The EHR Report

Electronic health records have led to recent issues appearing in the court system that can potentially convolute physician defense. Both health care attorneys and physicians are grappling with new technology that brings with it the need for close attention to new areas of detail. Certain habits, or lack of habits, can affect the medical-legal environment. Physicians who are aware of these issues can take steps to reduce their exposure.

One of the largest problems seen with EHRs is the failure of physicians to review dictated records. After a note is dictated into the electronic system, health care providers should be encouraged to read it and any accompanying documentation such as prescriptions.

Voice recognition systems are not foolproof and can lead to inaccuracies in the transcription of operative reports, office notes, and prescriptions. When a doctor is deposed and has to explain that what the record says is not really what he or she meant it to say, it decreases his or her credibility with the jury and undermines subsequent testimony. When a physician says that the record is not an accurate representation of what occurred, the jury is left with an impression of carelessness and a failure on the doctor’s part to take the time to ensure patient safety. Taking a few minutes to guarantee the accuracy of the record at the time of creation can save years of explanation after a case has been instituted.

The failure of the physician to review his or her notes can also lead to the veracity of the EHR being called into question. We are aware of at least one case in which an emergency department physician was asked to testify at trial about her interaction with a patient from many years prior. Understandably, the emergency department physician did not have a recollection of the visit and intended to rely on the record. The EHR documented the care that was provided, but the physicians had not signed it. At trial, the doctor was not allowed to testify about what she did for the patient. The rationale was that the doctor did not recall what was done, and her failure to sign the EHR contemporaneously meant that there was no evidence that the EHR was accurate.

A physician should be able to say that his or her custom and practice is to review the EHR before it is finalized and make any updates or addendums as needed. That way, even if there is no signature, the physician has given credence to the accuracy of the records.

Health care providers should be encouraged to use the "free-text" section that is available when it adds to the accuracy of the record. Often, the "drop box" does not provide an adequate selection to describe the history or physical. In anesthesia cases, for instance, the EHR drop box may allow only a description of "awake," "drowsy," or "unresponsive." These choices, while true, do not give an accurate picture of the patient. If a patient in the postanesthesia care unit is technically awake but not properly responsive, that should be documented.

Similarly, in the primary care physician’s office there are times when the general description of how a patient is looking can be informative and integral to the physician formulating an assessment. An example might be the case of a sick child. The child may be curious, playful, and smiling when pulling at the stethoscope. If we are using that information as an important part of our decision as to whether or not that child is seriously ill, then that level of detail should be included in the record. The term "NAD" (no acute distress) does not reflect the level of observation that influenced the decision not to do further testing.

If the drop box is the only source of information utilized, then the true description of the patient is not contained within the records. Sometimes, the most important bits of information cannot be explained utilizing drop boxes.

Another common issue is the failure of EHRs to document when a patient calls the physician’s office but is not actually seen for an appointment. The patient alleges that he or she called the doctor multiple times to report a problem. The HER, however, may not have any record of such a phone call. Physicians need to ensure that they are made aware of these telephone calls and that some type of note is made. The note should not just indicate that a call was made but also should document the physician response and recommendations.

Finally, a new area of concern that has emerged is failure to follow up on a recommendation once it has been made. An ideal situation would be for the EHR or physician office to send a follow-up reminder if an important test is not done. This reminder to the patient should be recorded as well as whether the patient went through with the recommendation and steps the health care provider took to encourage compliance.

This overview does not represent an exhaustive list of EHR issues but rather highlights some common issues along with steps that can be taken to minimize errors, with a goal of increasing overall safety for the patient and decreasing liability for the health care provider.

Mr. Marcoz is a health care attorney in Wilmington, Del., who is shareholder at Marshall Dennehey Warner Coleman & Goggin in the Health Care Liability Practice Group. His areas of practice include medical malpractice and dental insurance defense. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.

Electronic health records have led to recent issues appearing in the court system that can potentially convolute physician defense. Both health care attorneys and physicians are grappling with new technology that brings with it the need for close attention to new areas of detail. Certain habits, or lack of habits, can affect the medical-legal environment. Physicians who are aware of these issues can take steps to reduce their exposure.

One of the largest problems seen with EHRs is the failure of physicians to review dictated records. After a note is dictated into the electronic system, health care providers should be encouraged to read it and any accompanying documentation such as prescriptions.

