The Daily Apple™© Volume 2, Number 8
August 9, 2013
PGY 41, Day 40
Electronic Medical Records: Flaws and Dangers
ALWAYS GO TO THE PATIENT FIRST
Here are ten reasons why you & every provider should ALWAYS go to the PATIENT FIRST and NEVER go to the record first, or copy and paste from the ELECTRONIC MEDICAL RECORD (EMR)
1. SICK PATIENTS CHANGE FAST: INTERVAL CHANGES IN HISTORY AND PHYSICAL EXAMINATION WILL BE MISSED
You may miss clinical changes that are important to early diagnosis and treatment
2. THE RECORD MAY NOT BE ACCURATE: THERE MAY BE ERRORS AND OMISSIONS
Previous examiners may have skipped parts of the history or physical examination
3. SOMETHING MIGHT HAVE BEEN MISSED IN THE LAST EVALUATION
The natural history of most diseases includes a preclinical, or undetectable phase, which may or may not be symptomatic. Frequent evaluation of the patient, including repeat history and physical examination is an essential part of early definitive diagnosis and treatment.
4. THE RECORD MAY BE INCOMPLETE
5. YOU MAY BE LOOKING AT THE WRONG RECORD
6. SOMEONE MAY HAVE MADE AN ERRONEOUS ENTRY INTO THE RECORD
7. DISEASES EMERGE OVER TIME: EARLY & DEFINITIVE DIAGNOSIS AND PRECISION TREATMENT MAKES A DIFFERENCE
This is intuitively obvious and proven empirically for several diseases. Follow the data and use your intuition for now. Target: Early Definitive Diagnosis and Precision Treatment
8. THE MORE PEOPLE WHO EVALUATE THE PATIENT (NOT THE RECORD) THE MORE ACCURATE WILL BE THE EVALUATION
Intuitively obvious. Do you need proof? Talk with me and we will do some research to prove it.
9. THE MORE OFTEN THE PATIENT IS EVALUATED, THE MORE ACCURATE WILL BE THE EVALUATION
As in number 8 above.
10. COPY AND PASTE IS CHEATING, PLAGIARISM & FRAUD
Yes, and it is a bad idea to cheat patients and cut corners on patient care. This is a problem that results in suboptimal outcome. Do you need proof for this?
SUMMARY AND CONCLUSION
Sick Patients, especially when critically ill, can change rapidly. The natural history of each disease, the way in which each disease presents in a particular patient (host), the preclinical phase and the clinical presentation can vary dramatically from one -DISEASE<>PATIENT (host)- to another. This is the reason for frequent and repetitive patient evaluations. In other words, frequent evaluation by multiple providers increases the accuracy and speed of diagnosis and proper treatment, and this is the right thing to do for all patients at all times. It is NEVER OK to cut corners on patient care.
Electronic Medical Records make it very easy to cut corners, to go to the record first, to copy and paste, to take the note that someone else wrote, to copy it and paste it in as if it were your note. In other words, if you don't write the note based upon your history and physical examination ... if your note is not based upon your evaluation of the patient, you are cheating the patient. Don't do it! ALWAYS go to the PATIENT FIRST. To copy in paste is plagiarism, fraud and cheating the patient out of best possible care.
At best, the Medical Record, Electronic or otherwise, is an imperfect reflection of the patient. In other words, even if it is a "perfect" record, or a "perfect" EMR, it is limited by our knowledge of the patient at one point in time. Over centuries, the medical profession has learned a few things that are easily undone by the EMR. You in the EMR business? HIT people? Do NOT ENABLE COPY AND PASTE for history and physical examinations and interval notes.
Each note, history and physical examination should stand alone at a point in the timeline of each patient's life. It is a reflection of each physician<>patient relationship at one point in time. Each is personal and unique ... not to be undone by technology or methodology. And, if done properly, Doctor, your notes will be accurate and lead to better and best outcomes in patient care.
Salute! Amore e buona fortuna. It is all about Love. There is not enough money in the world to make this right.
Join us. Help Build Better Health and Healthcare through Patient<>Physician Cooperation and Cooperatives @ www.ihealsolutions.com and our non profit @ www.VeritasHC.org
Dr. Mike
Michael F. Mascia, MD, MPH
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