The Day the EMR Went Down

One of my favorite stories illustrating the harms perpetrated by the Corporate Practice of Medicine on both physicians and patients is The Day the EMR Went Down. During my first couple years as an employed physician, I transitioned from Urgent Care to full-time Family Medicine as I built up my patient panel from zero to over 3700 patients. At this point in time, I saw my own patients on Monday-Thursday, and on Fridays, I saw urgent care patients in the mornings and then saw my colleagues’ patients in the afternoons, so they could enjoy a half day off. 

On this particular Friday, the EMR (electronic medical record system) was not working. This was not a major issue on the Urgent Care side because patients could be seen for their acute issue, paper prescriptions could be written if necessary, and paper notes could be written to be scanned into the system later. On the Family Medicine side, acute issues could be handled in a similar fashion; however, most appointments on the Family Medicine side were not for acute problems. They were follow-up visits for chronic conditions or annual wellness exams. These types of appointments require a thorough review of the medical records, including past primary care visits, specialist visits, lab results, imaging, preventative screening, medications, medication allergies, etc. I knew that, at best, these appointments would be a waste of time and money for these patients. At worst, there was a very high risk of harm in attempting to blindly treat patients for their chronic conditions without access to their records. 

As a physician, the solution was obvious. I told one of the receptionists to call the patients to explain the situation and reschedule their appointments. However, the office manager refused to allow these appointments to be rescheduled as it would reduce the clinic revenue for the day. She called me a “Princess” and said “You know, clinics used to function without an EMR”. I tried to explain that clinics used to have paper charts and that we did not have access to any charts at all. In fact, over the course of the past decade, I had trained in multiple hospital and clinic settings, many of which with paper charts, others with electronic systems, and some with a combination of the two. I had no problem with paper charts; I only took issue with the plan to attempt to see patients for follow-up without any chart whatsoever. I was stunned by the absurdity of this smug administrator insinuating that my demand for basic patient safety was a high-maintenance request, akin to refusing to work because the espresso machine is broken.

The worst of these appointments was a patient coming in for “mammogram results”. Of course, I did not have her mammogram results. One could presume that there was significant concern for breast cancer and that the purpose of the appointment was to discuss this possible diagnosis in person and refer to a breast surgeon for a biopsy. However, in insurance-based practices, often patients are scheduled for appointments to discuss ALL lab and imaging results, even normal results, simply to increase clinic revenue. Also, it was possible that the appointment was scheduled to reassure an anxious patient with a minor abnormality on screening mammogram where diagnostic mammogram was needed although suspicion for breast cancer was low. It was even possible that there was no concern for breast cancer at all and that mammography suggested an abscess, which needed to be treated in person with incision and drainage. I ended up seeing this patient, performing a breast exam, which was normal, and apologizing to her profusely for not having results for her. She was scheduled for follow-up with her PCP and left with heightened anxiety over the still unknown mammogram results.  

Of course, I did my absolute best for each patient who came in that day. I saw them all as New Patients without any records, which was very time-consuming. Since most of them had simply scheduled follow-up visits at the request of their PCP, the true purpose of these visits was neither known nor achieved, and they were scheduled for yet another follow-up appointment. I’m sure I attended to some acute complaints, as is typical during the average Family Medicine appointment; however, the only ones who were truly satisfied with this clinic day, were the corporate administrators, happily counting their riches.

As a Direct Primary Care physician, I no longer need to worry about being personally abused and gaslit by healthcare administrators. In nearly six years of DPC, I have never lost access to my wonderful EMR (Thanks AtlasMD!), but if I did, my patients needn’t worry. My current practice is flexible enough to be able to easily pivot as challenges arise. If I had a patient scheduled for an in-person appointment to discuss mammogram results, I would already know those results by heart. I am grateful for DPC because I can now practice with both rationality and compassion, and I can protect my patients from the abuses of the Corporate Healthcare system.