Voice recognition systems are not foolproof and can lead to inaccuracies in the transcription of operative reports, office notes, and prescriptions. When a doctor is deposed and has to explain that what the record says is not really what he or she meant it to say, it decreases his or her credibility with the jury and undermines subsequent testimony. When a physician says that the record is not an accurate representation of what occurred, the jury is left with an impression of carelessness and a failure on the doctor’s part to take the time to ensure patient safety. Taking a few minutes to guarantee the accuracy of the record at the time of creation can save years of explanation after a case has been instituted.

The failure of the physician to review his or her notes can also lead to the veracity of the EHR being called into question. We are aware of at least one case in which an emergency department physician was asked to testify at trial about her interaction with a patient from many years prior. Understandably, the emergency department physician did not have a recollection of the visit and intended to rely on the record. The EHR documented the care that was provided, but the physicians had not signed it. At trial, the doctor was not allowed to testify about what she did for the patient. The rationale was that the doctor did not recall what was done, and her failure to sign the EHR contemporaneously meant that there was no evidence that the EHR was accurate.

A physician should be able to say that his or her custom and practice is to review the EHR before it is finalized and make any updates or addendums as needed. That way, even if there is no signature, the physician has given credence to the accuracy of the records.

Health care providers should be encouraged to use the "free-text" section that is available when it adds to the accuracy of the record. Often, the "drop box" does not provide an adequate selection to describe the history or physical. In anesthesia cases, for instance, the EHR drop box may allow only a description of "awake," "drowsy," or "unresponsive." These choices, while true, do not give an accurate picture of the patient. If a patient in the postanesthesia care unit is technically awake but not properly responsive, that should be documented.

Similarly, in the primary care physician’s office there are times when the general description of how a patient is looking can be informative and integral to the physician formulating an assessment. An example might be the case of a sick child. The child may be curious, playful, and smiling when pulling at the stethoscope. If we are using that information as an important part of our decision as to whether or not that child is seriously ill, then that level of detail should be included in the record. The term "NAD" (no acute distress) does not reflect the level of observation that influenced the decision not to do further testing.

If the drop box is the only source of information utilized, then the true description of the patient is not contained within the records. Sometimes, the most important bits of information cannot be explained utilizing drop boxes.

Another common issue is the failure of EHRs to document when a patient calls the physician’s office but is not actually seen for an appointment. The patient alleges that he or she called the doctor multiple times to report a problem. The HER, however, may not have any record of such a phone call. Physicians need to ensure that they are made aware of these telephone calls and that some type of note is made. The note should not just indicate that a call was made but also should document the physician response and recommendations.

Finally, a new area of concern that has emerged is failure to follow up on a recommendation once it has been made. An ideal situation would be for the EHR or physician office to send a follow-up reminder if an important test is not done. This reminder to the patient should be recorded as well as whether the patient went through with the recommendation and steps the health care provider took to encourage compliance.

This overview does not represent an exhaustive list of EHR issues but rather highlights some common issues along with steps that can be taken to minimize errors, with a goal of increasing overall safety for the patient and decreasing liability for the health care provider.

Mr. Marcoz is a health care attorney in Wilmington, Del., who is shareholder at Marshall Dennehey Warner Coleman & Goggin in the Health Care Liability Practice Group. His areas of practice include medical malpractice and dental insurance defense. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.

Electronic health records have led to recent issues appearing in the court system that can potentially convolute physician defense. Both health care attorneys and physicians are grappling with new technology that brings with it the need for close attention to new areas of detail. Certain habits, or lack of habits, can affect the medical-legal environment. Physicians who are aware of these issues can take steps to reduce their exposure.

One of the largest problems seen with EHRs is the failure of physicians to review dictated records. After a note is dictated into the electronic system, health care providers should be encouraged to read it and any accompanying documentation such as prescriptions.

Voice recognition systems are not foolproof and can lead to inaccuracies in the transcription of operative reports, office notes, and prescriptions. When a doctor is deposed and has to explain that what the record says is not really what he or she meant it to say, it decreases his or her credibility with the jury and undermines subsequent testimony. When a physician says that the record is not an accurate representation of what occurred, the jury is left with an impression of carelessness and a failure on the doctor’s part to take the time to ensure patient safety. Taking a few minutes to guarantee the accuracy of the record at the time of creation can save years of explanation after a case has been instituted.

