Hello Electronic Medical Records, Farewell Paper Charts
Access to information in our daily lives has been redefined and simplified, an expectation of living in the 21st century. As such, one would reasonably expect that patients’ medical charts be computerized, given the recent advances in information technology. Like the paper version of the medical record, the computerized chart serves the same purpose—a communication tool to document and share information concerning a patient’s contact with health care professionals and the treatment received. Unfortunately, acceptance of the electronic medical record in psychiatry has been slow, regardless of the practice setting—inpatient, outpatient, private, or academic.
The mere mention of paper-based patient records (PBPR) conjures an unwieldy mammoth sheath of papers, as well as a sense of foreboding. The thought of combing through PBPRs to familiarize oneself with an “inherited” panel of patients from a graduating senior resident is daunting. The frustration at the disorganized information in the chart is minimal compared with the illegible penmanship by myriad clinicians. Journeys to the chart room to retrieve and return PBPRs are wasteful, especially when the unavailable chart has been signed out to another clinician.
My introduction to an electronic chart in psychiatry occurred almost two years ago. An EMR system was implemented shortly after I began my adult outpatient rotation. Despite the many disadvantages of the standard paper-based chart, its replacement was initially met with dread. Many residents cited anxiety with an unfamiliar medical record format; others acknowledged deficiencies in their typing or computer skills. For the technophiles, or “techies” like me, adapting was fun, exciting, and relatively easy compared with the challenges for the technophobes. From my perspective as a resident, the EMR possesses several distinct advantages over its paper-based version. These include the following:
• Chart accessibility and retrieval: A key feature of the EMR is its accessibility. Depending on how the system is designed, it can be accessed from anywhere, locally or remotely, 24/7 with just a few keyboard strokes. Furthermore, the EMR’s multi-user capability allows for simultaneous use by two or more clinicians—one with the ability to write in the chart and the others with read-only access.
• Accurate and legible notes: Illegible handwriting of clinicians, a common, longstanding problem in PBPRs, becomes a nonissue with the EMR. Legible, neat notes are a welcome feature to any clinician seeking specific patient information. Additionally, the option of printing of non-narcotic prescriptions directly from the patient’s EMR minimizes medication errors.
• Availability of an organized chart: In a PBPR, the tedious page-by-page search for specific information, such as medication changes, is circumvented because the EMR is organized for effortless information retrieval. Historical reference in monitoring the patient’s progress with treatment is simple. While it may be challenging to the clinician to record all the information mandated by adherence to good medical practices, as well as compliance to state and federal regulatory codes and accreditation standards, the task is accomplished easily in the EMR.
• Continuity of care and accountability: The EMR’s “Note” function facilitates the effortless exchange of information not only between the multiple disciplines but also various clinicians within each discipline. In addition, the availability of the information in an emergency room or outpatient or inpatient setting enhances the continuity of care.
• Security and electronic signatures: The Health Information Portability and Accessibility Act (HIPAA) mandates safeguards for the protection of patient medical information. The EMR, as a password-protected system, controls access to patients’ confidential records and provides additional protection of the records. Privacy is further maintained with security controls that track access to patients’ information.
Today’s EMR system is far from perfect, but its dynamic character and inherent ability to be customized to accommodate new data elements or formats as necessary are a major benefit. These are some of the other practical shortcomings to the EMR that I have encountered:
• Nonintegration of medical laboratory and other clinical data: A patient’s overall health is reflected in a medical record through the inclusion of annual physical exams and pertinent clinical laboratory data (example, lithium blood levels). A limitation of the EMR is the absence of integration or linkage of these data stored within other computerized systems. Regrettably, the consequence is a fragmented and incomplete electronic patient record.
• Failure to include a patient’s original documents and correspondence: Documents and correspondence to and from the patient are part of the patient’s PBPR, but are not included in the EMR. Instead, they remain part of the paper-based record. As technology improves, however, these hard-copy documents could be linked to the EMR using multimedia techniques to achieve a more comprehensive patient record.
• System crashes: A very rare but paralyzing moment occurs when the computer system crashes, and one is left with no chart during the visit. The design and installation of electronic backup systems and procedures assure that if such an event occurs, data retrieval is possible with minimal loss of data.
Overall, despite the anxiety-filled transition toward an electronic patient chart, I still choose the legibility, organization, and accessibility an EMR offers. So far, I have managed to integrate it into my daily practice as a resident. My exposure to the EMR leaves me hard-pressed to even consider practicing in a setting without the availability of this technology. ▪
Dr. Tahil is the chief resident in psychiatry at St. Luke’s-Roosevelt Hospital Center in New York City. She holds master’s degrees in medical informatics and public health.
