Paperless medical record not all it's cracked up to be

Commentary. By Edmond Blum, MD, AMNews contributor. Feb. 17, 2003.

New York City's Health and Hospitals Corp., the nation's largest municipal hospital system, is going paperless. In doing so it is going with the flow. The electronic medical record is touted as a cure for all that ails the paper record: illegibility, inaccuracy, inaccessibility and incompleteness. Beyond that it offers decision-support systems and facilitates population medicine via its databases. It has become an essential technology.

Yet as a primary care physician in one of HHC's largest facilities, I have serious misgivings. So do many of my colleagues.

The EMR has become an essential technology for health care and can be an immensely valuable tool, but going paperless is crossing the Rubicon, a critical boundary, a line which may be that of diminishing returns.

The problems have to do with the limitations of how data can be entered, and how physician entry of those data may inadvertently inhibit patient care. As the Institute of Medicine has noted, this is the greatest single challenge that has consistently confronted system developers.

In an EMR, data may be entered in free-text form, in coded form or in a form that combines both. Trade-offs between the use of codes and free text exist, but the more precisely the physician tries to represent a complex description in code, the slower and more costly the coding effort becomes. In free text, physicians can express complex information at the speed of thought.

This is most evident in general internal medicine, in which the bulk of the patient record must remain as free text: history, examination findings, progress notes, discharge summaries, assessment and plan. This text, which conveys the interpretive and narrative parts of the medical record -- including the indispensable nuances and ambiguities -- is essential for diagnosis and management. The information it contains can be expressed only in natural language, not by structured databases and coded options. Without it, there is nothing to connect the dots of coded data into a coherent and meaningful picture.