The failure of the physician to review his or her notes can also lead to the veracity of the EHR being called into question. We are aware of at least one case in which an emergency department physician was asked to testify at trial about her interaction with a patient from many years prior. Understandably, the emergency department physician did not have a recollection of the visit and intended to rely on the record. The EHR documented the care that was provided, but the physicians had not signed it. At trial, the doctor was not allowed to testify about what she did for the patient. The rationale was that the doctor did not recall what was done, and her failure to sign the EHR contemporaneously meant that there was no evidence that the EHR was accurate.

A physician should be able to say that his or her custom and practice is to review the EHR before it is finalized and make any updates or addendums as needed. That way, even if there is no signature, the physician has given credence to the accuracy of the records.

Health care providers should be encouraged to use the "free-text" section that is available when it adds to the accuracy of the record. Often, the "drop box" does not provide an adequate selection to describe the history or physical. In anesthesia cases, for instance, the EHR drop box may allow only a description of "awake," "drowsy," or "unresponsive." These choices, while true, do not give an accurate picture of the patient. If a patient in the postanesthesia care unit is technically awake but not properly responsive, that should be documented.

Similarly, in the primary care physician’s office there are times when the general description of how a patient is looking can be informative and integral to the physician formulating an assessment. An example might be the case of a sick child. The child may be curious, playful, and smiling when pulling at the stethoscope. If we are using that information as an important part of our decision as to whether or not that child is seriously ill, then that level of detail should be included in the record. The term "NAD" (no acute distress) does not reflect the level of observation that influenced the decision not to do further testing.

If the drop box is the only source of information utilized, then the true description of the patient is not contained within the records. Sometimes, the most important bits of information cannot be explained utilizing drop boxes.

Another common issue is the failure of EHRs to document when a patient calls the physician’s office but is not actually seen for an appointment. The patient alleges that he or she called the doctor multiple times to report a problem. The HER, however, may not have any record of such a phone call. Physicians need to ensure that they are made aware of these telephone calls and that some type of note is made. The note should not just indicate that a call was made but also should document the physician response and recommendations.

Finally, a new area of concern that has emerged is failure to follow up on a recommendation once it has been made. An ideal situation would be for the EHR or physician office to send a follow-up reminder if an important test is not done. This reminder to the patient should be recorded as well as whether the patient went through with the recommendation and steps the health care provider took to encourage compliance.

This overview does not represent an exhaustive list of EHR issues but rather highlights some common issues along with steps that can be taken to minimize errors, with a goal of increasing overall safety for the patient and decreasing liability for the health care provider.

Mr. Marcoz is a health care attorney in Wilmington, Del., who is shareholder at Marshall Dennehey Warner Coleman & Goggin in the Health Care Liability Practice Group. His areas of practice include medical malpractice and dental insurance defense. Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor-in-chief of Redi-Reference Inc., a software company that creates mobile apps.

In response to our request for comments, readers have graciously flooded our inbox with a variety of e-mails full of opinions on electronic health records.

This has been an overwhelmingly positive and educational experience. Through your comments, we have been reminded that health information technology is a field rife with debate. Here, unlike most other areas of medicine, it is still impossible to define a single best practice that can reliably be employed in every EHR implementation.

Although we are convinced that it is the timeliness of the subject matter that actually drives readership, we truly appreciate the personal words of affirmation we receive every month. And though we do try to respond to feedback individually whenever possible, we think it is important to again say thank you to everyone who has cared enough to read and respond. You help us to better navigate the murky waters of electronic health records and help make sure that our comments are grounded in the day-to-day experiences of a wide range of users.

RTEmagicC_fws78gn6_Skolnik_and_notte.jpg.jpg

Over thenext few columns (with the permission of the authors), we will be publishing many of the comments we have received. Not surprisingly, the majority of messages discuss negative experiences, with an occasional e-mail that speaks to the benefits of the EHR. The focus has really been on how the transition to electronic health records has changed the physician/patient experience and the efficiencies – or inefficiencies – introduced by the use of EHRs. Many respondents expressed appreciation for the opportunity to vent their frustrations, and this further underscores the need for better, more open discussion on the topic.

