All y’all EHR-using folks don’t know how good you have it.

The author, Chief Medical Information Officer of 3 million paper medical records.

For fun, I’ve set my Zoom background with an actual vintage 1997 photo I took of the medical records room in the basement of University of Colorado Hospital on Ninth Avenue in Denver (back when giants walked the earth). This aisle featured 6 stacked rows of medical record charts AND piles of paper record folders ON TOP since we were out of room (not shown). This was one of 29 aisles of records in the Records Room, holding ONLY the latest 3 years of records: the rest were retained (for 27 years) in a downtown warehouse.

Fun fact: we turned down lots of innovation partnerships and offers of free services because the medical information locked in those paper records was too difficult to pull out:

  • We have a Pulmonary Function mobile van parked out front: send us all your patients who currently smoke and we will screen their lung function for free!
  • Hey, our insurance company will pay you a bonus payment if you can prove all of the patients who have had a previous heart attack are taking aspirin! (true story, a clinic trying to prove this using paper medical records and clerical staff paid more gathering the data than they received in bonus money)
  • Quick: the mobile mammogram bus is coming next week: let’s call all our patients who are due for mammography screening!
  • We have a new diabetes educator visiting for a couple weeks! Can we contact all our patients with diabetes to come for a free visit?
  • Uh, oh! The medication Bextra is being recalled by the manufacturer; quick: call all our patients taking that medication! (True story: 1/2 of our clinics were able to run a report on our EHR at the time and call affected patients immediately; the other half, still relying on paper records, had to say… “well, when the patient calls for a prescription refill in a few months, THEN we’ll tell them…”)

Fortunately, it is simple in our current EHR to run ad-hoc reports to do all this now. Whew! And, we can do predictive analytics on this data to save lives that would have blown my mind back then.

Here’s another flashback:

Don’t tell the post office; this is where all their bins went

THIS is the Medical Records intake room, back when we were ONE hospital, 40 clinics (we’re now 12 hospitals, 800 clinics). On average, 6 vertical feet of paper, received EVERY DAY. Fifty medical records staff, filing, sorting, pulling, sending, receiving, creating new charts. And, still, we were 2 WEEKS behind on filing.

We had over 20 transcription services, all local, receiving tiny tape-recorder dictaphone tapes, transported by COURIER from the doctors dictating. As an aside, some of us remember hearing doctors mumbling their ultra-fast, only partly understandable dictations walking the halls between patients. On average, outpatient transcriptions took about 2 weeks to complete and print out, mail, and file back into the record. Inpatient daily transcriptions were ordered STAT for 3x the cost and typed same day, arrived by urgent courier in the late evening and taped into the paper chart.

I am proud of my doctor handwriting

For the record, here’s a paper progress note I wrote in 1999 on “non-carbon paper” sending the original copy to Hospital Medical Records, and then keeping the yellow copy in a “shadow chart”: a duplicate set of medical records kept in our “off-site clinic” because … we could not count on Hospital Medical Records to pull the relevant charts for clinic patients scheduled each day.

Don’t even get me started on our appointment scheduling system. “Oh yes, thanks for calling! So you’re looking for Dr. Lin’s next available appointment? Sorry, nothing for the next 3 weeks. Oh, you’d like to see the next available doctor? =sigh= OK I’ll pull down the other twelve 3-ring binders, one for each doctor, and see who might have an open spot.”

Are you keeping track? 50 medical records staff at the hospital to maintain Main Medical Records, and 1-2 additional medical records staff at EVERY clinic (about 40 clinics) to keep a shadow chart. Because we don’t trust each other to keep track and deliver records on time!

Hello, dolly

Oh, and meet this guy. In 1997, our medical information (see: x-ray films, paper medical records, dictaphone tapes) moved at the speed of rush-hour traffic on Colfax Avenue. Seven miles each way, 12 leased buildings throughout metro Denver. Two round trips every day.

With all this person-power and effort, the result? On a typical clinic day, I would see about 18 internal medicine patients. Main medical records would successfully deliver charts for about 9 patients. Our clinic’s shadow chart system would deliver charts to my exam room for about 6 additional patients, leaving, on average THREE patients with NO CHART. Just a piece of non-carbon paper, with handwritten vital signs and a list of patient-reported allergies that day. Mind you, there was no such thing as a clinical computer system at the time. As a result:

“Hi Doc! It is great to see you! What did my cardiologist tell you about me when he saw me 2 weeks ago and did all those tests? He said that I should come talk to you about his report.”

