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Deciphering the medical procedure form and EMR



Going to your physician or, let’s say, cardiologist for a wellness checkup or some testing? If it’s a cardiologist, let’s look at what happened to a colleague recently and then you decide how you should proceed. NB: hospitals, institutes and group practices, I’m informing your patients right now.

Before anything, let’s look at the wreck that is EMR (electronic medical

records) and consider that for a moment. There are a number of packages for this type of record keeping and it seems ALL of them have problems. Why? For a variety of reasons, but I’m not a programmer, so I’ll just try to give you a few examples of the problems. Again, you decide what YOU want to do about this because it does mean your future medical treatment AND your insurance rates or reimbursement will be affected.

One physician, an internist, who sat rapidly typing away as the patient detailed her symptoms, came across a glitch (noted by the patient). What was it? Wrong medication. What to do about it? “Oh, I can’t change that. It’s the hospital’s database and I have no way to change anything in it.”

Is that a copout or what? Yes, clearly there should be a way to correct mistakes in the medical record whether it’s a paper file or a digital one. Who to go to for this correction? “I really don’t know. We just input our data and the hospital takes it from there.”

Why would you have a “patient portal” where patients could review their medical records, if they can’t ask for corrections when they find mistakes? Does that make ANY sense to you? My colleague’s record said she’d missed a pneumonia shot when she was six months old! She wasn’t even in their system when she was six months’ old, so where did that come from? Oh, it says 1969. Excuse me, 1969? Were most hospitals even using computers then? No, they weren’t and databases were still glimmers in programmers’ eyes.

Proceed to the next record, at another physician’s “institute” office. At the bottom of the detailed medical record on the screen was a listing of six or seven things. Mostly wrong and needing correction, but what did the tech say when it was pointed out to her? “Oh, we don’t even pay attention to that. It’s the hospital that puts that in and it doesn’t mean anything to us.” Doesn’t mean anything? Then why is it in the medical record? Didn’t have a clue. So, this information is meaningless to anyone? Why hasn’t it been cleaned and corrected. Don’t know.

Now let’s proceed from the medical records morass to the printed information given to patients when they are being scheduled for medical testing. How about a test that entails the injection of a nuclear tagged material into your veins? Suppose you were given a “patient information sheet” that indicates it was for a nuclear stress test with infusion, but that’s not the test you are being scheduled for? How would that strike you? When you asked the tech why the patient information form said it was a “nuclear” stress test and that was not what you were scheduled for, and that person said, “Oh, we use that form for both tests. It’s okay, the hospital uses it for both tests.”

Would that be okay with you since it would not accurately outline the test, the contraindications and the type of material being infused? How would you know if you were allergic to the material being used, even if they told you it was “pharma?” Excuse me, but “pharma” is a term used widely for pharmaceutical or bigpharma which means pharmaceutical firms. “Pharma” alone means nothing. As far as I know, there is no infusion material called “pharma.”

What about the major hospital with which this practice is now affiliated (and which probably owns the practice)? Why are they permitting such sloppy record keeping in their EMRs? And why don’t they have TWO forms; one for nuclear stress testing and one for the other “pharma” test? Is that too much to ask them for by way of being transparent?

The office quickly cleared, the MD left via a back door and the only two people there were a woman at the front desk and one tech. What to do? Okay, call the MD the next day and tell her that the form is NOT okay and you are NOT going to sign for the procedure. Yeah, see how well that goes over.

Medicine is no different from the legal field these days. It’s all about billing and hours and 15-minute appointments with as much testing as you can convince the patient to have. Kind of like selling cars, isn’t it? Get them to buy all the bells and whistles so they’re sure they’re in good health? Oh, yes, and be sure to provide the code that will justify whatever testing your ordering even if the patient doesn’t have a history of that problem.

Caveat emptor, my friends, caveat emptor.


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DR. PATRICIA A. FARRELL