One letter that reflects a balanced sentiment, yet captures the overall flavor of the thoughts expressed by our fellow physicians, came from Dr. Marc D. Grobman, a solo family physician in Wilmington, Del. Dr. Grobman adopted Practice Fusion, a free ad-supported EHR that we mentioned in a previous column. He relates his experience before and after the EHR, and how it has affected his practice:

"So let’s start with my routine before EMR [electronic medical records]. I would arrive at the office at 8:30 a.m. after seeing my kids off at the school bus. I would greet my staff and start seeing patients at 9:00 a.m. During the day, messages would pile up in the little basket for me, and I would quickly jot answers to questions or requests and hand them back to my staff between patients. During lunch, I would quickly eat ... and then jump to the mail, sign everything then enter into a Word file for the patient (the poor-man’s EMR) and then bring it to the staff for filing. The filing would often take days to accomplish because, being solo, I have only two other staff members.

"Now my days at the office begin at 7:45 a.m. (after rising at 5:30 a.m. to shower, eat, and check the EMR for prescription renewals, use the Delaware Health Information Network [DHIN] to look for admissions to the local hospitals and download the lab results, H&Ps, consults, radiology reports, and so on) with a grab of incoming faxes off the fax machine. I then race to my desk and turn on the computer and scanner to scan everything. Then I race to upload the material before the patients start at 9:00 a.m. Between patients, or most often at lunch, I answer "Messages" on the EMR, write Rx’s and handle any other things that come up. During lunch I also take time to scan and upload as quickly as possible. Same routine after lunch. Before I go home @ 6 or 7 p.m., I make sure everything is scanned so I can upload after dinner at home. No filing any more for the staff, since I scan and upload everything."

On first glance, Dr. Grobman’s experience seems quite discouraging, as he has seemingly transitioned his job description from physician to staff. He even goes on to admit being "baffled" by trying to find any meaning in meaningful use. But his closing thoughts do not express regret. Instead, he shares this:

"I do like using the EMR. I like being green and not needing paper, files, folders, stickers. ... I do find it worthwhile to have [an electronic] copy of the paper forms I do fill out for prior authorizations or pre-exclusion questions or legal request-just in case, you know, someone on the other end loses it. Is the trade-off worth it? In the end I am just more than slightly positive about this whole process."

This letter does a wonderful job of articulating some of the advantages and irritations of a successful EHR implementation. Dr. Grobman also alludes to another interesting theme: frustration with the meaningful use incentive program. Again, he is not alone here. Some readers, like Dr. Michael Laidlaw of Rocklin, Calif., admit to rejecting the government incentive program altogether. Dr. Laidlaw writes:

"What made me abandon the incentive this year (I qualified for and was reimbursed for stage 1) is when I realized that I spent the first 2-5 minutes of each visit endlessly clicking a bunch of garbage to make all the green lights show up on the [meaningful use] meter. I said to myself: ‘I’m not wasting precious seconds of my life and my patients’ time to ensure some database gets filled with data. I didn’t go into medicine for this. It is not benefiting my patients or me. I hate it.’ I actually refused to take the $10K+ this year. I have even accepted that I would rather be penalized in the future. What is worth the most to me is AUTONOMY."

In reviewing all of the feedback we’ve received, this idea seems to come up again and again. Physicians are willing to accept the time-consuming idiosyncrasies of electronic health records but are offended by the idea of technologic or governmental intrusion into the physician-patient relationship. We will continue to explore this idea in the coming months as we share more reader comments and response to the column.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a company that creates mobile apps. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

In response to our request for comments, readers have graciously flooded our inbox with a variety of e-mails full of opinions on electronic health records.

This has been an overwhelmingly positive and educational experience. Through your comments, we have been reminded that health information technology is a field rife with debate. Here, unlike most other areas of medicine, it is still impossible to define a single best practice that can reliably be employed in every EHR implementation.

Although we are convinced that it is the timeliness of the subject matter that actually drives readership, we truly appreciate the personal words of affirmation we receive every month. And though we do try to respond to feedback individually whenever possible, we think it is important to again say thank you to everyone who has cared enough to read and respond. You help us to better navigate the murky waters of electronic health records and help make sure that our comments are grounded in the day-to-day experiences of a wide range of users.

