Electronic Medical Wrecker

Image

 

I need to say a few things about the EMR (Electronic Medical Record), EHR (Electronic Health Record) or whatever you would like to call it this morning.

Our system in the SC Department of Mental Health has been using an EMR system for several years now. The telepsychiatry program I work in also has a modified version of that same record keeping system. When we talked about the rollout of this system a decade or more ago, it caused fear and trepidation among the thousands of mental health workers in our system who were used to pen and paper, writing process notes and prescriptions by hand, and taking notes on yellow legal pads or in spiral notebooks as they helped those who suffered from depression or schizophrenia.

For some, it was so anxiety-producing that they simply decided to retire rather than face the uphill battle of learning to use a strange new system that to them was nothing short of a career-killer. It was sad for me to watch several caring, seasoned therapists and doctors decide to walk away rather than learn a new way of doing things. They collectively held the institutional memory of our system, and this was a great loss to both the system itself and many of the newbies who were just starting their own careers in the public mental health arena. 

So, one of the first casualties of the electronic medical wrecker was the experienced mental health worker, a dinosaur who trudged off into the mists of time, mumbling about technology and pulling a cart loaded down with thick, fraying medical charts behind him. 

Are there other casualties even now, years after the adoption of this system of keeping medical records? I think there are. Now, let me say, for the benefit of the two of you who are reading this and do not know about my love of all things technological, I am not a Luddite. I love my computers and gadgets and apps and programs. I still feel that the EHR has many shortcomings and puts one more layer between patient and provider, weakening the doctor-patient relationship.  How?

If you have ever gone to see your own doctor and she must pay attention to the screen in front of her (be it iPad or laptop or desktop or iPhone) more than she pays attention to you, you have felt that sense of diversion of energy. The doctor is so fixated on check boxes and lists and forms that need to be filled out that she cannot make nearly as  much direct eye contact with you. She cannot watch for that little twitch of your face, that tell tale movement of your hand because she is entering your current medications as she takes your history. The attention paid to the patient must be sacrificed, at least in part, because of the need for increased screen time. 

Satisfying the demands of the EMR at each visit takes away from the time that the doctor might have to think, process what he has just seen, and come up with innovative responses that would help his patient. If  family practice doctor must see a patient every 7-10 minutes and also included the electronic documentation in that time period, less and less time is being spent on clinical thinking and processing. Even if the note is completed later, a huge chunk of the day’s time is given over to record completion that is prescribed in a very specific way.

Doctors that I have talked to say that because of the new record keeping demands they have less time to relax, regroup and think during the work day. They are usually worried about keeping up, getting medical record tasks done for the day, and do not feel that they can let up until that task is done, even if it means skipping lunch or getting home late for dinner. 

Granted, the EHR makes it much easier to go back later and read a doctor’s notes, as legibility becomes a given. Documentation is much more complete, usually, even though in our own system I see that notes are getting shorter and have less content since time is of the essence. There is no longer that satisfying feeling of being able to physically flip through a paper record, knowing exactly how far back in the record one must flip to get to labs, nurses’ notes or history and physical. Like the pleasant and satisfying feeling of holding a beloved book in one’s hand and turning its pages, the experience of using a paper chart will be one that many a  medical student of today may never have. 

Once again, let me be clear that there are many aspects of the new electronic health records that I appreciate and even like. That being said, I think we as doctors are having to give up many other aspects of the day-to-day physical practice of medicine that I hate to see us lose. 

What has your own experience been with the electronic medical record? Has this been as a practitioner or as a patient? Did you feel slighted or cheated? Did you feel more rushed? Did the record keeping detract from the direct time with your doctor or patient in any substantial way?

As always, I’d love to hear what others think about this latest change in medicine and how it has impacted your own interactions in the world of medical care. 

Have a good Monday, my friends. 

About these ads

15 thoughts on “Electronic Medical Wrecker

  1. I was at a large Midwestern health system when the big switch came. We all thought it was hilarious when people who complained were enrolled in a mandatory human resources course on coping with change. The big thing now, years later, is when the system goes down for maintenance or upgrade and everything is thrown into chaos, everything is late, people have to remember the old paper charting, orders cannot be put in, the Er switches to a greaseboard, etc.

