Electronic health records aren't easy - just ask a doctor

I would like to tell you that after some months of talking to doctors and researchers I understand what the future of electronic medical records will be. But I can't.

Indeed, it is possible that when all is said and done, your family doctor may look back at the age of dusty, hard-to-read paper files in a steel filing cabinet and say: "golden age."

It could be that the anticipated flood of electronic information to your doctor's office is going to make family medicine worse for the physician but better for the patient. Consider the following examples.

When I visited Dr. Michelle Greiver's family practice in north Toronto, she was going through what might be described as if not electronic medical record hell, then as EMR purgatory.

And she is a believer. In fact, she began a blog in 2005 describing her practice's changeover to electronic records because she wanted to show what it was like when your office and work life were reconfigured.

She told me she thought there were going to be learning peaks and valleys, but that after a year or so the system would prove its worth, and the blog would end.

Neither has happened.

The day before my visit, her secure line, the one that allows her to send requests for tests and receive tests back from hospitals, went down. The day of the visit, the whole system was just irritatingly slow.

This has been going on for three-plus years now, and she is getting fed up.

"You are looking at a completely bipolar doctor," says Greiver. "I love my EMR. I hate my EMR. It is like having a two-year old. You don't know when they are going to have a tantrum next."

No sign of infection here

For another view on digital health, you can go to the Edmonton mall office where Dr. Allen Ausford and four colleagues look after 11,000 patients. Positive vibes virtually light up the exam room, which has two computer screens to exhibit electronic records.

An early adopter, Ausford has turned his clinic into an almost mandatory stopping-off place for Alberta health officials.

Since Netcare, Alberta's electronic medical record program, allows for almost all records — including tests, imaging and doctor visits — to be shared around the province, Ausford can point to exactly the kind of clinical success stories EMRs are supposed to bring about.

For example, there was the young girl with a painful peeing problem who kept visiting drop-in clinics. The continual diagnosis was that she had a bladder infection, and so she was given antibiotics. But after the pain appeared for the third time in six months she was sent back to Ausford, her family doctor, with the recommendation that a surgical examination of her bladder be conducted by a specialist.

Before going ahead with that, however, Ausford decided to look at all the results of all her urine tests and, lo and behold, there was no sign of infection.

"Before EMRs I would only have known that if I called the three clinics and asked for the results, and I have to confess I wouldn't probably have done that."

So, instead of a possibly painful trip to a surgeon, Ausford kept looking and discovered what turned out to be a milk allergy.

Don't throw out the baby

Having listened to Ausford, I'd like to say that just making the system more stable and permitting records to be moved around easily will make family doctors convert to electronic records in the near future.

But I can't — for a very surprising  reason. The old system might actually do some significant things better.

Greiver, for one, has collected data from her office to show that there was a 10 per cent decline in the quality of patient care in the first years following the switch to electronic records. Basic things like patient callbacks and followups suffered. Indeed, if you were a patient who was already worried about the quality of your family doctor's care, seeing them while they were switching from paper to paperless records could be unnerving.

The other element to consider is that the digital world may be changing the doctor's main job.

"Let's be honest," says researcher Dave Ludwick. "Doctors have gone to school to become doctors, to understand how the body works and remedy that body's failings, not to do IT. And yet with electronic records, IT suddenly becomes their job, too."

Ludwick has just completed a doctorate at the University of Alberta and recently wrote several papers detailing the struggles of 47 Alberta family practice doctors with EMR.

What his research points to is that the intimacy of the doctor-patient interview, the act of listening, may be in danger.

Stated baldly: "We are concerned that physicians do not have sufficient computer skills to take notes and navigate an EMR while listening to a patient in an encounter," Ludwick writes.

Information overload

Another thing to consider here is that it takes family doctors - who at best may spend 20 minutes with a patient — longer to create records electronically than just scribble things down on paper: a time increase of 17.5 per cent, according to a 2005 study.

Because we pay doctors on a fee-for-service basis, this suggests that implementing EMRs in their offices means doctors will get paid less. However good EMR is for the patient, this is a disincentive to doctors to change.

Maybe these are just teething pains. Maybe when the system gets more stable and doctors adjust to the new technology, well, maybe all the bad things will disappear.

But then I speak with Dominic Covvey, founding director of the Waterloo Institute for Health Informatics Research at the University of Waterloo, who tells me you can't look at an electronic health record in isolation. "In one way, it becomes a dumping ground for all other records."

If that turns out to be case, he says, the switch to digital record keeping "is going to be very useless, because there's going to be hundreds of millions of data points per patient."

Back in Alberta, Ausford, the EMR enthusiast, is aware of this information overload as well.

He estimates that if he reviewed all daily information flowing in from all his 2,000 patients, he would spend his entire workday doing nothing else.

With this in mind, some practitioners are trying to do is create a vastly simplified, one-page summary of what is going on with a particular patient. Ausford proudly showed me one he helped develop in Alberta.

The summary is fine if nothing much is wrong and if people accept the authority of the compiling doctor, but when something mysterious shows up, everything may change.

How doctors think

In the complexity surrounding the debate over electronic health records, we often overlook one critical element — How Doctors Think, which is the title of a book by Dr. Jerome Groopman of the Harvard Medical School.

Groopman argues that many doctors make up their minds about a patient in 18 seconds — but they regularly get things wrong. He uses as an example his own wrist injury, which was misdiagnosed by three doctors.

To combat this, he advises patients to adopt three strategies. Ask doctors if there is anything in their medical history that doesn't fit with a diagnosis. Ask if there is anything else their condition could be. And, finally, ask if there could be more than one thing wrong.

The implication of this is that if more and more computer-savvy patients begin taking their doctors through this list, the doctors will have to re-read the records, review images, re-analyze drug interactions, and so on.

Consequently, they may not be able to avoid the plunge into the information morass, which electronic records will inevitably become as they track patients through their entire lives. In the era of paper records one simply couldn't retrieve or track everything, and thus the information overload problem was effectively circumvented.

With this in mind, I asked Nikki Shaw, a health informatics specialist at the University of Alberta who wrote the classic how-to book on EMR for general practitioners, what she would do if she had the power to smooth the entry of e-health in Canada.

Everyone thinks that electronic records must be better, because everything computerized is by definition better, Shaw says. However, she would seek a human fix to the information tsunami that is coming.

"Get more doctors," is her solution. "Until we have enough doctors who can treat patients and not have people waiting, we're never going to solve the problem."

Geez. To a certain degree at least, people may still trump technology.