RTEmagicC_fws78gn6_Skolnik_and_notte.jpg.jpg

Over thenext few columns (with the permission of the authors), we will be publishing many of the comments we have received. Not surprisingly, the majority of messages discuss negative experiences, with an occasional e-mail that speaks to the benefits of the EHR. The focus has really been on how the transition to electronic health records has changed the physician/patient experience and the efficiencies – or inefficiencies – introduced by the use of EHRs. Many respondents expressed appreciation for the opportunity to vent their frustrations, and this further underscores the need for better, more open discussion on the topic.

One letter that reflects a balanced sentiment, yet captures the overall flavor of the thoughts expressed by our fellow physicians, came from Dr. Marc D. Grobman, a solo family physician in Wilmington, Del. Dr. Grobman adopted Practice Fusion, a free ad-supported EHR that we mentioned in a previous column. He relates his experience before and after the EHR, and how it has affected his practice:

"So let’s start with my routine before EMR [electronic medical records]. I would arrive at the office at 8:30 a.m. after seeing my kids off at the school bus. I would greet my staff and start seeing patients at 9:00 a.m. During the day, messages would pile up in the little basket for me, and I would quickly jot answers to questions or requests and hand them back to my staff between patients. During lunch, I would quickly eat ... and then jump to the mail, sign everything then enter into a Word file for the patient (the poor-man’s EMR) and then bring it to the staff for filing. The filing would often take days to accomplish because, being solo, I have only two other staff members.

"Now my days at the office begin at 7:45 a.m. (after rising at 5:30 a.m. to shower, eat, and check the EMR for prescription renewals, use the Delaware Health Information Network [DHIN] to look for admissions to the local hospitals and download the lab results, H&Ps, consults, radiology reports, and so on) with a grab of incoming faxes off the fax machine. I then race to my desk and turn on the computer and scanner to scan everything. Then I race to upload the material before the patients start at 9:00 a.m. Between patients, or most often at lunch, I answer "Messages" on the EMR, write Rx’s and handle any other things that come up. During lunch I also take time to scan and upload as quickly as possible. Same routine after lunch. Before I go home @ 6 or 7 p.m., I make sure everything is scanned so I can upload after dinner at home. No filing any more for the staff, since I scan and upload everything."

On first glance, Dr. Grobman’s experience seems quite discouraging, as he has seemingly transitioned his job description from physician to staff. He even goes on to admit being "baffled" by trying to find any meaning in meaningful use. But his closing thoughts do not express regret. Instead, he shares this:

"I do like using the EMR. I like being green and not needing paper, files, folders, stickers. ... I do find it worthwhile to have [an electronic] copy of the paper forms I do fill out for prior authorizations or pre-exclusion questions or legal request-just in case, you know, someone on the other end loses it. Is the trade-off worth it? In the end I am just more than slightly positive about this whole process."

This letter does a wonderful job of articulating some of the advantages and irritations of a successful EHR implementation. Dr. Grobman also alludes to another interesting theme: frustration with the meaningful use incentive program. Again, he is not alone here. Some readers, like Dr. Michael Laidlaw of Rocklin, Calif., admit to rejecting the government incentive program altogether. Dr. Laidlaw writes:

"What made me abandon the incentive this year (I qualified for and was reimbursed for stage 1) is when I realized that I spent the first 2-5 minutes of each visit endlessly clicking a bunch of garbage to make all the green lights show up on the [meaningful use] meter. I said to myself: ‘I’m not wasting precious seconds of my life and my patients’ time to ensure some database gets filled with data. I didn’t go into medicine for this. It is not benefiting my patients or me. I hate it.’ I actually refused to take the $10K+ this year. I have even accepted that I would rather be penalized in the future. What is worth the most to me is AUTONOMY."

In reviewing all of the feedback we’ve received, this idea seems to come up again and again. Physicians are willing to accept the time-consuming idiosyncrasies of electronic health records but are offended by the idea of technologic or governmental intrusion into the physician-patient relationship. We will continue to explore this idea in the coming months as we share more reader comments and response to the column.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a company that creates mobile apps. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

In response to our request for comments, readers have graciously flooded our inbox with a variety of e-mails full of opinions on electronic health records.

This has been an overwhelmingly positive and educational experience. Through your comments, we have been reminded that health information technology is a field rife with debate. Here, unlike most other areas of medicine, it is still impossible to define a single best practice that can reliably be employed in every EHR implementation.