  2. When the record becomes more important than the patient, there’s something wrong. It isn’t the case, of course, but that’s the feeling many of us get. It’s just an unfortunate fact of life these days, and it happens everywhere, not only at the doctor’s office. What concerns me most is the time factor, as it now seems time has been “value-engineered” out of the healing equation altogether. This is a great loss, particularly for the psych patient and his/her physician. There must be a way to resurrect a 20 minute standard appointment–15 minutes for talk followed by a 5 minute “refractory” period, for data entry and re-capitulation, or reading year-old magazines while EMR requirements are satisfied. Psych appointments should not be any shorter. Otherwise, there’s really no point. At two patients per hour (twice the rate of 20 years ago), more healing would occur and the clinician might get a few minutes between patients to catch up or review the next case. No matter how instantly readable and accurate EMRs are, because time has been so thin-sliced, I often feel I have to remind my therapist who I am and why I’m there–and that’s just downright spooky when you’re dealing with people you’ve know for a decade or more. You find yourself thinking, “Why bother?”

  3. Another ironic twist in my communications with you, Greg. I worked in Medical Records at Redmond Regional Medical Center in Rome, GA for a good while just prior to my daughter’s, Dana’s, wedding in July of 1990. I was “moonlighting” to help fund the most beautiful “military wedding” I believe that has ever been held in the Darlington School Chapel.

    The record-keeping at that time was a total nightmare, and I personally saw so many things that could have been corrected,(but were not) because some “relatives” of administrators were being hired as part-time workers. One of those, in particular, did everything possible to get fired because he did not want the job. (But that is another story)

    Anyway, I know that there have been many needed improvements since then, but I do agree that when I see my own personal doctor, he is looking mostly at the laptop and not at me. I really appreciate my family physician (he is terrific); but it feels a bit strange to be talking to someone’s EAR because that is generally what I see. No real complaints…just an observation.

    Keep up what you are doing, Greg. You make those of us…not just two…who read what you post really think about things that we have not considered for a while. Hugs, Ms B

  4. I love and hate the electronic medical records. I hate that even though I belong to an HMO, that my HMO physicians aren’t connected to each other. I hate that I’m not given more access to my chart. I’d like to go to a page and see a list of all of my upcoming appointments; another page that lists all of my past appointments, My meds-I can’t see my listed allergies.
    What difference does it make if the doctors are staring at a monitor or flipping through pages of handwritten notes? If the doctor and I look at each other-we have old-fashioned eye contact. If I look when his nose is buried, or he looks at me while I’m digging in my purse, redoing my ponytail or staring at the way-we don’t have eye contact.
    There are pros and cons in life, especially in the medical field.

  5. I’m on my second one, and maybe will be transitioning to a 3rd – primarily due to (lack of) company / vendor support. The main thing the EHR has done for my practice is that it has allowed me to get rid of paper charts. Saved a ton of space in my new office not having to make room for filing cabinets. But this does not mean that we are paperless – we’re on our 3rd set of scanners – there’s still a ton of paper that passes through the office. But at least (as long as it doesn’t get scanned into the wrong chart) it’s all in one place. Easy to find. Unless the server crashes… yes, been there too.

    In addition, one of the promises of EHR’s was that they were going to talk to each other. I can’t talk to the doc across the hall from me thru my EHR. We email, text and call. Just like we did before. That’s what happens when there are several hundred (thousand?) EHR vendors and none have any incentive to talk to each other.

    Last comment – I don’t chart in my exam rooms. Tried it – too cumbersome. So I take notes and then go back to my office to chart. Either between patients, during lunch, or at the end of the day. Just like I used to with paper charts. I’ve just never figured out how to add that bit of electronics into the exam or consultation room without interfering with my interaction with the patient. How do I have a real conversation and discussion with a newly diagnosed breast cancer patient if I’m constantly looking away from her and her partner to enter data into my chart? Have not figured that out.

    Thanks as always for the discussion.

  6. heliox

    We have those little mini meltdowns from time to time now as well.

    It feels really weird to be dead in the water, totally dependent on the system to come back up (or not) so that work can be done in a timely manner.

  7. Rob,

    I love this:

    “because time has been so thin-sliced, I often feel I have to remind my therapist who I am and why I’m there–”

    You have just given me another blog post, my friend.

    I hate it when that happens, but I will be the first to admit that it does happen…

  8. Mary,

    Point taken, although to me the EMR seems to have (literally and figuratively) taken things out of our hands just one more time, creating a little bigger distance between patient and doctor.

    Greg

  9. Dr. Attai,

    “one of the promises of EHR’s was that they were going to talk to each other.”

    Yes! I’m sure we have the technology to do this. After all, the simple, ubiquitous ATMs can talk between banks enough to make sure we get charged that extra $3 for using a “foreign”machine!

    I agree with you completely about the charting in the exam rooms. I too still take notes in the room while I’m with the patient. Just seems less intrusive and hampering to me. Then I also make time, somewhere, to add these notes into the EHR.

    Thanks as always for stopping by and commenting.

