In the last column we discussed what electronic medical record (EMR) software authors should include within their promotional website. This time, let’s take a step back to discuss what an EMR is, or more importantly, what it is not.

The medical record started out as a method by which the clinician could get a quick reminder regarding the content of previous contacts with a given patient. If a clinician wanted to know when the last time the patient was seen, what medications have been tried in the past, or the names of the patient’s kids, the medical record was the place to look. I saw the same dentist for 20 years; each winter, my dentist would ask whether I’d gotten in any skiing yet. I was always impressed with his recollection that I enjoy skiing. It wasn’t until many years later that I stole a glance at my record, a simple dental chart with little notes indicating where and when I had received fillings. There, at the top, in pencil, was an additional little note that said “likes skiing.” That’s the purpose of the medical record; it allows for better customer service, better rapport with the patient, and the jogging of the aging clinician’s memory.

Times have changed and clinicians often work in teams, particularly in our line of work. Insurance coverage has changed, and patients change doctors and clinicians nearly as frequently as clothes. The medical record therefore changes hands frequently and operates as an efficient messaging service among treating clinicians. As a result, it can no longer simply include brief memory jogging devices but must also include a more complete description of the patient’s history.

Less importantly from a treatment perspective, but more importantly from a liability perspective, are all the issues regarding protection of our own hindquarters. So now, not only do we have to write about the patient, but we also have to document what we did. Extensive summaries — explaining that we actually saw the patients, spent 30 minutes with them, discussed various treatment options and their pros and cons, explained the importance of what must or could not remain private and confidential, and so on — are all in the medical record. However, none of this information is really important from a patient-centric point of view.

In the meantime, a number of new forms have made their way into the medical record, which earlier consisted only of blank sheets of paper. And here I must admit to a complete lack of respect for one of them — the Treatment Plan. My plan for treatment is always the same: “Consider all available options on an ongoing basis depending upon the severity of the patient’s symptoms, then, implement the best of the available options based upon a discussion held with the patient. Continue such implementation until the patient improves, then repeat the process.” Why I have to, for every patient, fill out a form in which I say essentially the same thing in an individualized manner for each patient is beyond me, but this is an example of when an EMR would come in handy. Based upon an interpretation of the available history and diagnoses for a patient, the programming could be set up to generate a treatment plan. Wonderful — I could ignore the treatment plan entirely, letting the computer generate one for signature so that the folks who inspect our program would be satisfied that we have their beloved form completed. Every few months, depending upon regulatory need, the EMR would notify me that 200 treatment plans need to be updated. “Would you like me to update the treatment plans?” the EMR would ask. Indeed, I would. And I would push the appropriate buttons for both the update and my electronic signature. I’ve just saved myself a few hours of wasteful and inefficient work.

There is a form in medical records these days that represents a rolling medication prescription history. Never mind the fact that the medications are noted in the medical record itself; we need a separate page detailing the medications separately. And there’s another form representing a rolling list of the current diagnoses. The list of forms is quite long; as a result many programs are no longer using manila folders for charts. Rather, they are using small three-ring binders!

An EMR is NOT supposed to be an electronic representation of the physical chart. That is, you shouldn’t have individual forms replicating what would be in a contemporary medical record. The EMR should instead be something quite simple; a useful record of what is necessary to treat the patient. The EMR should be programmed to provide the rest. If you ask it to provide you with a list of all the medications the patient has ever been given, it should provide that. If you want a list of all the clinicians who have ever had contact with a given patient, the EMR should figure it out and give you the list. Given the appropriate information, the EMR should be able to generate the forms required to meet various needs.

What has inspired me to think along these lines? I’ve recently been setting up an electronic medical record for a new addiction center. One government consultant, unfamiliar with EMRs in general, has been quite strenuously telling me to make certain that whatever EMR we use has all the forms that the local regulations require. I’ve struggled as to how to tell him that the EMR won’t have any forms, that there won’t be any paper, that everything possible will be done within the EMR, thereby allowing clinicians to efficiently and effectively get their work done. Their work is to treat patients, not to waste their time filling out forms. He wants us to have a medical records room anyway because the regulations require us to have a secure room for paper. “What will you do with lab results or with files from other programs,” he asks. “Scan them,” I reply, “into the EMR.”

There are certainly cases where an EMR is a very bad idea, and we’ll explore those in the last of this series in the next column.

What are your electronic record experiences? Have you found them to make your workplace life more or less efficient? Tell me what you’ve discovered at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Dr. Gitlow is a member-at-large of the American Society of Addiction Medicine's Board of Directors. This column represents his personal opinion and does not imply any position or policy taken by ASAM.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2005, v.6, n.4, pp.34-35.

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