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Perspective: Finding My Way to Electronic Health Records

Regina Benjamin, M.D., M.B.A.

The 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 under-served 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.

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

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

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

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