Although I'm headed into traditional medical librarianship, being in the thick of healthcare IT for years has left an indelible impression on me. Granted, most of that time I had no earthly clue exactly how the different components I was ordering in my purchasing role to the tune of millions of dollars to avert zomg Y2K!1!!!1!! were or how all the billing systems worked with one another, but during my health informatics classes I had way too many moments of Oh! THAT'S what that was about! I still remember an Ask Me About HL7 button someone had in his office a decade ago, then last year in an agonizing class... there was HL7. Aie! Flashbacks!
As a result of all that, I'm acutely sensitive to the issues surrounding electronic health or medical records (EHRs or EMRs). I'm still not seeing a clear trend in definitions to distinguish one from the other so my own preference is EMR. Whenever I see anyone writing about EMRs, I am usually there. I love seeing the issues from as many viewpoints as possible because there is so much concern and so little agreement over just about every component of them.
One concern I have seen mentioned repeatedly as both a praise (saving time, improving accuracy, insurance coding) and a caution (reducing accuracy due to copying wrong info) is the ability to copy descriptive text that is frequently used in patient records. I have seen some modified versions of this happening as part of my own healthcare, although without grilling the medical staff it appeared to be the use of pre-formatted template wording from one section of my EMR to another that didn't have a template.
Today I read a post in Health Care Renewal, a group blog concerned with "Addressing threats to health care's core values, especially those stemming from concentration and abuse of power" that highlighted a term for this phenomenon from a New England Journal of Medicine editorial that put an entirely different light on it for me: Clinical plagiarism.
It could be that I'm so recently from grad school where we had the Fear of Plagiarism drilled into us more than anything else, but the more I think about it the more I agree with calling a spade a spade. We expect students to research the literature and case studies, but come up with their own terms and thoughts while properly citing their resources. Why should we expect any less from our doctors? Do we want to be the patient who is either copied or pasted, with whatever makes our medical history unique and 'off the charts' (i.e. no standard template wording exists for what we have going on) either carried forward or someone else's information accidentally given to us without our knowledge? Consumer views of EMRs are not full compendiums of medical data and terminology and generally offer summaries of lab tests, after-visit summaries and related material in regular language.
These are the things that keep me up at night if I'm not careful.
5 hours ago