Page 8 - Volume 69 Number 2
P. 8

I Have Something To Say
... about electronic health records (EHR): they have become both blessing and curse. In the following essay, I will try to bring historical perspective and context to the EHR, and try to explain how we got where we are and perhaps speculate how best to deal with it. In Part I, I will trace the evolution of the use of computers in medicine, as I have experienced it. In Part II, I will try to look at where the
EHR is going right and going wrong. Last weekend, received an e-mail
message from a referring physician
asking a question about a patient that
was being referred to me. At home, on the weekend,
I was able to pull up the patient’s medical record and imaging studies, review them, and respond to the question within minutes. In situations like this, when I can link to electronic communications, medical records and imaging to solve problems and answer questions, the EHR is a marvelous tool. Who among us thought prior to the PC era that the application of computing technology to medical care would accomplish this!
Later, however, when I pulled up the unsigned notes from a dozen recent patient care visits, I felt quite differently. Now I had to review, edit, verify, addend, sign, attest to, and bill, all the while taking care to ensure that I had met the requirements for “meaningful use” (whatever that is – but that’s another story). Any happy feelings I might have had for the EHR rapidly turned to anger and frustration. It is this kind of inefficient, time- wasting activity (among other defects) that seem to be unavoidable in the EHR that has made EHR’s the subject of increasing criticism since they were mandated prematurely by governmental action a few years ago. Who among us thought that the application of comput- ing technology to medical care would come to this!
I have never been a computing hotshot, but I began to use computers in my science courses in college in the 1960’s, when IBM mainframes first became available and their applications explored to do scientific computations that would otherwise have been incredibly time consum- ing. In 1964, my physical chemistry laboratory experi- ments required as a prerequisite the ability to write simple programs in Fortran, so that we could carry out lab experiments involving x-ray diffraction and nuclear magnetic resonance and crunch the numbers in the
IBM 1420 (about the size of a two-partner business desk) that had been installed in the lobby of the Chemistry building. We used larger-than-legal sized IBM program- ming sheets and typed out boxes of punch cards, which we fed into the machine. The message for future
scientists (and budding physicians) was pretty clear: computing was something that was going to be important, a skill to be acquired.
When I was in medical school in the late 1960’s, clinicians with an interest in the potential applications of computing had begun to design programs for medical data acquisition: a computer program to take patient histories and make triage decisions based on simple decision trees. In my final semester, I took a non-credit elective in medical comput- ing, but there being no real practical
applications, it was mostly theory, i.e., how to convert analog information (words and numbers) into digital data (O’s and l’s). After all, the personal computer had not been invented yet. Bill Gates and Steve Jobs were barely out of diapers.
During my surgery residency at Yale-New Haven Hospital, I became interested in health services research, a field of inquiry that merged social science and health care, just emerging at the Yale School of Public Health. With very primitive tools, I undertook a study of health care delivery in the emergency room. This required acquisition of a large amount of social science-type data on patients, their problems, days of the week, times of day, level of staffing, time spent in the ER, and the like. The goal was to understand how an emergency room functioned at a time when the demand for emergency health care services was rapidly increasing and causing consternation all around.
IBM had by that time come up with a basic data analysis program called Cross-Tabs that made cross- tabulations and correlations possible for analyzing large data sets. The computing skills I had learned in physical chemistry were thus put to use in the pursuit of social science. Computing runs were done at the Yale Computing Center in a glass enclosed, temperature- controlled space housing a room-filling mainframe computer with large spinning spools of magnetic tape. Supplicants punched their cards and pushed the boxes they filled through the window to the acolytes that served the machines. I spent many late nights there, because the only time someone like me could get time on the computer was after 10 p.m. Seven or eight years later, I continued that type of research after my arrival at Michigan, now entering data at CRT terminals attached to mainframes at one of University of Michigan’s several computing centers.
The era of personal computing came to the University of Michigan in the mid-1980’s, when most of us acquired
By Richard E. Burney, MD
8 Washtenaw County Medical Society BULLETIN APRIL / MAY / JUNE 2017

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