Thursday, August 26, 2010

Sugeon General Regina Benjamin on EHR(electronic health records)

Finding My Way to Electronic Health Records
Regina Benjamin, M.D., M.B.A.

N Engl J Med 2010; 363:505-506August 5, 2010

ArticleThe recent oil spill off the Gulf Coast may prove to be one of the great environmental challenges of our lifetime. It is yet another devastating blow to the Gulf region, a place I call home. My heart goes out to the people there who are concerned about how this latest disaster will affect their livelihood and their health. Though the full effects of the spill remain to be seen, already the health needs of Gulf Coast inhabitants are increasing during this time of crisis. Physicians in the area will need to adapt and find innovative ways to efficiently deliver health care for an already underserved population. I recall my experiences as a physician during the crises of Hurricanes Georges and Katrina and try to remember how I adapted.

The day after Katrina hit, I drove through Bayou La Batre, a small fishing village on the Gulf Coast where I practiced medicine for 23 years. The damage didn't look so bad when I pulled up to my clinic. However, when I opened the door, I nearly fell sick from the smell of dead fish and crabs. Furniture had been tossed around the office every which way. All the patient information — all the paper records — were ruined. I remember thinking that I had tried to prepare for this kind of crisis and recalling that I had strongly considered moving to electronic health records (EHRs). But money was tight, as it was for many small practices throughout the country, and it eventually came down to a choice: I could either install an EHR system or pay the electricity bill. Searching for a source of courage, I recalled the reasons why I had chosen to become a family physician.

Like many physicians just out of school, I believed strongly in primary care — my mother, father, and brother had all died of preventable diseases. As a National Health Service Corps scholar, I now had the privilege of making a difference in a small community.

Bayou La Batre was my assignment. I was familiar with the town, since I had grown up in nearby Daphne, where my family has been since the early 1800s — the Seafood Capital of Alabama, a shrimping town, where people made their living on the water. But the seafood industry had been hurting, which meant that there was little money for health insurance or out-of-pocket copayments, and more important, that there weren't enough primary care physicians.

Many of my patients spent most of their time on the boats, going out for 2 months at a time. Skipping from coast to coast was part of their job. I remember one patient who had been out for nearly 3 weeks and had used superglue to treat a gash on his hand. My patients had to improvise, and they had few medical options for managing their illnesses, whether acute or chronic. I felt I had arrived in the right place at the right time.

Well, perhaps it wasn't exactly the right time. In 1998, Hurricane Georges made landfall in the Gulf Coast, causing over $100 million in damage to Alabama alone. My clinic was destroyed. Without a building in which to treat patients, my nurse Nell Bosarge and I spent the next 2 years driving my pickup truck to their homes. Eventually, I mustered the resources to rebuild the Bayou La Batre Rural Health Clinic — on higher ground this time, and on 4-ft stilts. Meanwhile, we managed to save the drenched paper records of our patients by carefully drying them in the hot Alabama sun.

In 2005, Hurricane Katrina came, again threatening to destroy the Bayou La Batre Rural Health Clinic. We had 48 hours to evacuate the area and, given the new secure location of the building, saw no reason to pack away all the paper medical records. When I returned to the Bayou, the building had been destroyed by the water. Nell and I knew we had to get everything out of there, or else it would mildew. We spent just as much time clearing out the medical records — again placing them in the sun in 90-degree weather to dry them, carefully turning them over — as we did trying to salvage the structure of the place. This time, I could not make house calls to my patients' homes, because the vast majority of their homes had been destroyed, too. Our staff set up a makeshift clinic in the auditorium of the local shelter, while volunteers and donations helped us prepare for a January 2 reopening.

Tragedy befell the Bayou Clinic once again, when, in the early morning hours of New Year's Day, just before our clinic was to reopen, a fire broke out and the clinic burned to the ground. This time, the precious patient records — the ones that Nell, the staff, and I had spent hours drying and recovering on two separate occasions — were completely destroyed. We were forced to rely on memory and intuition in treating our patients. Any information on allergies, coexisting conditions, and specific family history was now left to recollection.

Having lost the Bayou Clinic three times, I knew we had to have a better way of practicing. I needed to find a way to deliver high-quality health care to people who didn't have a lot of money. From the experiences with the hurricanes and the fire, I knew we had to be able to evacuate the clinic quickly, while still safeguarding the vital patient information. Whereas I had previously decided against installing an EHR system because I couldn't afford one, I now realized I couldn't afford not to have one.

Our trials did not go unnoticed. Wonderful people from all over volunteered their time and money to help us rebuild. A generous donation from a private foundation supported our efforts through the Katrina Phoenix program, helping us rebuild our clinic with computer hardware, in coordination with a generous EHR vendor and with the help of good-hearted student volunteers from Bentley College in Waltham, Massachusetts. They also provided us with support, teaching us how to use the system and helping to implement it in our practice. Needless to say, Nell and I were relieved when we turned on the switch and became a paperless office.

Though it is challenging to persuade some doctors and nurses to convert from paper records, “buy-in” was not an issue at the Bayou Clinic, since Nell and the rest of the staff were adamant about never having to “bake charts in the sun” again. The new system we implemented allowed us to easily track and document our patients' histories; with a click of a button, we could send a prescription or remind patients of upcoming mammograms, thus improving the quality of care. Practicing medicine became easier for the clinicians and better for the patients.

With the availability of new incentive payments made possible by the Health Information Technology for Economic and Clinical Health Act (HITECH), and assistance for the transition to electronic health records available from regional extension centers, small practices like mine now have the kind of support that I had — and fewer reasons to delay a decision that should have been obvious long ago.

Until the day we turned on our EHR system, I was still using pens with waterproof ink. It is a very good thing — for both me and our patients — that my fellow physicians and I don't need to use those pens anymore.

This article (10.1056/NEJMp1007785) was published on July 13, 2010, at

Disclosure forms provided by the author are available with the full text of this article at

Source Information
Dr. Benjamin is the Surgeon General of the U.S. Public Health Service, Washington, DC.

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