Although we are convinced that it is the timeliness of the subject matter that actually drives readership, we truly appreciate the personal words of affirmation we receive every month. And though we do try to respond to feedback individually whenever possible, we think it is important to again say thank you to everyone who has cared enough to read and respond. You help us to better navigate the murky waters of electronic health records and help make sure that our comments are grounded in the day-to-day experiences of a wide range of users.

RTEmagicC_fws78gn6_Skolnik_and_notte.jpg.jpg

Over thenext few columns (with the permission of the authors), we will be publishing many of the comments we have received. Not surprisingly, the majority of messages discuss negative experiences, with an occasional e-mail that speaks to the benefits of the EHR. The focus has really been on how the transition to electronic health records has changed the physician/patient experience and the efficiencies – or inefficiencies – introduced by the use of EHRs. Many respondents expressed appreciation for the opportunity to vent their frustrations, and this further underscores the need for better, more open discussion on the topic.

One letter that reflects a balanced sentiment, yet captures the overall flavor of the thoughts expressed by our fellow physicians, came from Dr. Marc D. Grobman, a solo family physician in Wilmington, Del. Dr. Grobman adopted Practice Fusion, a free ad-supported EHR that we mentioned in a previous column. He relates his experience before and after the EHR, and how it has affected his practice:

"So let’s start with my routine before EMR [electronic medical records]. I would arrive at the office at 8:30 a.m. after seeing my kids off at the school bus. I would greet my staff and start seeing patients at 9:00 a.m. During the day, messages would pile up in the little basket for me, and I would quickly jot answers to questions or requests and hand them back to my staff between patients. During lunch, I would quickly eat ... and then jump to the mail, sign everything then enter into a Word file for the patient (the poor-man’s EMR) and then bring it to the staff for filing. The filing would often take days to accomplish because, being solo, I have only two other staff members.

"Now my days at the office begin at 7:45 a.m. (after rising at 5:30 a.m. to shower, eat, and check the EMR for prescription renewals, use the Delaware Health Information Network [DHIN] to look for admissions to the local hospitals and download the lab results, H&Ps, consults, radiology reports, and so on) with a grab of incoming faxes off the fax machine. I then race to my desk and turn on the computer and scanner to scan everything. Then I race to upload the material before the patients start at 9:00 a.m. Between patients, or most often at lunch, I answer "Messages" on the EMR, write Rx’s and handle any other things that come up. During lunch I also take time to scan and upload as quickly as possible. Same routine after lunch. Before I go home @ 6 or 7 p.m., I make sure everything is scanned so I can upload after dinner at home. No filing any more for the staff, since I scan and upload everything."

On first glance, Dr. Grobman’s experience seems quite discouraging, as he has seemingly transitioned his job description from physician to staff. He even goes on to admit being "baffled" by trying to find any meaning in meaningful use. But his closing thoughts do not express regret. Instead, he shares this:

"I do like using the EMR. I like being green and not needing paper, files, folders, stickers. ... I do find it worthwhile to have [an electronic] copy of the paper forms I do fill out for prior authorizations or pre-exclusion questions or legal request-just in case, you know, someone on the other end loses it. Is the trade-off worth it? In the end I am just more than slightly positive about this whole process."

This letter does a wonderful job of articulating some of the advantages and irritations of a successful EHR implementation. Dr. Grobman also alludes to another interesting theme: frustration with the meaningful use incentive program. Again, he is not alone here. Some readers, like Dr. Michael Laidlaw of Rocklin, Calif., admit to rejecting the government incentive program altogether. Dr. Laidlaw writes:

"What made me abandon the incentive this year (I qualified for and was reimbursed for stage 1) is when I realized that I spent the first 2-5 minutes of each visit endlessly clicking a bunch of garbage to make all the green lights show up on the [meaningful use] meter. I said to myself: ‘I’m not wasting precious seconds of my life and my patients’ time to ensure some database gets filled with data. I didn’t go into medicine for this. It is not benefiting my patients or me. I hate it.’ I actually refused to take the $10K+ this year. I have even accepted that I would rather be penalized in the future. What is worth the most to me is AUTONOMY."

In reviewing all of the feedback we’ve received, this idea seems to come up again and again. Physicians are willing to accept the time-consuming idiosyncrasies of electronic health records but are offended by the idea of technologic or governmental intrusion into the physician-patient relationship. We will continue to explore this idea in the coming months as we share more reader comments and response to the column.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a company that creates mobile apps. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.