Friday, September 23, 2016

The Good Old Days

by Dr. Edwin Leap, MD, FACEP

Ive been reminiscing about the good old daysof medicine.  I think about those times because I remember when medicine was focused on the sick and when practice was challenging & exhausting, but at its heartfun!  So what changed?  Lots of things.  But two things in particular come to mind: EMR and HIPAA.

First, lets discuss EMR, or Electronic Medical Records.  Where once we used paper charts or simple dictation to record information on patient care, now hospitals and physicians are increasingly forced into purchasing and using expensive and complex computerized record-keeping systems.  This was a growing trend already, but the Affordable Care Act made it all but mandatory, with rewards for implementation and fines for noncompliance.  Many small hospitals and practices, in fact, struggle to pay for the cost of implementation even as EMR companies make vast amounts of money.

Ill render unto Caesarhere.  Paper systems are problematic.  The can be illegible.  On paper, written by hand, it is difficult to document complex medical encounters and procedures.  And thus, the next clinician involved may have trouble understanding what happened before.  (As will the attorneys in malpractice suits.)  Finally, hand-written charts lose charges and are often down-coded in billing when insurers cant find the information they need, or find enough information to generate a proper bill.  Paper charts arent perfect. Likewise, dictated charts, while better, have longer turn-around times.  But both are faster and generally make physicians happier than the monstrosities that are modern electronic medical records systems.  

Indeed, to give credit where credit is due, electronic systems capture lots (and lots, and lots) of data.  And they can be helpful in retrieving information from previous visits.  And some use voice recognition dictation programs.  This kind of real-time dictation can be helpful.

And yetEMR sucks the fun out of medicine.  Because EMR systems leave clinicians slaves to the keyboard.  The sound of modern medicine is the sound of typing.  And the great anxiety for physicians, and nurses, is the terrible tension between doing the thing we love, which is patient care, and doing the thing our employers mandate, which is hour, upon hour, of mind-numbing data-entry, all the while trying to move patients in a way that provides the best satisfaction scores and the lowest wait times.  

EMR are rarely designed with clinicians in mind. So, while the flow of the log-ins, clicks, drop-down menus, signed orders, time stamps, discharges and all the rest make perfect sense to programmers, billing companies and data-collectors, its an electronic nightmare for those of us who simply want to get back to our patients.  (The commonly told joke is that physicians are the highest paid data entry clerks in the country!)

In the end we care for the sick and let the charts pile up.  We then end up with in basketsor to do listsfilled with hundreds of clicks and signatures that we have to do on our own time, after shift, to satisfy the appetite for information that administrators and government agencies desire, even when little of it contributes substantively to the care of the sick, injured and dying before us.  And woe-betide those who are delinquent in completing records!  E-mails and threats will abound until they are completed.

Older physicians and nurses, less computer savvy, sometimes simply leave.  They retire, taking their incredible skills and knowledge with them.  Younger physicians and nurses are frustrated, but have no other option except to press on and type away, longing for the bedside and the people they spent years learning to treat and comfort.

What about HIPAA?  The acronym stands for the Health Information Portability and Accountability Act. Passed in 1996, among the goals of this federal legislation is the protection of the confidentiality of patientsprivate medical information.  Like so many things the government touches, it had a noble intent.  But now it is less a law and more of a bludgeon.  

Currently, in order to protect privacy, patients are yearly advised of their HIPAA rights and expected to sign forms to that effect.  And physicians are constantly beset by log-ins and passwords.  This may seem like no big deal.  Every computer has a log-in screen!  In fact, plenty of applications exist to store all of our various and sundry passwords for our many programs and devices.  However, the average physician will have a log-in and password for the hospital computer system, then for the electronic medical records (EMR) system and a separate set for the radiology system. And if a physician works in more than one facility, the number of log-ins and passwords just keeps climbing.

Our nurses have a similar burden of logging into EMR computers, but also have to access the medication dispensing cabinets which are password protected.  Taken together, its very difficult to move patients quickly, chart effectively or maintain a train of thought because we are constantly accessing computers and trying to remember new passwords.  (Biometrics like fingerprint scans and others might help, but were not there yet.)

Furthermore, HIPAA terrifies every clinical staffer because they are warned, over and over, that violating privacy is a federal issue.  Even innocently handing the wrong instructions to the wrong patient can be a huge problem.  To make it worse, clinical employees of a hospital can be fired for simply looking up their own labs.  (Their own labs!  In other words, protected from their own prying eyes!)  Their privacy ensured, their job terminated.  

And where we formerly handed lab and x-ray reports to patients so they could take them directly to their physicians, now they must go through the medical records office the next day or later to obtain what is, in fact, their own information.  (Again, protected from their own snooping.)  Or they must have their physicians office request them with the appropriate release of information signed.   

And when we, the physicians who cared for a critically ill patient, transfer them to another hospital, its pointless to check on their progress.  Hello, this is Dr. Leap and I transferred Mrs. Howard, the multi-trauma yesterday after intubating her and placing a chest tube.  Can you tell me how shes doing?’  ‘All we can say is that she is in the hospital.’  Great.  Thats good quality control, to be sure.

HIPAA has indeed protected privacy (except of course for instances of computer hacking or carelessly placed and lost computersall too common).  But it has also created a vast industry of programs and consultants, and left clinical and clerical staff slower, and more anxious, than ever.
No, things arent what they used to be.  Many issues conspire to make modern medicine difficult; an aging population, complex diseases, rampant addiction, resistant infections, high costs, high expectations and many more.  In the end, however, HIPAA and EMR reflect a common core issue, which is the disconnect between the administrative and political forces that govern medicine (and stand to profit mightily from supervising it) and those who day in, day out, must practice it in the presence of living, bleeding, hurting, dying, fearful human beings whose bodies have no password, and who care less about privacy than survival.

And until that chasm is bridged, its unlikely that medicine will ever again be as fun as it was before.  But I can imagine, cant I, a shift without a computer and a chart without a log-on screen?  Ah, to sleep, perchance to dream…’

Logging off.
Edwin Leap, MD, FACEP

Dr. Edwin Leap is a happily married father of four children in the process of becoming adults. He practices emergency medicine in the southern Blue Ridge Mountains.  In addition to his career in medicine, Dr. Leap writes monthly columns for the Greenville News, Emergency Medicine News and The South Carolina Baptist Courier.  He also blogs at  From faith to family and from culture to medicine, he covers every topic with humor, insight and compassion.


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