Episode: 405
Title: HPR0405: Electronic Medical Records
Source: https://hub.hackerpublicradio.org/ccdn.php?filename=/eps/hpr0405/hpr0405.mp3
Transcribed: 2025-10-07 19:53:25

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This is Hacker Public Radio Episode 0405 for Mundi, the 20th of July 2009.
Tid's show is entitled, Electronic Medical Records.
It is hosted by Jindic and is about 17 minutes long and carries an explicit flag
Tid's show is licensed under a CC by NC Saul License.
This episode of HBR is brought to you by an honesthost.com.
Get 15% discount on all shared hosting with the offer code HBR15.
That's HBR15.
Better web hosting that's honest and fair at an honesthost.com.
Hi everyone, this is Jane Doc. This is an HBR episode about electronic medical records.
I am a medical doctor who lives and practices medicine in New Mexico.
My specialty is pediatrics and I'm very interested in Linux and free and open source.
I've been using Linux for about a year and a half.
I bought a triple EPC with the original Xandros operating system on it.
And I really love this computer.
In the course of hacking and modifying the computer I learned to use the command line
and found that I really enjoy the freedom of Linux and open source.
I started listening to more Linux podcasts and discovered HBR.
And since there are hackers out there who are interested in these kinds of things,
I thought I would do an episode about electronic medical records also called EMR
from a medical doctor's standpoint.
I first started using EMR when I was in training.
This was about 10 years ago and the system was pretty archaic.
It was developed at a medical college that I was at.
And it involved scanning in the pages of a patient's medical chart.
These pages were kept in JPEG files and some of these could be pretty large files
up to a megabyte in size.
If you remember how slow the connections and how slow the computers were back in the 90s,
it could take a while to pull up one of these pieces of paper up on the screen so I could review it.
Sometimes it took 30 seconds, sometimes it took 60 seconds.
And since a patient's written medical chart is so large, often in the hundreds of pages,
if I had a 10 minute encounter with a patient to be able to review their medical charts using
this electronic system was completely inefficient.
But again, it was an archaic system.
And even now, 10 years later, EMRs are still at the very beginning.
Let me tell you about medical records, medical records of any type, written or electronic,
and why they're important.
Learning how to document what happens in a patient encounter is something that takes years to learn.
It is part of the medical training.
Now, medical school in the US is four years, and doctors usually go through a residency,
since I was in pediatrics, my residency was three years.
And in medical school and in residency, you learn how to assess patients,
and then after you assess the patients, you have to write down what happened during the patient
encounter.
Part of this process is to help the doctor think in a systematic way,
and also it's a way for doctors to communicate with each other.
It's like our own language.
Writing things down in a medical record helps me follow a patient in time.
And so if I see a patient once a year, I can look back and see what happened
in the previous years when I've seen them.
It also helps for doctors to communicate with each other.
If one of my patients sees a specialist, the specialist will write me a letter
talking about what happened during that medical encounter.
Another important reason to have a written medical record is the legal aspect.
If a patient decides to sue me, then what I wrote down in the medical record
is my defense in front of a court, in a jury, and a judge.
Another important part of the medical record one that doctors are not very comfortable with
is to track.
And not for a doctor to track things or for doctors to track things in between themselves,
but rather for insurance companies and government agencies such as Medicare and Medicaid
that pay for medical care, it's a way for them to track what a doctor does.
What kinds of diagnoses does that medical doctor tend to use?
What kind of medications?
What kind of tests is this doctor expensive?
In other words, there are a lot of conspiracy theorists out there.
I hope I leave that EMR is simply a way to control doctors,
that is non-physicians controlling what doctors do.
Now I'm not naive, there might be some of that to this,
but I think there is something to be said for an insurance company or a government agency
to follow doctors in a reasonable manner.
And anyway, EMRs are the way of the future, and that's likely to be an important part
of any future electronic medical record.
Let me give you an example of good medical record keeping.
There is a specialist who my patients see.
I refer my patients to see her because she's an endocrinologist,
and they have special needs that I cannot provide for them based on my own training.
This endocrinologist has been in practice for many years,
I think maybe 25 or 30 years, and she's very good at
writing down the things that happened during her encounter with my patients.
She sends me letters discussing what went on between her and my patients.
And she's very thorough.
She gives me a subjective aspect of what happens,
so she interviews the patients and learns, say, what kind of exercise they do,
or what kind of diet they follow.
And then she does objective measurements where she takes their blood pressure
and she looks at what labs they've had that she can report on.
And then she does a physical exam and discusses her physical findings
and ends her notes with an assessment and a plan.
Now, she dictates her notes.
I'm not sure if she dictates it into an electronic system or not,
but since she dictates it, I know what she's thinking.
And I know why she did this plan and what she plans to do in the future.
It's very good and it's very helpful for me.
Not only that, these letters are written to me,
and they're usually about a page and a half.
I can review them in about 15 seconds.
And so very quickly, I know what this endocrinologist plan is for this patient.
That in turn helps me take better care of that patient.
