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Many dermatologists are scrambling to enact various parts of electronic medical records (EMR) in their practices in time to regain a fraction of the cost in rebates from the government. I find myself in the same situation and very unhappy. What seemed like an idyllic dream as described by industry lobbyists is a bit messier in reality. Our office has spent eight months in theoretical planning, two months in serious implementation, and five days in practical use of our new system, and it hasn't been exactly smooth. Time will tell if the system works and if the amount of tears shed per employee decreases over time.

Meanwhile, the digital world has brought on significant issues with employees who are on Facebook at all times of the day, iPhones going off randomly in the hallways and nurses' station, and patients who are reluctant to share their email addresses with us. This is further complicated by the fact that we can't reach patients on their phones to relay information and lab results and most of them don't have a home phone anymore! Could the next step be clinicians forced to communicate via text: “OMG – U have BCC! – Ur Dermatologist”?

All levity aside, the situation is quite different than even a mere decade ago when the digital world was still relatively nascent and email was still only an option. Today, those who don't have email are looked upon as weird folks, the equivalent of the person riding a horse through town in the 1920s with cars buzzing by them. Our principal problem is that the medical world hasn't caught up with the needs and demands for privacy balanced against the equally competitive need for market relevance in the social media realm. One result is that dermatologists have blogs (me included), some of which tread the line between what is appropriate and what is too much information. At the same time, the Today Show has a bevy of dermatologists lined up to perform procedures on cue, all timed to coincide neatly with the ad for Viagra at 30 past the hour.

A Necessary Adjustment

How do we adjust to this new world, and how do we retain our dignity in this space? These are all questions that will need to be answered over the next several years. Meanwhile, my practice has implemented a few guidelines that provide foundation for what we consider appropriate.

We have a strict policy on appropriate use of computers at the office. While we realize that employees must check insurance eligibility and communicate with patients via the Internet, we monitor usage carefully, and if there is a question as to whether an employee is visiting Facebook, chat rooms, eBay, or other less appropriate sites during work, we can investigate that. Most outside IT firms can help with this, or a simple check of a particular computer's Internet history can provide an answer.

Our employee handbook has been updated to reflect a zero-tolerance policy for misuse, and we have terminated two individuals so far because of this. We have circulated several emails to the staff letting them know about this policy and have reiterated this after any terminations to make the point clear. The staff has been informed that we reserve the right to look over their computer history and email logs.

We have also explained the need to keep emails and phone calls to a minimum. With the advent of smart phones, there is no way to keep employees from texting/ calling and emailing during the day, but we insist that these calls be kept short and only for important matters. Additionally, we encourage the use of smart phones during breaks only, if at all possible.

As for patient communications, we have our patients sign a form at check-in that allows us to communicate with them via email. We have one or two employees that are designated to manage these emails. Before we allow any employee to be in communication, I and/or our director of nursing check his/her email skills and etiquette. Templates have been created for emails, and only certain results (benign pathology, normal labs, and culture results) are communicated via email unless absolutely necessary. Some patients will insist on this method while others will refuse it. It does, however, allow us the opportunity to relay information via relevant methods to the majority of our patients.

Facebook is a very special situation. While we manage thousands of “friends” on our Facebook page, any patient who wants to “friend” me personally is directed to our company page. We try to keep that page professional, yet approachable, but this is always a challenge, especially since different employees on a day-to-day basis manage it. If comments come through the Facebook page that we feel are inappropriate or concerning (“Can you get me the phone number for that nurse who took care of me…”), we delete them and contact the patient in question offline. On the other hand, we delight in the positive comments and pleasurable interactions that do occur and can enlighten our day.

Resistance is Futile

Circling back to the all-consuming task of EMR implementation, my staff and I realize that we must do this, as resistance at this point is futile and eventually self-defeating. We have lightened our load a slight amount and are going to meet the criteria for Meaningful Use this last quarter of the year, while seeing all new patients in the new EMR system. As time goes on and our templates become more effective, we will gradually meld in the returning patients and scan their charts to the system.

Silver Lining?

The one good thing I see about the EMR implementation so far is that it allows for quick and error-free photograph filing in the various patient charts with the iPads we now use. Ask me in four months about the rest of it!

Joel Schlessinger, MD is Founder and Course Director of Cosmetic Surgery Forum. He practices in Omaha, NE. The 2012 Cosmetic Surgery Forum will be held from Nov. 29 – Dec. 1 at the Venetian/ Palazzo in Las Vegas, NV. For more information and to register, visit Contact Dr. Schlessinger at

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