How an EMR gets in the way of doctor-patient relationships

For all of the glorification of EMRs and EHRs and pushing into the new age of digital healthcare, I thought I would throw in my 2 cents from the dark side of electronic health record keeping.  To be honest, there are a few things that could be greatly improved.

Now, before I get a whole bunch of unsolicited email from EMR vendors out there waiting to pounce on me with sales pitches of how theirs is better and I should give it a try, I should say that I’m very happy with my current EMR system and not looking to switch.

That notwithstanding, there are a few simple concepts that no EMR system to my knowledge has gotten right yet.  It’s even possible that it may be hard to ever get right, and a lot of it has to do with mouse clicks and typing.

During my average day, I feel the need to maintain at least some eye contact with my patients, mostly because I’m a bit uncomfortable with the amount of time I have to spend looking at my computer.  I’m a bit of a slave to the computer system in that sense.  I know I could do all of the documentation after the patient is gone, but I’m afraid of missing something in the documentation.  You could say I could just scratch notes on paper to avoid missing anything, but this is not in keeping with the lofty goal of being paperless, now is it?  Maybe the lofty point is just to eliminate paper charts.  Still, scraps of paper doesn’t really sound modern or safe now, does it?

I also feel a bit uncomfortable giving up my nights and weekends just to “look good” in front of my patients.  A burned out doctor who has no life outside the office to spend with family and friends, and who ultimately quits the profession because of such, is not an ethical thing to expect of physicians, is it?

And so, for now, I do my best to incorporate a bit of eye contact, but still spend time typing away with the patient across my desk watching me and telling me about their issues.

The EMR still requires a lot of additional tasks outside of documentation: electronic prescribing, reviewing messages from staff and performing additional tasks as necessitated by these messages.  And all of these tasks take a considerable amount of time.  Up until now, they have required human intervention to complete, but what about the future?

One of my recent hobbies is reading history texts.  Interestingly, one of the stimuli that encouraged the Europeans to seek an alternative passage to the Far East was the excessive trading fees imposed by transmitting goods through Muslim and African nations.  An alternative route that would allow the elimination of hefty fees and allow them to run their import-export businesses cheaper and more efficiently was the dream.

If we can automate all of the EMR tasks more effectively using a Siri-like voice-activated platform, then medical providers may be able to achieve all of their work during normal business operating hours, face the patients when they speak, and have a better quality of work and home life than their predecessors.  I’d love to be able to tell my computer to send in a scrip refill for thyroid hormone and it would be done, without the need for any other steps or human involvement, but that remains a far off mirage at this point.

The more an EMR can do for me, the more time I can spend in humanistic and meaningful contact with patients.  I dream of actually living the dream but for now live in the reality of a less than perfect world.

About the author

Dr. Michael West

Dr. Michael West

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC in 2009. He can be contacted at doctorwestindc@gmail.com.

7 Comments

  • This is a great post. I read an interesting article this week how most software industries (like CRMs) have had decades to be developed and fine-tuned. The ERM industry is fragmented, young, and changing at a break-neck pace.

    We are currently being introduced to technologies that we never imagined would exist 5 years ago. It won’t be long before the ideal EMR (or at least an EMR with the features above) comes into existence.

    I’m excited to see what the future holds as this industry grows up.

  • Discrete reportable dictation,(DRT) a process written about on this very site recently, is proving quite helpful here, especially with the narrative-based notes a physician is accustomed to using. His engagement with the EMR would be limited to reviewing notes much as he does anything he’s dictated in the past, or the e-prescribing or sharing with the patient their test results. Basically, his encounter with the patient remains what it has been historically but his records are still electronically based.

  • Having lived and worked in a few countries, I have seen some countries where Electronic Medical Records have been in use for quite some time. In the UK and Israel it seems that the Medical professionals have gotten used to the balance of the inputting and management of information and making eye contact with patients. the Doctor tends to either briefly review the EMR patient record just before or at the start of the appointment. Then the Doc asks about the complaints, does the normal narrative assessments that they feel they need to and looks directly at the patient, repeats the complaints they think the patient has described (this repetition is more routinely done in UK)- (noting the type of narrative: comprehensive, problem focused etc is important for reimbursement in the US), notes complaints in a system that has been tweaked over time to have a wide range of list of complaints listed that they can easily and quickly select (either through inputting the first two or three letters and scrolling) and then, in the UK especially- they have generated a lot of evidence based medicine that they incorporate into their EMR- not sure how detailed- but the system gives some suggestions of possible issues- and what to check for to get a more specific idea of the complaint. Then the Medical Professional can return to eye contact and do whatever investigation or asking further questions that may be necessary to determine the present medical issue- and then they go back to the computer to input whatever answers they feel they have gotten- which pulls up a list of possible present issues- and the Medical professional uses their training and experience to decide whether they agree with any of those possibilities or have their own idea- then they select or input what their current diagnosis might be- and then – in the UK and in Israel (very advanced in Israel) the EMR brings up a listing of treatments and/or Medications that may be appropriate for this current diagnosis- and the MD then decides what to offer- and talks about this with the patient, making eye contact. This seems to have become the norm. I have noted that there is a focus on efficiency and time management- but any disadvantage this may pose seems to me to be overcome over the ease of return visits and developing a relationship with one’s MD. Patients learning to be more forthright from the start about their concerns and issues seems to also have gone a long way to helping the MD use the time most efficiently and effectively. In other words- being upfront – for example- if there was a past personal history of back problems and the patient is worried there current pain may only increase- they should just say that upfront. If the patient had past of serious and painful sinus infections and are currently having symptoms they recognize as being the start of another one- they should speak up right away. So I think there are some cultural constructs to become more familiar with in addition to software improvements. We must remember- software is a great aid but it cannot replace the MD!

  • First of all I completely agree with you. In addition I feel that the transportability of lab. work, imagining, etc. and diagnoses would be sufficient for the purpose for which EMR’s were intended.
    The details of the exam have no reason to be transportable. Also, I have rummaged through pages of printed EMR’s with negative findings, a plain waste of paper and time. Like so many new ideas brought to market, the sales pitch gets way ahead of the products usefulness. Why should be the beta testers for a product that has not shown its worth to medicine. Because we have to and there lies the rub.

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