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Bad beans

Over at ACEP’s blog The Central Line, Graham Walker tells us why he wants a national EMR.  Graham’s vision is compelling, yes, what with all that information and stuff.  As an emergency physician, I want a national EMR, too.

But what if I were the patient?  Let me put on my hypothetical patient hat, and respond to Dr. Walker:

  • A patient comes in to see me. I immediately get a list of their medical problems, prescribed medications, and allergies. This list is with actual real words, not “the little blue pill,” or “the white one, I take 10 milligrams — or is it 100 — 3 times — or is it two times — a day.”

If, when I came to see you, I were comatose and being ventilated by the paramedics, great.  But I’m here because I just ate some bad frijoles refritos and now have intractable vomiting, I’m not so sure sure I don’t want to discuss my entire medical history with you.  You’re not my regular doctor, you’re someone who can treat my acute nausea, vomiting, and dehydration.

  • I can see who a patient’s primary medical doctor is, and get quick access to their communication info.

Does “their communication info” mean the letters/emails between me and my doctor?  I don’t want you to see that either.  Not for this vomiting episode, anyway.

  • I can see when the patient last saw said doctor, or went to an Emergency Department, or was admitted to my — or any — hospital.

Hmmm, if I went to an ER in the next town over because I needed a foreign body removed from my rectum, I don’t want to tell you that.  I just ate some bad beans tonight, doc.

  • I can talk to the patient, already knowing if they carry a diagnosis of heart failure, diabetes, hypertension, smoking — to help narrow my differential.

Good to see you still want to talk with me after interrogating the computer.  I hope to persuade you that my vomiting doesn’t have anything to do with my high blood pressure.

  • I can see if the patient just had a work-up for problem X, perhaps changing my disposition of the patient.

Since I’m just a little dehydrated I’m sure your disposition decision won’t change too much this time.  I’m goin’ home.

  • I can input orders electronically and write my chart electronically, allowing me to be more efficient and see more patients.

Good man.  I’m sure you don’t need a national emr for that.

  • And in this fantasy world, I could even arrange for a follow-up appointment for the patient!

Don’t worry about it, doc.  I’ll call my own doctor in the morning if the suppositories you prescribed for me tonight don’t work.

So there you have it.  As an ER doc, I’m with Graham.  I’ve had too many patients that don’t think “diabetes” counts as a “medical problem” and who fail to mention it when I talk with them.*  Computers!  How I love you!  But in addition to problems about interoperability, we still have to address some privacy concerns before we roll out any national EMRs.  Or at least, the hypothetical young-and-healthy-but-food-poisoned patient in me thinks so.


*Medical school taught me to ask “open-ended” questions, as in “tell me about your medical problems.”  But that approach often fails in the ER.  Residency taught me to ask very specific, yes-no questions.  Not merely “do you have any major medical problems?” because that’s not specific enough — the literal (and witty) patients will often answer, “yes” and stop talking.  Instead, the only way to extract the diabetes history out of some patients is to narrow your eyes, raise your eyebrows, tilt your head, slow your speech, drop your voice, and ask, “Do you have diabetes?”  The trouble is, you can’t do the same song and dance with every possible disease.  “Do you have dermatomyositis?”  Which is why my ER doc side wants a national EMR.

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