My peer review work frequently includes the need to peruse medical records maintained by another clinician. Usually, for my practice, this is for the express purpose of determining answers to questions of medical necessity or disability. As a result, I’ve spent thousands of hours over the years looking at records that come from a wide variety of clinical settings. Years ago, the majority of such records were handwritten, generally brief, and when written by a knowledgeable clinician, covered the required elements with a minimum amount of ink. We’re just beginning to cross the boundary in our reviews now, where more than half the reviewed notes are generated by an electronic medical record system.

These reviews of computer-generated notes are noteworthy for their size. Two factors account for the greater bulk: 1) clinicians following policies and procedures meant to minimize liability are documenting everything; and 2) the electronic medical records are designed to efficiently document everything.

Years ago, I’d see a patient and might write, “Patient seen. Slight improvement from last visit. Continue current regimen.” Given the same circumstance, a more recent note might say, “Patient seen individually for 45 minute contact. Mood has improved and patient appears somewhat more inclined to attend AA meetings. The patient is not a danger to himself or others. He gave consent to continuing with his medication after I discussed with him the potential ongoing side effects as well as the various alternative treatments that are available.”

The electronic medical record note, covering the same material, takes up an entire page and includes checkboxes on all the neurovegetative symptoms of depression, a listing of any substances used since the patient was last seen, a separate entry on a medication list regarding any prescriptions written or samples dispensed, and often no individualized note whatsoever. This latter point is amazing to me as it presumes that the checkboxes and automated notations cover all of the required points to make an ongoing diagnosis and to be reimbursed for the right code. The presumption is correct but, unfortunately, as a clinician, the note tells me nothing about the patient.

All I really need to know is contained in one sentence from years ago. If progress notes covering several months time are read at once, they will inform the reader that the patient has shown slow but persistent progress, or perhaps rapid deterioration, but whatever the change, it’s obvious in a quick scan of a few pages. That’s no longer true. An inefficient time-consuming wade through checkmarks and listings sometimes doesn’t result in any indication as to what the important issues were in this patient.

This country is clearly being moved along a political agenda that includes the implementation of electronic medical records, despite our best interests. That’s not to say electronic medical records aren’t useful or potentially beneficial. It’s simply to say that I have yet to see an implementation of one that serves to reduce the workload of the clinician writing the note, and improve the ease with which a reader can quickly synthesize the critical points covered in the note.

I spent some time searching the web to find out more about specific programs that are available. I wanted to find a description that incorporated at least this information:

a) What platforms does the software support? Our clinic runs on Macs, so if your software is only for Windows, we’re looking elsewhere. Tell us that up front.
b) How much does the basic software cost? I’m not interested in your package that includes a server and a few computers. All I want to know is how much your software is. Microsoft tells me how much Word costs. You can tell me how much your EMR costs.
c) How long have you been in business?
d) What programming is the underlying engine for your software?
e) What do the interface screens look like?
f) What does the output look like? Can the output be easily configured for specific needs (e.g. internal, external review, sent to patient, etc.)?
g) Do you have prescription writing capabilities? Can prescriptions be sent to an email address, such as that of a specific pharmacy?
h) Can I scan information into the computer and append the .jpeg to the patient record, so that I can easily bring in non-electronic material?

Needless to say, I didn’t find any such site. Much of the problem stemmed from sites that weren’t complete. Websites can take a week or two to get running. The trick is to implement them in stages. The first stage might simply be a page of text providing some background. With that in place, you have time to set up your next page with some basic links. Once ready, that replaces the text-based page, and you can program your new page with graphics and animation. But that doesn’t go up until it’s ready.

A website that says “Under Construction” doesn’t do much for making me feel comfortable that you know how to program an electronic medical record. For all I know, I’ll click on New Patient Record and get an error message saying, “Under Construction.”

Things will change once all clinical offices need to have an electronic record, but I’m worried that with this being politically rather than clinically driven, we’ll end up with a record that is there for managed care, a record that is meant to protect us from liability, but not one that accomplishes what the simple handwritten notes did ; namely, to communicate the most important information with as little ink and paper use as possible.

What are your electronic record experiences? Have you found a descriptive website that honestly shares all the critical information about a specific medical record software package?

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, June 2005, v.6, n.3, pp.57-58.

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