As the requirement for electronic medical records (EMR) extends to every doctor's office, beyond the hospital and into the community, the effect will be seen not just on doctors and nurses but on the patient in the exam room.
Until now, complaints about EMR until now have been dismissed as the grumpy old man syndrome: Older doctors simply cannot adapt to the new technology and good riddance to those old geezers. Actually, if The Phantom's observations are correct, many of the very doctors who have quit or been fired because of their refusal or inability to use the computer for record keeping are just exactly the doctors we should not be losing, for reasons we can get to later. But the issue now affects every doctor, from medical student doctors-to-be, to interns, to more experienced doctors.
The EMR has less impact in surgical specialties, where record keeping was always far less important than what happened in the operating room. But for internal medicine and Pediatrics, the "cognitive" specialties, record keeping has always been important, if not central to the care of patients, and it has always been the cross borne by suffering medical types.
Record keeping is essential to "medical" specialties because records of drugs given, responses to those drugs (blood pressure, heart rate and rhythm, changes in body chemistry) are the essence of those specialties, from internal medicine to endocrinology, gastroenterology, kidney, hematology, oncology and infectious disease. If you give a drug, you need to know the response to that drug. Records become central.
Central, but not the first priority. The first priority is the patient.
We have a version of computerized medical records in my office, and the nurses, medical assistants and sometimes the doctors become so focused on getting through each screen and on to the next (because if you miss a spot, you cannot get to the next part of the record, like trying to order something on line and forgetting to put in your email or zip code) so you get stuck. There is a computer in every place a patient may be and some they are not. The medical people look at the screens and not the patients, and spend most of their time making eye contact with the computer.
We now have to drag a nurse away from a computer screen to get her to get the shoes and socks off the patient, to remove wound dressings, because the nurses and doctors are all busy examining and interrogating and responding to the computers. The patients are often not examined adequately or even allowed to give their stories as they want to give them. They are asked the questions lined up on the screen on the computer. But a free flowing narrative, entering the story the way the patient wants to tell it, forget that. There is no program for that.
In police work, cops on the beat "juke the stats" which is to say, rather than sitting down with a woman on her stoop and getting to know her, so the cop can come back and talk to her after a shoot out or a rape has occurred in her neighborhood, the cops have to bang heads on that street and arrest people for drinking alcoholic beverages on the street, or for jay walking. Those arrests do nothing to improve community safety or quality of life, but they make the stats for the cop look better. Similarly, the records for the doctor are what he or she will be judged by, even if he has not examined the patient, listened to the patient, the record will show he has done his job.
We used to say, "The better the surgeon, the worse the note," which is to say, the fine surgeons who had great surgical technique often wrote de minimus notes. But their patients did well, where the patient of the guy who wrote lovely, flowing notes in the chart was the one with the wound infection, the wound dehissence , the post operative complications.
So now, at least in the shake out phase of EMR, we have the medical version of "juking the stats." Bad doctors will look good. Good doctors will look bad, and the medical record will be page after page of pretty looking, but empty, often erroneous, well printed in good font style, and useless as a medical record.
Well. it is never quite as simple as you lay it out but, in this case for sure, you make a very valid point. Of course, some good doctors can use the computer quite well and so will continue to look good. Many say it takes weeks or months before they get back to treating the patient rather than treating the computer. However, a number have pointed out that by involving the patient in the process of generating the EMR, the patient has corrected errors the MD made in recording the history or the drugs being taken, which previously would have simply gone into the note incorrectly. Moreover, the ability to give the patient a printout of their medications and recommended actions at the end of the visit has been seen by the patients as an enormous positive. These steps suggest that even good doctors may not have been as good as they thought they were and EMR has improved the entire experience for the patient - once the MD becomes comfortable with using the computer in this way.
ReplyDeleteAnonoymous,
ReplyDeleteI've used a version of EMR for years, and type as the patient speaks and can print out med lists and notes to give to the patient and all of that is very positive. But, the fact remains, for better (and there is some better) or for worse, the presence of the EMR elevates the importance of the act of keeping a medical reoord, and the potential of shifting the focus of the doctor or nurse from the patient to the record is, to my mind, a real risk of EMR.
On another front--I am told the VA system had a very simple, effective EMR which the government was going to make available free to all doctors and practices who wanted it, but Republicans in the Congress nixed that because commercial makers of proprietary EMR systems had lobbied them. Thus the EMR became another victim of moneyed interests and what should have been a force for public health became just another "private sector" force feeding on the teat of the government it decries.
The Phantom
Great post. My coworkers and I were just talking about the advantages and disadvantages of electronic medical records software. I will have to send this around the office. Thanks so much for sharing, this was very interesting.
ReplyDeleteLauren,
ReplyDeleteI just saw my dermatologist and the medical assistant used an IPAD to log me in and she took my picture, so the doctor will have a chance of remembering me whenever she brings up my file, but the most amazing part is she took a photo of each of the three lesions they lopped off me, before the shave biopsies, so if one or more comes back malignant, they'll know what it looked like before. They didn't do it, but they could map nevi and pigmented areas, so this should be a vast improvement in the quality of dermatologic care. In an endocrine office, where physical findings are less important, likely not such an advantage. Ultimately, EMR ought to help manage the drudgery of medical record keeping, but first people will have to agree on how to keep these records so they don't simply act as legal briefs but as tools which improve medical care rather than getting in the way of it and impeding communications rather than enhancing.
--The Phantom
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ReplyDelete