Let me contrast this with other specialists who use more typical
electronic medical records and in short, when I read their reports,
I have no idea what their plan is or why they came up with that plan
or even what their assessment is because the EMRs that they use can be so restrictive.
The typical EMR program uses a template.
Templates are like drop down choices that you get to click on
and a lot of people who are, say, involved with healthcare reform,
believe that templates are a good thing because it helps a doctor,
it helps a doctor to prevent making mistakes.
If you have to click on something, it means that you didn't miss it.
For instance, a very important part of seeing patients is seeing if they
smoke cigarettes. If you smoke cigarettes, it affects your assessment of your plan.
Now, I am a pediatrician and I see little babies.
And sometimes I have to send these babies off to a specialist to be evaluated.
And these specialists may not be pediatric specialists.
But part of their electronic medical record template is to ask the patient if they smoke cigarettes.
And when I get a report back from these specialists, often there will be a line saying
the patient denies smoking cigarettes.
Now, I very much doubt that this specialist asked the infant, a four-month-old infant,
if he smokes. I doubt if this specialist asked the parents if the infant smokes.
But nonetheless, since it was part of the template and since it has to be answered,
he answers it. This leads to inaccurate medical records and also using templates really
interferes with the doctor's way of thinking, the doctor's way of organizing.
Again, to be able to make a good medical record, this takes a lot of training and takes a lot
of time and a typical EMR template disrupts that organization.
One other thing I wanted to mention in this episode, there are many, many complexities to
electronic medical records. But I didn't want to spend too much time on too many complex issues.
I wanted to focus on a few simple issues. And one of the simple issues is cost.
EMRs are very expensive. They tend to be proprietary and they all use windows, which I hate.
But they're also very expensive. Practice my size would cost about $300,000 to implement a good EMR
system. Most of that cost goes into the software. The cost of hardware keeps going down and down,
but the software is just so expensive. I don't have $300,000 to spend on an electronic medical
record system. Now that being said, there is a provision in the stimulus package that was passed
by the US Congress that provides for reimbursing doctors if they implement an electronic medical
record system. They will give you up to $45,000 or even $65,000 per physician if they implement
a suitable electronic medical record system. The trouble is $65,000 is not going to pay for your
typical EMR. It will cover some of the costs, but not all of them. And nobody really knows what
certification means or what determines if an EMR is suitable. So until those details are cleared up,
a lot of doctors are going to be very skeptical about getting a new EMR system.
Let me tell you what I would like to see in an electronic medical record system.
Now I'm a realist and I know that electronic records are the way of the future and I don't
think there's any denying that. I don't necessarily think that EMRs are better than written records.
In a way, they may be more efficient. I don't think they'll cost any less, but if it's done right,
maybe it'll work out well. So here's what I would like. First, it has to be Linux-based.
I don't want to use a Windows-based system. And unfortunately, all of the programs that I have
seen in the market have been Windows-based. I don't think Windows operating system is stable enough
for something as important as a patient's electronic medical records. And it's awfully expensive.
Plus, it's closed and I want the freedom to have an open system.
There are open source medical record programs out there. One was based in the United States.
It's been used in the Veterans Administration Hospital. And it is open. Unfortunately,
this is a hospital-based program. It's not really based for private practice, such as mine. And
also, most patients in the VA system, they tend to be older and they tend to be men and they're
also veterans. I don't have any adults in my practice. I don't have any veterans and I have both
male and female. So a program like that wouldn't necessarily work for my practice. However,
with a good programmer who I would be happy to pay to help me, maybe we can change some of these
open source programs to fit my needs. If you Google open source electronic medical records,
you come up with a list of really quite a few programs. There's one called Open EMR.
There's a GNU project, I think it's called GNU Med. And so there are programs out there that
maybe can be used as a basis for my practice's electronic medical records. I have two years to
think about this. My senior partner will be retiring in about two years and she refuses to use
electronic medical records. You're going to find this attitude with a lot of older generation
physicians. And so I do have time to think about this. There's another program called Amazing
Charts that's a close proprietary system. However, the guy who developed that program is a family
practice physician and he set up this EMR for his own office. And it's actually a good program.
If only I could adjust it for my needs and my pediatric practice.
One of the things that I like about Amazing Charts is that it incorporates voice recognition.
It's a Windows system and it uses a dragon for its voice recognition. Again, I think that being
able to dictate notes into an electronic medical record system will produce more effective
medical records. Well, that's about all that I wanted to cover over electronic medical records.
Again, I'm a medical doctor. I'm looking to develop an EMR for my own practice. And I'll be happy
to pay someone or maybe find someone who will pay a programmer to help me develop a project.
It does not have to be started from nothing. There are other programs out there that I think
a good EMR can be based on. And in the open source model, what I would like to happen is develop
a program for my practice that I could share and distribute to other pediatrician's offices
so that the costs can be limited. Again, my name is Jane Dock. And if you have any questions
or if you'd like to hear more about electronic medical records or even healthcare reform,
please contact HPR and I'd be happy to contribute more. And so then, take care.
Thank you for listening to HACRA Public Radio. HPR is sponsored by Pharaoh.net.
So head on over to C-A-R-O dot N-E-T for all of us in need.