    Greg

  10. Dear Dr. Greg—-Do you know what the best thing was about my paper charts? Somebody wrote on the front that I’m allergic to ACETAMINOPHEN and MY TEMP IS 95.6- 96.2.
    It’s not just the EHR that’s taken a little bit more out of our hands and put distance between the patient and physician- it’s the totality of the factors of the electronic digital medical world. like those digital machines that take temps, etc. They won’t register a temp below 98, and most of the young nurses don’t know how to use an old-fashioned thermometer.
    I think the last good year of medicine was the early 1990s.

  11. Wow. Never really thought about it in those terms, but you’re right. Most everything is automated to the point that people are no longer taught how to actually really do the procedures.

  12. Dr Greg–The details–somebody realized they couldn’t get my temperature. Some type of nurse, came in and said-Open wide- She just jabbed the thermometer into a tonsil stub-hard. I screamed. It swelled up the stub. A few weeks later I had a CAT scan with contrast-The reading radiologist called it as a possible new cancer on the edge of the radiation area. I told my disbelieving oncologist that it was from my temp being taken at the hospital. Previous health providers had told me that I had a stub-thank goodness for old-fashioned doctors. Dog bite + cancer/radiation = pasteurella. I contacted my ENT through the EHR about it. He had me in by 24 hours-Yes I had an inflamed tonsil stub. After a spray-a shot with a big needle-he took a type of pliers and pulled out the offending stub. Felt like my whole stomach was coming out. Good news-biopsy was negative of any type of cancerous cells-just a tonsil-other good news. Other good news is that other reading radiologists should see symmetry in my throat and nobody will get freaked out.
    Back to the temperature-they sent in another nurse. She knew not to stick it straight back and poked my cheek a few times. I had her untie my infected arm. I opened my mouth and pointed at the base of my tongue. I took her hand- guided it-shut my mouth. She got my temp. She said that she’d teach the others how to do it. I was released from the hospital with a fever and no antibiotics. Problem caused by EHR. The ER gave me a weak dose of the wrong antibiotic-Sun. am. I made a marine sgt sound sane. I didn’t want to return to the ER-go around town dripping pus and fluids. I got into my PCP a few days later (remember that I had a raging temp of 98.1 by that time. I’m used to that.) and he hospitalized me. He wrote that the surgeon should write a new script for an effective antibiotic. The EHR said -Antibiotics under his name- I went home late at night and checked all of the pharmacies the next day-no script. I called the clinic-told to get there now- I went and his nurse was in the lobby waiting for me, as he wanted to check it himself.
    Dr. Greg-except for one, all of the nursing staff were the sweetest people that you ever met, but I’d rather have had had a cranky ex-POW USN nurse at the other end of the thermometer. Seems like a hospital would have all of these ITT, Apollo, Brown-Mackie-learn online nursing school students know how to take a temperature. Oh the really good news-all of the cancer tumors were killed-the dentist says that I’m keeping all of my teeth-and I don’t look half bad from the surgery.
    Thank you for listening to me. Your patients are lucky to have you. You might be looking at your patients on a monitor, but they have your attention and concern.

  13. Greg–first let me say, I’ve been reading you a while and really appreciate the reality you bring to your posts. My parents live in Aiken, I’ve been there, and I think it’s cool that you are from the area. Now, on to THIS post. I’m an RN case manager for a large health insurer (local, I might add, which is cool) in my state. I specialize in managing members who are in skilled nursing facilities. SNFs are woefully behind the times when it comes to EHRs–they are, almost to one (at least in my state) still on paper. Since I do my job at home, this makes it a total PIA to get documentation. Yes. I still use a fax machine. All my “work”, however, is done online, logged in to the health plan. I access records from the health system hospitals and clinics with ease. I love it. EHRs literally make my job a billion times easier, and the health system I work for has really embraced this. Now, on the other hand, I’m also a patient. Some providers are a lot better than others at documenting and actually making “contact” with their patients than others. For example, the mental health PA that I see is really good at it. I really felt like he listened to me and internalized what I was saying. My internist, on the other hand, sucked. She barely make eye contact for our entire 40 minute “get to know you” appointment, rather, she stared into the giant EHR screen. I wish our physician groups would embrace scribes, rather than me sit there talking to the side of her head. It was pretty unpleasant, and I barely felt like I’d been “seen” at all. On the third hand, I really like have MyChart online to go to–it’s pretty cool to be able to get my lab results, xray results, etc., and to have all my appointments in one place. I also like the ability to message either of my doctors to ask a question.

    So there you have it. A mixed bag for me :)

  14. NewMex

    Excellent excellent comment that captures a lot of the issues and the big picture, both positive and negative. Thanks for addressing both sides of the exam table as well.

    Small world, isn’t it?

    Thanks very much for reading and commenting. I appreciate it.

    Greg

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s