An ongoing dialogue on HIV/AIDS, infectious diseases,
December 6th, 2015
Do Electronic Health Records Make You a Better (or Worse) Clinician?
Earlier this week, JAMA Internal Medicine published a study entitled, “Level of Computer Use in Clinical Encounters Associated with Patient Satisfaction”.
A more descriptive title would have been “More Computer Use in Clinical Encounters Associated with Reduced Patient Satisfaction”, as here’s the take home point:
High computer use by clinicians in safety-net clinics was associated with lower patient satisfaction and observable communication differences … Concurrent computer use may inhibit authentic engagement, and multitasking clinicians may miss openings for deeper connection with their patients.
As I’ve mentioned before (probably more times than you’d like), the computer’s power to grab our eyes away from our patients is one of the things I like least about EHRs. Of course people are less satisfied with their care when their doctor spends tons of time typing away at the keyboard and looking at the glowing screen.
(Brief aside: Some clinicians mention triangulating the encounter by having both patient and doctor review information from the EHR together. Yes you can do this sometimes, but this tactic really doesn’t work when taking a detailed history. Plus, it’s a capitulation — the computer is now the center of attention, not the patient. Finally, it’s all but impossible to pull this off in many exam rooms, especially those originally designed with no computer in mind. You’d practically have to ask your patient sit on a step-stool or hang from a trapeze over your shoulder to make this work. Not such a brief aside after all, I guess.)
I’m bringing this difficult situation up again not solely because of the published study — similar findings have been reported before. This feeling of being trapped by EHRs is not just an issue for patient satisfaction, but clinician happiness as well. One of my colleagues received a letter from her PCP, informing her that she (an experienced internist) planned to retire. It included this paragraph, which I’m sharing with that doctor’s permission:
So it’s not just the patients who don’t like it — we clinicians aren’t too thrilled either. This internist is hardly the first to complain about becoming a click-slave, though she’s the first I know to use this venue (a letter to patients) to express her opinion.
But the EHR must be good for some things, right?
Of course — a short but not all-inclusive list of the benefits could include trending of lab results, bringing up previous medication histories, displaying radiology images, reviewing other clinicians’ notes, issuing reminders about health maintenance tasks, and receiving warnings about dosing errors, allergies, and drug-drug interactions. Access to records remotely is a huge bonus.
Note I’m deliberately excluding the billing and medicolegal features, as frankly they are usually irrelevant to quality patient care. They are part of EHRs for other reasons. See here for what I think of that “functionality” (a word which always makes me cringe).
All of which makes me wonder — do EHRs make us better at what we do? Or worse?
Help please.
And just in case you missed it …
[youtube http://www.youtube.com/watch?v=xB_tSFJsjsw&w=560&h=315]
13 Responses to “Do Electronic Health Records Make You a Better (or Worse) Clinician?”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
Biography | Disclosures | Summaries
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All of my training has been with electronic medical records and I am not willing to work in a medical environment without an EHR or even one with a particularly bad EHR. I think the anxiety regarding the EHR is similar to what we experience with any emerging technology within a practice. Think about the electronic spreadsheet and how it changed accounting. It’s clear to me which one is superior but I am sure there are many who were unwilling to adapt.
Jesse,
Thanks for your comment. I’ve been using some form of EHR since the early 1990s, and agree I could not imagine practicing without one today, largely for the true benefits that I cite above. For the record, I have used at least 5 different versions.
One problem is that they are growing more complex with every iteration, and hence becoming more difficult to use. It’s the opposite of what we see in most other areas of software development.
Paul
During child psychiatry postdoc clinical rotations before the advent of EHR, I often found significant information in margin notes. I could scan information quickly, looking for information that ‘jumped out’ — sometimes signaled by handwriting emphasis. Now as a non-clinical scientist, I deal with computer issues, miss-keyed data, and incomplete knowledge transfer — aware of how much worse it would be to shift my focus away from a patient who needs my concern and full attention.
Medical knowledge, clinical perception and EHR need optimal integration. Instead, EHRs separate and sanitize data which increases inattention and fatigue. E.g. Roadway designers found the shortest distance between two points had lethal side effects, and now design curves into, not out of, highways. Our hippocampus shuts down when everything begins to look the same.
But most likely, more redesigns will result in MORE medical funds pouring into more software companies who espouse the venerable sports cheer: We want another one just like the other one! Go, programmers, go!
I’d like to now which EHR’s Jesse uses. As a locum tenens physician, the many I’ve used were all designed by non- medical people and added 2 hours to the work day. If one had a scribe, as some do, to enter the new material and pull up the old, it can work.
