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Fam Pract Manag. 2007;14(2):16

"Why I Never Had an Atari Video Game System” by Dr. Mitchell Cohen [The Last Word, September 2006] is an excellent article about approaching electronic health records (EHRs) with caution. The people who are shoving EHRs down our throats are the same people who think pay for performance is the ultimate answer to the ultimate question. They seem to think that the best way to gain control over their “flock” is to force us to follow “best practice guidelines” and adopt EHRs, which can be easily data-mined. The trial lawyers will try this route to shut down the practice of real medicine.

Dr. Cohen's explanation for why he has not yet purchased an EHR sounds like a lot of rationalization to me. It reminds me of people describing their preference for horse-drawn carriages over cars and justifying it by saying things like “It's good for me to work harder” and “I can make do” and then pointing out the smell and unreliability of early automobiles.

The studies Dr. Cohen cites are not that surprising. Technology does not lower error rates; the proper use of well-designed and well-implemented technology does. Most of the studies of EHR use have been from large hospitals and large groups that do not address the day-to-day workings of an EHR in a private practice.

My 10 years with an EHR have improved my ability to care for patients and enhanced my life in many ways:

  • I can look at patients' medication, allergy and problem lists from home when I am on call. I can get chart information, labs, ECGs, etc., from the emergency department and nursing home at any time of the day or night.

  • In the event of a natural disaster, I could put all of my charts in my pocket before leaving town.

  • I am reminded of my patients' health maintenance needs every time I open every chart, so I do well on pay-for-performance scores.

  • I have never lost charts, and more than one person can look at a chart at the same time.

  • When I order an injection or an ECG, the information goes to my note, my nurse and the billing staff automatically, before I leave the room. No one has to wait for paper or worry that it will be lost as it is moved.

  • I don't have to transcribe immunization records; I print them out. When patients transfer, I don't have to pay someone to sit in front of a copier for hours. I hit a button and the chart prints – legibly.

  • I can do a “Would you see Joey, too?” visit (and charge for it) without leaving the room or waiting to get a chart.

  • I can print out a patient's lipid numbers for the last 10 years so he or she can see the trends and how a change in medicine, diet or weight changed the numbers. I can also print out complete medication lists with instructions.

  • I can generate a referral letter that includes a problem list, medication list, allergies and comprehensive history with the click of a mouse. I can generate the same information, with recent labs if I want, for an admission history.

  • I don't have to rely on patients' memories. I often remind them of surgeries they have had or medications they had forgotten make them violently ill.

  • Have I mentioned legibility?

You can do some of this stuff with a paper chart, but the time and energy involved is immense.

Dr. Cohen, follow me around for a day and then tell me you don't want what I have. You may never have gotten that Atari, but you don't deny wanting it.

Author's response:

Dr. Newman's analogy comparing EHRs to the horseless carriage is useful to me as well. The automobile was indeed destined to surpass the horse-drawn carriage, but even this technological transition was not without problems: high-speed motor vehicle fatalities, greenhouse gas emissions, foreign oil dependence and, arguably, war – to name but a few. I agree EHRs are inevitable. My practice is even in the early stages of this transition (see my essay “Auld Lang Syne: Practice Management Resolutions for the New Year,” FPM, January 2007). I believe we should proceed with adoption of EHRs, but we must be mindful of unintended consequences and not blindly assume all that is new is better. While I cannot deny I wanted that Atari, I am now grateful I was never given one. I appreciate Dr. Newman's offer to follow him around for a day and would certainly reciprocate to remind him that one does not need an EHR to provide quality health care.


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