What Are Electronic Medical Records Going to Solve?

Read Transcript

The availability of an electronic medical record is clearly a double edged sword. It's a brilliant thing to be able to share records with your colleagues and your patients, and having access to things like laboratory tests, and X-ray studies can be a big time saver and can cut costs because there's not going to be a reduplication of effort, but one of the problems has been tying remuneration to documentation.

What started to happen 25 years ago or more is that doctors were paid on what they did, but the insurance company said, unless you document that you did it we're going to assume that you didn't do it. And I started to look more and more carefully in medical records and saying we're not going to pay you for this because you didn't document.

Well, that didn't go on very long before doctors said well I'm going to start documenting a lot of stuff that previously just happened but didn't get documented, and you'd like to think that most practitioners are ethical, but it's not a very [xx] from that to a system that facilitates documenting everything even if it didn't really happen.

So, sometimes automated records give information that's misleading because they suggest that things  happened but didn't some of the systems are designed so that the default is, everything is put in and you have to remove it, and that's clearly not good. In these days it's a real [xx] test a lot of times to go through a medical record and figure out what the hell was important, because a simple and careful record is going to be a page and a half of stuff that's mostly nonsense.

A lot of the skills that you have as a practitioners this days believe it or not is going through medical records and calling what's useful information from what's simple garbage. And I don't think that there's been any real movement recently or up to this point to address that particular problem, so right now what people what people are getting as medical records is really a lot of stuff that's very unimportant to many cases.