Lost in Translation: Electronic Records and Health Reform

A typical day at work will invariably find me hunched over a piece of paper, staring at a jumble of illegible loops and lines, trying to figure out what on earth five loops and a squiggle is supposed to convey to the reader.

No, I am not a handwriting analyst, a historian of ancient writing, or a translator of foreign languages. I am a medical student, simply trying to read the paper progress note of another physician or resident in attempt to figure out what happened to my patient during his visit two months ago. This frustration contrasts to a recent gig at a VA hospital whose medical records and charts are completely computerized; a model system where I was able to breezily click through the past medical history of my patients. As an incoming medical professional in an already digitized world, I am constantly disgusted at the inefficiencies and difficulties that arise from using paper charts.

How Common are EHR’s?

Electronic medical record is one of the current buzz words in the health care field. A recent study published in the New England Journal of Medicine this past spring found that only 1.5% of hospitals have a comprehensive-electronic record system present in all units . Other recent studies have found that a small percentage of physicians’ practices currently utilize electronic health record (EHR) system or CPOE (computerized provider order entry) at all practice locations, leaving a larger majority of our hospitals and health care providers to sift through endless piles of paper every day to learn about their patients.

Costs and Benefits

Those who doubt the inherent benefits of comprehensive EHR implementation put forth the financial objection that estimates over hundreds of thousands of dollars for many physician practices to implement and maintain such a system. However, some studies show that the costs to the health care system created by the problems using paper charts have the potential to outweigh the costs of an EHR in the long-run. More importantly, even if ultimately shown to be cost neutral, effective use of electronic health records have been shown to improve quality and save lives. Many of these quality gains are realized with robust systems that include evidence-based decision support tools to providers.

The Scary Truth

The old joke of physicians having illegible handwriting holds true in my experience: for the majority of physician providers, their writing is difficult to read at best. At worst, it is plain illegible. This creates a multitude of problems in our health care system that is a huge detriment to the efficiency, safety, and the economics and structure of the health care system. The most obvious and feared complications of simple bad handwriting are huge mistakes that can needlessly cost a life.

In its landmark report, to Err is Human, the Institute of Medicine estimated that up to 98,000 lives are lost every year from medical errors.  Not surprisingly, one study found that approximately 90% of  inpatient medication errors occur at either the ordering or transcribing stage.  I see nearly every day how easy it can be to make a mistake with a life-or-death magnitude simply by misinterpreting the wrong word or number from a chart leading to a dangerous drug reaction or an incorrect treatment. Even if I finally correctly translate all of the scribbled notes in the paper chart, it will have taken me five times as long to treat my patient, increasing the time it takes to treat the patient and increasing the chance of an adverse outcome. Talk about inefficiency in health care!

Aside from the danger and inefficiency, medical errors due to paper charts can wreak havoc on many other players in the health care system by causing a high number of lawsuits. When a physician is sued due to a medical error, it drives up the cost of the already sky-high malpractice insurance that all physicians have to pay. While it may seem to the general public that all doctors are rich and live to play golf, many have high debts from school, don’t make the big bucks, and work horrendous hours. Add high malpractice insurance, and this causes financial difficulty for physicians in certain specialties that can cause shortages of some primary care doctors such as obstetricians.

Alternatively, physicians might be forced to cherry pick their patients, only accepting Medicare and private insurance patients, causing uninsured and Medicaid patients to use the ER as their only health care venue, thus shifting the burden of cost to taxpayer’s wallets in the form of hidden hospital fees to compensate for many cases of avoidable uncompensated care. Many critics of EHR within medical field fail to realize that in improving the efficiency and safety of medical records translates far down the line to many aspects of the health care system. Indeed, in a time of health care reform, the transition of paper charts to electronic medical records will play a large role in improving the health care system.

Reason for Hope?

Through the ARRA EHR stimulus, part of the larger stimulus bill, Congress recently set aside $19 billion dollars, or the equivalent of over $40,000 per physician in a practice, to assist in implementing electronic health records (EHR) that meet meaningful use definitions (e.g., CPOE). This is a huge step forward in the attempt to computerize medical records across the country.

As a health care professional, I am excited to see the dedication to the improvement in health care of the current administration and frankly shocked at those who refusal to consider any reform to this health care system that is so obviously inefficient, expensive, and backward compared to any other developed industrialized nation. An entire overhaul of our health care system is required, in which EHR are only one part. However, the same critics of implementing EHR because it is “too expensive” are focused on the short term in all areas of health care reform, battling reform not because they have a better idea, but because they have no idea. I challenge any EHR or health care reform naysayer to step into my shoes for a day to read handwritten patient notes in a paper chart and to make a life or death decision based on an illegible scrawl. Our patients deserve better.