic medical records system is to create a great electronic medical record system and make it inexpensive or free, perhaps supported by a government grant, so it out-competes all of these other really-not-very-good systems that we have adopted for lack of a better options.

But that was not the story that I wanted to tell.

I actually wanted to say that providing medicine the way I think it should be done, at a time that is appropriate and in a place that is expedient, has been made much easier by the fact that I can access a patient's medical record from my laptop, anywhere I have internet access, and can send prescriptions and keep records in a way that lets me review what has happened, and later to remember what I have done.

Yesterday when I got back from backpacking, where there was no cell phone service and even google earth couldn't find me, I found a message on my answering machine from a patient who needed help. I was able to sit down at my laptop, see what medications she was taking, see what, if anything, other doctors in my practice had done for her, and discuss medications, side effects and interactions with her. I was then able to order the appropriate change in medication and relay it to her pharmacy, which would get the information the following morning since it was 9:30 at night. It was good medicine, practiced at the most appropriate time for me and the patient, and there were minimal associated costs.

Electronic communications have expanded the way that medicine can be practiced, including the possibility of web based communications to patients with shared problems, e-mail communication, video chatting and efficient communication between doctors of different specialties.  I don't use even a fraction of what is available, but I can certainly see what powerful tools exist.

Many things get in the way of making these electronic tools acceptable in our practices. The difficulties in buying functional software like I described in the first several paragraphs is one barrier. Issues of protection of privacy are another. Not least, however, is the fact that the majority of physicians are still paid only for face to face contact with patients, and there is no easy way to change that without fundamentally changing the business of medicine.

We could, of course, simply start charging for all forms of communication, and remain in the "fee for service" model. This would involve more complex billing plus long and incredibly irritating negotiations with public and private insurance companies. We could also fundamentally change the way health care providers are paid, and pay people like me salaries to do the jobs we now do without the complexities of scoring each problem solved, procedure performed or patient seen.

I think that electronic communication and record keeping can, at best, provide an excellent backdrop for community funded health care. Most physicians loathe the complexities of billing for the minutiae of our work, and we would love to be able to put all of our hearts and energies into the actual care of patients. If communities were able to hire the services of hospitals, doctors, nurses and other staff, we would be able to care for people using all of the appropriate and available technology. Our present system of billing keeps most of us firmly entrenched in communication technology that is many decades old.

Thursday, August 12, 2010

Estrogen: the pendulum swings again

The following essay addresses the present tendency of scientific medicine to rely heavily on studies which address the effects of treatments on populations rather than individuals.  It has been clear, always, before and after various large scale studies of the effectiveness of estrogen, that hormone therapy is good for some people and not good for others. Nevertheless, at great cost to patients in money and time and quality of life, we have at various times pronounced estrogen to be good either for everyone or for no one.

When the Woman's Health Initiative study was stopped in 2002 due to increase heart attacks and breast cancer in the women treated with estrogen and progesterone the non-medical press circulated the story extremely effectively, and within a year very few women did not know that the estrogen they had been prescribed and told would save them from all sorts of misery was actually toxic and evil.  It was a bad year for estrogen.

In the 8 years since then doctors, researchers and menopausal women have gradually processed much of the information that came from that large, double blind multi-center trial, and recommendations have matured. It is clear that conjugated estrogen plus medroxyprogesterone is not good for preventing dementia and leads to an increased incidence of breast cancer, heart attacks and strokes.  Statistically the combination of hormones does not lengthen a woman's life, but then it doesn't shorten it either. It does reduce hip fractures, colon cancer and diabetes. Some women feel better on hormones and some feel worse, but statistically quality of life is a wash.

But WHI was a huge study, involving over 160,000 women over more than 12 years. The amount of data from this group of women is tremendous and it is potentially powerful enough to answer questions like "which women experience which side effects?" and "who should take estrogen and who should not?" As an individual person navigating the shoals of menopause, these are the questions that are most relevant.

This issue of Internal Medicine News reports on Dr. Richard Santen's conclusions as part of a task force from the Endocrine Society on hormone therapy.  Apparently when one analyzes the subgroup of women in their early 50s and those within 10 years of menopause, a significant 30-40% reduction in overall mortality was seen in estrogen users, with or without progesterone. This is, of course, just the group of women who would be likely to want to use estrogen for treatment of the hot flashes, mood changes and sleep disorder so common in early menopause.

As a physician who sees many women as they experience the end of regular menstrual cycles along with the joys of waking up multiple times each night in puddles of sweat and being unable to remember what it was that they were supposed to be doing right now, I will again have to adjust my recommendations regarding the use of hormones. I will continue to struggle with answering questions about which forms of hormones are safest, how long to take those hormones, when and how to stop them. The WHI will be unable to answer many of these questions due to its study design. I will, however, have a new piece of information to support the women I treat who feel they really want to take estrogen.

Here is a link to the Internal Medicine News article.
http://www.internalmedicinenews.com/article