Health by the Numbers

Switching to ‘Paperless’ Health Records Creates Myriad Hassles Today that Will Pay Off with Better Research in the Future

First, a brief history of medical recordkeeping, as related by Dr. Randa Perkins, a board-certified family practice physician and executive director of Medical Informatics at Tallahassee Memorial HealthCare:

At the dawn of humanity, Ogg saw somebody die after eating a poisonous plant and told Ugg not to eat it. Or maybe he drew a warning on a cave wall. Time marched on, and an early physician developed a technique for expelling evil spirits, then wrote it down for the edification of others who came after him.

During the Crimean War, Florence Nightingale laid the foundation for modern nursing. She was also a “data junkie,” keeping detailed statistical information and publishing works to spread information about effective medical practices.

But it wasn’t until 100 years ago that surgeons began keeping medical records about specific patients.

“The rapid growth in science behind medicine required more detailed records,” Perkins explained during a recent appearance before the TalTech Alliance, a nonprofit created to promote technology innovation in Tallahassee. “We all know that negative outcomes happen in health care; we prefer that they happen less, if at all. Providers were documenting to communicate with each other and remind themselves about a patient’s history.”

Then insurance companies had their own needs for records, and the era of medical coding arrived. (Just FYI, 401.1 is hypertension. Perkins said she used that one a lot during her family practice days.)

And the latest revolution in medical recordkeeping is of a much more recent vintage, dating back to February 2009, when the newly inaugurated President Barak Obama signed the American Recovery and Reinvestment Act. It was a $787 billion effort to goose the economy out of the Great Recession. Of that total, $150 billion was dedicated to health care, most for Medicaid and health insurance subsidies. But $19.2 billion was set aside to encourage doctors and hospitals to ditch the paper and convert to electronic health records (EHRs).

EHRs existed at the time but, according to the New England Journal of Medicine, only 17 percent of physicians and 8 to 10 percent of hospitals were using them.

“Paperless” records became the goal and, in the beginning, it was Perkins’ job locally to get TMH’s 550 or so clinical providers to start keeping their records and writing their orders electronically. To say many doctors were reluctant to make the switch would be an understatement.

“As a clinical informaticist, I have had to walk the fine line between having a vision of the future of what we can do with IT … while recognizing the massive disruption this is causing the patient/provider relationship,” Perkins said. “You shouldn’t transfer to electronic just because you can; there should be a practical purpose behind it. Doctors are passionate about patient care and angry about anything that decreases their ability to see their patients efficiently. We’re hoping there’s a benefit at the end, and that’s what I see, but it’s hard to push that through.”

Florence Nightingale

Perkins said today they’ve eliminated the old frustrations and errors of paper recordkeeping — deciphering handwriting scribbles, for one — and created new ones, such as annoying pop-up menus or accidentally clicking the wrong box.

Perkins and her staff constantly work with Information Technology staff to make the systems more user-friendly and upgrade processes that need to change to keep up with advances in medicine. The stakes, she said, are high: “A glitch at home, no big deal; a glitch at the bedside kills somebody.”

The doctor spoke at the TalTech meeting to encourage the IT community to work on the problems — and they are myriad — that keep EHRs from being fully functional. For starters, there is what Perkins calls the “Tower of Babel” problem. “We have about 67 different kinds of EHRs in Tallahassee, and do any of them talk to each other? It’s like the United Nations out there, and we don’t have enough translators,” she said.

Many of the records that were transferred to electronic versions are in not easily searchable PDF versions and, because of privacy concerns, many times doctors will have to log in to several different systems to get a complete look at your medical records. None of which is comforting when said doctor is trying to figure out how to treat your heart failure in the emergency room.

So, for all the aggravation and glitches and difficulties getting systems to communicate with each other, what is that bright future Perkins sees from using EHRs?

For individuals, an electronic record could immediately be at the fingertips of every doctor you see, in the office or in case of emergency — your health history, medication lists, allergies, test results, contact information and more. If you are a do-it-yourself sort, there are currently online resources such as Microsoft HealthVault, where you can collect the information yourself.

But there’s an even longer view.

“Our very mortal patients are providing immortal data,” Perkins said. “To me, that’s a mind-blowing concept. If we get good information, this is research that our kids could use, their grandkids could use generations from now.”

Other possibilities come from the realm of science fiction.

Remember the tricorder from “Star Trek”? Where Dr. “Bones” McCoy would wave a gadget over a patient to collect information? The technology exists today — “We’ve got the Bluetooth. We’ve got the tablets. We’ve got all these cool things,” Perkins said.