DENVER – In as many as 220 million patient visits a year, physicians are treating patients whose medical records are missing information, according to a new study.Peter C. Smith, MD, and his colleagues at the University of Colorado Health Science Center in Denver conducted the study, published last month in JAMA, the Journal of the American Medical Association.
For Smith, the findings were both expected and surprising – and, on some levels, alarming.
It's expected, he said, because often there are many clinicians involved in handling one patient's treatment. The data do not always make it into every clinician's chart because their separate offices are not linked.
"Imagine if every control tower operated separately," Smith said. Researchers found that clinical information was missing in 13.6 percent of visits – or nearly one in seven visits. Among the information missing were lab results, dictations, radiology results, history and physical examination, and medications.
Doctors with fully functioning electronic medical records were much more likely to have the whole picture on a patient, Smith said. "They faced less than half the risk, vis a vis paper records," Smith said.
Scott Wallace, president and CEO of the National Alliance of Healthcare Information Technology, is surprised that anyone is taken aback by the findings.
"No one would have expected a better outcome," he said.
However, he said, studies like this one add to the mix of existing data that contribute toward the push for electronic medical records. While electronic records are likely to vary in effectiveness and completeness, said Wallace, they will be a vast improvement.
"There are no audit trails with paper records," he said. "Everyone knows that."
Peter Basch, MD, e-Health Initiative's medical director, was surprised the findings were not worse. He blames a system that has pushed doctors into seeing more patients by shortening the office visits. That might work just fine when treating an uncomplicated earache, he said, but it fails when treating patients with chronic complex illnesses.
Basch identifies the broader problem as "rushed clinicians working with inadequate information management tools (paper vs. the EHR), attempting to make sense of whatever islands of data are available and doing so within a dysfunctional reimbursement system that rewards duplicative services over thoughtful coordination."
Wallace agrees. "We have a bad system, and we need to fix it," he said. "Ambulatory care doctors are under siege.
Smith said the survey, indeed, points to a sick system. While the findings should not be all that surprising to the medical community, he expects they will contribute to making the system better.
"In order to start to solve the problem, we need to measure it," he said.