Um. I don’t have any of your records today. I see your blood pressure looks good and that you report no allergies to medicines though.”

“What?! I made this appointment to go over his report! That visit was 2 weeks ago!”

“Yes. Um. What condition, exactly, do you have? Why did we send you to my cardiology colleague? What do you remember that he told YOU? Can you help me out here?”

“This is disappointing. You mean you really have nothing on me? Do you at least have the blood test results or the echo result?”

“Um, no. I’m really sorry about this. Okay, tell you what, no charge for today, my apologies for wasting your time and I will call you later this week after I call and yell at my medical records people and maybe get your chart and see what it says.”

“Whatever. You guys should really get your act together. Okay, can you at least go ahead and refill those 3 medicines that you prescribed for me from last year? I’m about out.”

(Excitedly taking out prescription pad) “Sure, I’m happy to! Do you happen to remember the names of the medications and the doses and what they’re for?”

Let’s not even talk about loading up a 2-foot-tall stack of medical records in our arms, walking out to the car, throwing them in the trunk, driving home and dictating late into the night, and hopefully remembering to bring them back into the office the next day.

And, if there was an urgent need for a particular medical record? We would routinely have a couple staff members wandering the clinic, from office to office, desk to desk asking: “Do you have the chart for Peterson, Mary, or Smith, Joseph, or Samuels, Jane?” and thus not answering the phone, or rooming patients…

Of course, by contrast, with our current EHR, tap-tap-tap: instant access to any patient record.

Yesterday, for example, my patient met her oncologist to discuss a new diagnosis of metastatic cancer. Today, I was able to read her consulting note, review the pathology from a recent biopsy, refresh my education about peritoneal carcinomatosis in an EHR-linked online textbook, secure-chat and then phone call with the oncologist about prognosis and treatment options, set up a video visit with the patient and her family, and have a have a well-informed, thoughtful conversation about her next steps.

This speed and coordination would not have been possible in the era of paper charts.

Not as cool as Jimmy Fallon’s Thank you Notes

Wait! One more thing! Remember the good old days when we received faxed blood test results and then had to notify patients by writing a STACK of folded post cards? I faced a stack of these EVERY EVENING at the end of clinic. Please don’t ask me how many times a patient brought back a post card saying: “Um, this looks pretty important, but, I think you meant to send this to a different Peter Smith. I haven’t had a blood test in awhile.”

Yikes.

Our patient Portal, we call My Health Connection: we release test results to the patient online, and then send comments with our interpretations, arriving to the patient’s inbox instantly. Comment from my patient? “It feels like I have my doctor in my pocket. So cool.”

CMIO’s take? All y’all don’t know how good you have it.

On the other hand, are you old, like me? Do you remember those days?

On the third hand, in another decade, I hope folks will look back to TODAY and marvel how much better the future is.

Author: CT Lin

CMIO, UCHealth (Colorado); Professor, University of Colorado School of Medicine

2 thoughts on “All y’all EHR-using folks don’t know how good you have it.”

  1. All you MS Access-using folks don’t know how good you’ve got it – OK, a similar post from a data analyst point of view: Back when I was a kid, MS Access didn’t exist. Excel files ended in .xls, and there was a program (executable from the DOS prompt) to transfer data from DataEase (Yes, it was a thing; also executable from DOS prompt) to SAS (back when you could fit all the SAS manuals on one shelf) called DBMS/COPY, a separate piece of software to translate file formats. Now we can simply tell SAS where a MS-Access db (or Excel or REDCap, or a host of others) is and SAS will import data directly from it. No more writing hundreds of lines of code to go from data collection to analytics. Data sometimes came on 5 1/4″ floppy disks, or if people were fancy, 3 1/2″ disks. Remember having to format those? Yes, needless to say, I also remember those folded postcards.

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  2. All y’all MS Access-using folks don’t know how good you have it: Here’s a similar perspective from a longtime data analyst. Back when I was a kid, Excel files ended in *.xls (newly updated from Lotus 1-2-3), and the database we used was called DataEase (yes, it was a real thing) and it was executable only from the DOS prompt; Windows hadn’t been introduced. We had a separate program called DBMS/Copy to ‘translate’ DataEase files to so that SAS could read them (back when you could fit all the SAS manuals on half of one shelf). These days, you can simply give a location to SAS and the software will automatically read in tables from MS-Access (or Excel or REDCap or a host of others) seamlessly. No more writing hundreds of lines of code to transfer data from data collection to analytics. Oh, and variable names could only be 8 characters long in SAS. Yes, of course, I also remember the folded postcards for test results.

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