Friday, February 18, 2011

Thinking Outside of the Box

I know the electronic medical records get a lot of flack. Some of it is well-deserved. But as a pathologist who started training in a void, the EMR has been an invaluable addition to my practice. Traditionally, we pathologists work inside a black box. We rarely venture out of our lab closet caves - god forbid going to the floor to wade around in the muck of the paper chart. We all have computers next to our scopes, and gaining access to our patients in this manner - radiology, clinic notes, etc., makes the glass slide with a two dimensional slice of Easter egg dyed tissue spring to life.

Some clinicians are better than others. Surgeons and radiologists are notoriously brief, with rare exceptions. There is a certain infectious disease specialist at my hospital that writes so voluminously and well that I feel like I am sitting at the bedside of the patient I am puzzling over. There is a big difference in the large hospital I am primarily based at versus the small town hospital I rotate at once a month. In the smaller town, clinic notes are piped into the hospital medical records (must be easier there to do this I guess - less clinics, less complication) so I can access outpatient records - the clinician's thoughts can illuminate a tough GI biopsy and make it so much easier. It saves me lots of headaches and phone calls.

Performing wet reads on CT-guided needle biopsies in radiology is a particular sore spot. I know the radiologists are busy - drain an abscess here, do a paracentesis there, squeeze in another needle between a couple of radiofrequency ablations. But I still get irked when called to a lung biopsy and the radiologist doesn't know the history. I know, I know, I don't have to worry about causing a pneumothorax and putting in an emergent chest tube or dealing with a pulmonary hemorrhage - and they do. We all have our places in the cog of the medicine wheel. Thankfully, with EMR, I don't have to worry about what the clinician did or did not communicate to the radiologist - I can just open up the computer and get all the information I need to know. Information aids diagnostic accuracy, and ability to triage the specimen appropriately.

Take for instance the other day. I was sitting in my new (beautiful - yes still a closet in a lab, but with brand new coppery Formica and linoleum hardwoods that render me the envy of all the other pathologists) office and grabbed a CSF (cerebrospinal fluid) case. The cytotech screened it and called it negative. 90-95% of the time they are right. I picked up the cytospin, threw it on the stage, and looked in the scope. Low cellularity -appropriate for a CSF - a few lymphocytes and monocytes. But wait, what was that? A plasma cell? Plasma cells are never normal in the CSF. Often they herald chronic inflammatory issues or viral illnesses. I opened the EMR on the patient.

This patient had a diagnosis of plasma cell myeloma with recent acute mental status changes. So the lone plasma cell or two I was seeing, among the lymphs and monos, could indicate leptomeningeal spread of the patient's disease process. I reversed the tech diagnosis to atypical and added a lengthy comment - unfortunately there weren't enough cells to attempt flow cytometry to assess for clonality of the plasma cells to cinch the diagnosis. But with the information in the EMR I was able to get a more holistic picture on a couple of cells and provide better care for the patient. I cringe to wonder if I might have blown them off as lymphs without my crutch.

I open the EMR every day, all day, on almost every patient. In the rare instance that I see cancer in a specimen where there is no clinical or radiographic suspicion, I can take extra measures to ensure that I have the correct specimen and gain additional consults to firm up my suspicions. I am a pathologist, but with EMR, I no longer live in a black box. And for that, I am thankful. I really don't know how my predecessors got along without it.


  1. It's good to see how an EMR can help. Glad you got your new office. I need to come see it. :)

  2. I recently started using google health for my own "EMR." It is linked to both our prescription provider and to our insurance carrier, whom have write-only (they can't see it) access and update it regularly with information. It is a far cry from the panacea of completely interconnected health information, but I can easily print out a health history and take it from doc to doc without relying on my memory each time I sit down with a stack of forms.

    It has a lot of potential, but as with such things, it requires widespread adoption to become extra useful.

  3. You made your job seem really cool in this post. I just wanted you to know that.


  4. This right here is a prime example of the horrible communication among doctors about patients. Sometimes it is due to HIPAA concerns, but oftentimes I think it just has to do with a lack of time. Think of how much better we could take care of our patients if we communicated better with each other!!! (and yes, EMR helps me too, and I'm looking forward to our growing pains once my clinic implements it, FINALLY.)

