OUR NEW MEDICAL CARE SYSTEM

Before going into the practicalities involved in evolving new forms of health care, I would first like to review the subject of records. 

 In 1946 when I  took over my father's practice most physicians kept records if any on 3X5 cards. Obviously they were quick reminder notes only. I inherited more complete records on 5X8 cards but quickly switched to the innovative  letter size sheets of paper which were followed years later with printed forms that had  certain areas for proscribed information.

As this society became  a litigious one in which courts awarded outlandish amounts for supposed malpractice damage often based solely on what was not on the record. "If you did not write it down you did not do it" If you had a check sheet which you marked "done" or "OK" that inferred that you had asked or done it. In truth all it could mean in too many cases was that you had checked that line.  having to keep the paperwork on every test or xray even if normal the volume of the record would increase to actually be useless.

Physicians and hospitals had to keep such records to protect themselves from lawyers and a society that was more interested in what they 'can get" than in if they were victims of bad medicine. Doctors had to carry mal-practice insurance for their own protection because merits of a suit was a secondary consideration. There were times when no carrier would insure a doctor in New Jersey  because in cases that went to trial the awards were uniformly outlandish. Middlesex County's courts were notorious for their awards and therefore many lawyers would try to get the case heard in that County.After all the attorney would be paid from 33% to 50% plus expenses from the patient's award. "The coin drives the machine".

One of the troubles in  the past was that Specialists consultants would not communicate with the primary care physician . Patients began to bypass their "family doctor" and go directly to a specialist who felt no obligation to inform the one individual who could compile a valid information base.

Hospital records with the need to accommodate nursing reports, technicians reports, lab work, xrays etc. became a mess to dig through for valuable needed information. Often tests and xrays were repeated unnecessarily because the usable earlier data was missed.

Then along came the computer age first used  as a billing tool. In the 80's software for record keeping was first introduced. The quality and tools have greatly improved so that hospitals for instance have converted to a point where everything relating to a patient is in one file. WE now have the capability of sharing those files formerly by transfer of information but now by direct access.

Access to a file can be limited to those granted the privilege.At least that is the theory but in reality their is always the "Hacker". Irrespective of this the Computer Record can be a great improvement since i t c an b e easier to review in a compartmentalization manner, IE: All laboratory studies one place  xray reports another etc. But what is the value if the records consist of check sheet boxes not a record of personal observation. "Garbage in is Garbage out"

The computerized file can be a blessing in the hospital except to the doctor who never learned touch typing. It does mean a longer work period for the practitioner who  having been accustomed to making notes as he progressed on his rounds, now has to go to the terminal to enter into the records.

There are security firewalls for hospital records but they are not infallible, and it becomes easier for a person not involved in the patient's care to out of curiosity to access  the record.

However, the government has made my 8X11 sheet records obsolete by demanding the use of electronic records. As of this past week claims are going to be monitored and although reimbursement. has as yet not been cut, there will be bonuses for those that use electronic records. One can be sure that the insurance carriers and Medicaid will also demand that policy. The problem is that there are only two (2) proprietary software programs that are acceptable  and they are expensive.

The small individual or 2 man practice  has found it to be an economic burden to convert but they must do so. The alternative is to be absorbed into a large group practice or become an employee of a hospital sponsored group, a modality that is increasingly becoming the norm.

This is a major change in medicine delivery, one that I find to be a negative one. The patient has accepted being a consumer of health care and instead of seeing a physician who has a one to one relationship to him he now en trusts his care to a series of "providers" of various competencies. On a "routine visit" the only contact with a physician may be a very brief impersonal one.

For the doctor he will have become "9 to 5 worker" or whatever time slot assigned and once  off need not thin l about the cases he has  "treated" that day. The hospitals are employing physicians who see only  inpatients and the outside doctor no longer will treat them.once the patient is inside the hospital.

The tools for health care continue to advance but the all important human element will have disappeared. That may make no difference because the consumer is now accepting a commodity where price and efficiency is important.

This is from an recent article this past week on the first page of the Times about a family physician who is unable to cope with the above changes and wishes to retire but can't dispose of his practice:

"Sroka’s fate is emblematic of a transformation in American medicine. Doctors like him are being replaced by teams of rotating doctors and nurses who do not know their patients as well. The share of solo practices among members of the American Academy of Family Physicians fell to 18 percent by 2008 from 44 percent in 1986. And census figures show that in 2007, just 28 percent of doctors were self employed, compared with 58 percent in 1970. Many of the provisions of the new health care law are likely to accelerate these trends. “There’s not going to be any of us left,” Sroka said."

But