Is it too radical to say that EHR are a SCAM? There is no/minimal evidence that they enhance care. Access to the INFORMATION Is the idea – looking up an interaction, checking the history, reviewing past treatment responses + yes, reviewing any medical images (ideally with the patient). Ontario (Canada) just spent $1.3 B ($17.95 USD) on EHR for the province- resulted in some happy people in the Bahamas and no gain for 10 million Ontarians. The history of medicine is rife with wrong turns – but life is complex – maybe EHR’s will go the way of leaches- only to return in more specific and targeted ways (like leaches). Don’t forget we now INFECT our patients for their health (vaccinations and fecal transplants) compared to notions of protecting them from “bad bugs”. I look to the EHR users and designers to solve these problems – real soon please. As a Child Psychiatrist also – EHR will never work for my practice, and don’t get me started on Telemedicine. . .
I’ve become pretty proficient with our EMR, so I no longer complain about the extra time it takes. (The key for me is dictating the HPI and assessment, and clicking only for ROS, PE, and orders). However, I do find that it gets in the way of the patient interaction. My approach is to use a pad of paper to take the history, and click in the exam room ONLY for the things that must be done for the patient to leave (ordering labs, consults, x-rays, etc.) The remainder of my charting is done later in my office, between patients or at the end of the day. The patient knows I’ll be doing SOME computer work in the exam room, but it’s generally only at the end of the visit. I try to engage in small-talk during the process, but I haven’t mastered that skill yet.
I always use the EHR before the patient encounter NEVER during (unless a question comes up that the patient and I need an answer to immediately). In fact, I don’t even “visibly” take notes when the patient and I are “face to face”. They have my entire attention.
That said, the EHR is a very useful tool!! I used to do a lot of consultations on complicated patients. The day before I saw the patient I would review EVERYTHING I could find. In the days before the EHR that was the hospital charts, referral letters, previous consultations, x-rays, lab results etcetera. Anything I could lay my hands on. It’s amazing how you can feed all that information into the cerebral “soft drive” and it will work in the background. Now with the EHR I can save a lot of time, allowing me to do what I do best, listening to patients.
As a 63 year old FP, I have an ambivalent feeling about EHR: Love access to information in clinic and remotely, also ease of ordering tests, prescribing and referrals. Also like not having to deal with paper charts for patient visits or for messages. It does not help me in terms of evidence-based care or patient education much but some of that may be my lack of facility. Dislike many templated notes that I see which fail to capture depth and breadth of clinical encounter, also no apparent improvement in accuracy of med lists. Hate the inherent control given to “meaningful use”, insurers and their “quality metrics”. Also hate and refuse to give in to loss of face-to-face interaction in clinical encounters; along with poor quality of voice recognition it means I see about 20% fewer patients than before.
So far, ICD-10 appears to be designed for insurers and bean counters more than for us . . .
I wish there was a “Yes, but…” option in the poll. Like others who have commented, I cannot imagine to going back to the days of trying to read handwritten notes, med lists that are handwritten and stapled inside a folder, having to write out every Rx by hand, etc. But I detest the way the computer and its demands have become so central to the practice of medicine. Endless click boxes, pull-down menus, etc. have also added significant time to note-writing and do little to enhance patient care and patient safety. I recently had an experience of using paper progress notes during a power outage. I have to say it felt liberating, even though it simultaneously made me nervous about missing a drug interaction or contraindication.
Like some other commenters, I don’t sit in front of the computer during the visit, and I open it toward the end of the visit, to check BP, look at meds, etc. I like to talk to my patients and get their history without the computer as an intermediary. But that means spending a lot of time writing notes outside the exam room (in my case, at home), which can lead to burnout and resentment about how much the work is intruding on life’s other details, necessities and pleasures.
Dr. Abraham Varghese at Standford Univ refers to the computer as the “iPatient”.
I am obliged by my hospital and insurance providers to use an EHR.
While there are advantages to retrieving information I find that the costs far outweigh the benefits. Entering data, finding relevant information, ordering simple tests and medications reduce my effective time with patients and staff. I would love to see that the time spent is worthwhile or in any way improves patient care actually has been documented rather than theoretically anticipated. It probably reduces the number of trees required for patient information and documentation, but I would gladly spend time felling trees rather then wasting the time, the electricity, the equipment costs and the simple interaction with humans that the creation of the EHR requires, It probably serves the lawyers, the insurers, the government far better than the providers or recipients of medical care. And, planting more trees is probably far better for the environment and humanity at large
Your survey is somewhat problematic, by offering two specific reasons to select the respective yes or no choice. I answered no, but not for the reasons specified.
EMR is a disaster with dramatic declines in efficiency and proficiency. Key information is obscured when it is needed; on my EMR you can’t see the list of allergies when you are in the prescribing.
Looking through the consult notes and test results is very very inefficient. Now with the so called “quality initiatives”, mindless clicking multiplies; indeed I have spent more time on some patients mindlessly clicking than actually doing cognitive work with the patient. The quality I am able to achieve has declined dramatically as a direct result of the EMR.
Routine tasks take 10 to 20 times longer than on paper charts. A singe med refil once took me 3 minutes. I estimate that I could see 50% more patients a day if I didn’t have to use the EMR, and I would not have had to give up hobbies and time with friends to accommodate all the extra time it takes at home to get caught up on the work.