  5. Haha. As an m1 about to take histo boards this was really exciting to read! :). Makes pathology seem fun- something my histo class does not do.

  6. Ramona - can't wait for you to come see it!

    Michael - I've never heard of that. Sounds interesting. I think the panacea of completely interconnected health information is still a pipe dream.

    RockStarMDGirl - Pathology is cool! I'm still trying to convert you to the dark side.

    Kelly - we are all so busy getting through our day that communication does get lost, and it only hurts the patient. I am glad we have a decent EMR to bridge that gap.

    barefootmoses - Good luck with histo boards! Anything is fun if you put the right spin on it.

  7. I think EMR are great, though I know the switch is a pain for many. I'm glad it will be standard by the time I'm practicing!

  8. I think EMR's are great most of the time too. However if the doc doing the recording isn't accurate in what he's recording it can bias other providers too. If the info is wrong it spreads like wildfire anyway and is hard to correct.

  9. We are 5 months into EMR in my office. On GOOD days it adds an hour to my day, often longer. I am trying to keep a good attitude, but so far I'm not impressed. Hate the fact that its mandatory.

    At the hospital it is helpful, but currently there is no way to connect between the two.

    Feels like we are being forced to buy something before there is truly a master plan in place for how it is all going to work together.

  10. EMR's are great in theory. They are probably also good in a large clinic or hospital where primary care and specialists all use the same system. My private office cannot afford to invest at least 60K per physician (and that's not counting upgrades and repairs) for a system that will not communicate with other systems and which the government could announce as inadequate every few months.
    Larger problem is GIGO (garbage in garbage out), a phrase more commonly used for computers 20-30 years ago. We get lots of FAX'ed reports from consultants using EMR's. Seems suspicious when super subspecialist is documenting like a 2nd yr med student. So - we started asking patients. Did the physician really check your reflexes. Did the specialilst really look in yours ears. Etc. We're getting a lot of fiction in these reports! EMR's will be useful when they are created in the best interest of physician and patient. Not when they are created for billing purposes or for accrediting agencies or for insurance company scanning.
    Just to note I'm not completely technologically adverse, we set up e-prescribing about 2 years ago and continue to slog along. But it takes me 3X as long as writing a script.

  11. I'm not in any kind of medical field, so my only experience is on the other end. I'm puzzled by the comment this post opened up with. *Why* do EMRs get flack? I would've thought this would be an incredibly welcome innovation! All the information, in greater detail than you'd probably get in hand-written notes (and no handwriting to decipher), in one convenient and multiply-accessible location. Sounds great.

    In particularly the handwriting thing -- I don't know if doctors' handwriting is as bad as the stereotypes make it, but I had to take my husband to urgent care yesterday and when we were handed a prescription, the stereotype was strong enough that I looked at it and thought "hunh, computer-generated! Great!"

    I did have an encounter with an EMR this morning. I took my cats to the vet, and the chart for one of them was up on screen and I could read it. I found it amusing to note that our two cats who were "American shorthairs" in the US are "Europese korthaar" (European shorthair) in the Netherlands.

  12. Sara - the reason for some of the flack is that first, EMR's are VERY expensive. Over $50,000 per physician just to set up. Who provides the money? In most primary care fields that would cause bankruptcy. Next, it's disruptive to the practice for the months that it takes to transition. It also includes too much information. If you have to wade through 10 pages of irrelevant material, the really important items get overlooked. So, in theory, most of us are not against EMR's. It's just that they are presently impractical and expensive and time consuming. Your vet can choose any simple system desired for his/her own practice. In people medicine, the system has to be compliant with ever changing government standards, complicating the picture. I hope that explains why some of us are not ready to jump on the bandwagon.

  13. Paige Storm- I agree- I have seen wrong info on patients copied, pasted, and to borrow a cliche- go viral. Not good. I guess it can happen in a paper chart too.

    Dr. Nana and Rh- thanks for elucidating the problems from a clinic standpoint. I can't speak from experience, only what I read, since I am luckily hospital based and don't have to worry about the cost of implementation or the problems with connectivity. We do have a lot of struggles with getting our lab results to our clinics. It's tough to have a mandate without a good plan.


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