Why My EMR Report Card Contains Mostly Metadata

I graduated near the top of my class from the second oldest university in the world, and one of the best medical schools on the planet. I have 44 years of post graduate experience in a part of the United States, where there is a severe lack of specialists and where a small cadre of primary care doctors see more and do more than in many other parts of this country.

If and when I look at my personal report card in my new Epic EMR I find that I am average or worse. What that means is that I’m not real quick in responding to routine messages and other such things.

I almost get the feeling that clinical competency in primary care doctors is so much taken for granted and so commoditized that the only thing that matters is how fast we are at getting patients out the door and clerical tasks completed.

Metadata, as I call the majority of items in my EMR report card, is the typically invisible information on a CD, for example: Recording date, copyright holder, maybe the album cover photo for displaying on your device. But imagine if this was all you got, if the piece of music wasn’t there. That’s what it feels like sometimes in primary care: The clinical work we do is invisible while the metadata blocks the view of what really matters.

Would you pick a brain surgeon, if you needed one, based on their speed in the operating room or at the computer? I suspect neither.

There are a few clinical measures also in these report cards, but they are set as if they are absolute, immutable laws. And do they really reflect the quality of our care?

Quality measures in medicine are basically substitutes for the real information we wish we had.

We measure surrogate outcomes, like hemoglobin A1c and blood pressures. But the person with perfect numbers could suffer a fall one day from hypoglycemia or hypotension and break a hip. The diabetic could get urosepsis from their Jardiance pill that causes them to excrete more glucose in their urine. And the perfect blood pressure person could develop kidney failure or a life threatening arrhythmia from spironolactone or valsartan, or lupus from their hydralazine. In studies, such things are tracked and judgements are made that, for a majority of patients, the benefit of a particular treatment outweighs the risk. But, in practice, we don’t know who they are. If our patient is almost “at target” and the next drug we add could be the one that will harm that particular patient, is it worth doing? Polypharmacy is a dirty word some of the time, except when patients have several medical problems and are supposed to meet several numeric targets.

There is nothing in my report card about whether my diagnoses are correct, whether my workups are appropriate, whether my patients trust me or even like me, and what my clinical batting average is when it comes to actual outcomes.

Medicine is full of decisions, judgement calls, that should be made together by physicians and informed patients. The word patient-centered has become meaningless, because doctors who let their patients in on clinical decisions and respect their refusal to do certain tests risk getting bad quality scores.