Is Physician Interaction Bad Regardless of EHR?

I think that EMR and HIPAA has some of the best readers out there. They aren’t afraid to say what’s on their mind and share views even if they’re counter to the predominant thinking. Plus, they aren’t just doing it to be contrary. In fact, I’d suggest in most cases they do so because they sincerely and deeply care about the state of healthcare. They want to improve healthcare and the lives of patients.

One such response came from G. Foster on a post titled 6 Rules for Ethical Data Handling in a Health Organization. For those who missed the comment, here it is:

In my work, I coach Physicians to achieve Meaningful Use of their Certified EHR technology. In my personal life my interaction with Physicians is as a patient. In my work, when Physicians complain that the “new” EMR technology comes between them and their patients, as expressed in the article “A Child’s View of EMR” I bite my tongue. That’s because, I have yet to experience a relationship in which a Physician engages me in my own care.

I’m releasing my tongue from the grip of my teeth. I do not believe that the medical record (paper-based or electronic) disrupts the relationship between Physician and Patient. It is the Physician’s social skills (i.e. bedside manner) and attitude toward patients in general and patients from subgroups specifically that disrupts those relationships. While I try to keep an open mind, I have observed that Physicians present bias against patients by certain conditions, gender and race within minutes of the patient’s first visit.

When patients describe their complaints, Physicians cut off their comments mid-discussion. While there may be some eye-contact between patients and Physicians using paper-base medical records, Physicians don’t listen to their patients. Instead, Physicians believe they know what’s going on just by looking at a patient. To a point that may be true, but Physicians rarely acknowledge the non-medical judgments they make, which often become the basis of a patient’s paper-based medical record. For example, an overweight or obese patient merely needs to eat less and exercise more, there is no reason to consider the endocrine system… even if the patient clearly describes (or tried to describe) symptoms of Cushing’s syndrome, hypothyroidism or PCOS. A female patient is a hypochondriac, even if she describes (or tried to) a family history of cancer, heart disease or diabetes, which test would show she has inherited. African-American patients aren’t in pain; they are drug seekers, despite having undiagnosed fibromyalgia, lupus or ankylosing spondylitis.

My first adult-care Physician infamously cut me off to state “you are too young to be having all these aches and pains.” He ordered no tests or referred me to any specialist. One year later, dramatic weight gain was among three new symptoms. Again, the doctor was not concerned and told me these new symptoms were unrelated and a part of a cycle that was totally up to me to continue or resolve. I always wondered if that Physician took me seriously and engaged me in my own care, rather than dismissing my complaints or blaming me for my poor health; could I have prevented an array of new symptoms, resolved the core condition afflicting me and lived a higher quality of life these past 25 years?

I believe that paper-based medical records, NOT EMRs, are the dream of lawyers. Let’s consider my first adult-care Physician, again. If my condition, untreated, was fatal and I died, my surviving family would have wondered, why I didn’t know about my condition and followed the lifesaving treatment plan. They would have gotten a lawyer, who in turn would have gotten a court order for my entire medical record, from all Physicians whose care I sought. And what would have been noted in the paper-based medical record? Would those paper-based medical records serve well as evidence for a wrongful death lawsuit?

When I speak with Physicians who claim that EMRs stand between them and their patients, I tell them my story and ask them to examine their attitudes about patients and they may be unconsciously expressing them during office visits. Perhaps they didn’t perceive paper-based medical records as standing in the way, because the medically relevant notes were few and far between requiring less attention. If Physicians have always engaged patients in their care, even when using paper-based medical records, they will continue to engage patients in their care when using EMRs.

Now that the CMS is pushing Physicians to use EMRs in a “Meaningful” way, I suggest developing EMR workflows that 1) support patient engagement. It’s the patient’s medical record, so why turn your back on the patient when updating their progress note on paper or electronically? Laptops and tablets make it easier to maintain face-to-face contact with a patient while having the electronic progress note readily available to you both. 2) Meet CMS Meaningful Use. The CMS Meaningful Use rules were established so that the focus is NOT on the technology. If your focus is on the Technology, then have a candid conversation with your vendor about developing the EMR so that you can maintain your patient-centered approach to care. Additionally, until Physicians have had a chance to fully consider the most Meaningful Use of Certified EHR Technology for them and their patients, the CMS criteria serve as a good (not perfect) blueprint. Which brings me to 3) drive EMR use that is Meaningful to you and your unique patients, going beyond the stereotypes of conditions, gender and race.

This was my initial response to G Foster:

Thanks for sharing your views. Quite interesting to consider the question of whether physicians are really engaged in care (EMR or not). That’s a hard question to answered and likely is all over the board depending on the doctor.

Although, I think we have to be careful in a number of ways. For example, if we assume physicians haven’t been as engaged as they should be, that doesn’t mean that EHR can’t still make it worse (or better depending on your view).

The biggest challenge I see is that the reimbursement model incentivizes many of these behaviors. That’s tough challenge to solve.

These are some deep and complicated issues that we’re talking about here. One thing I know that won’t resolve them is to act like they’re not a problem. The reality is that for many doctors, this isn’t a problem (EMR or not). However, many of the issues regarding physician interaction with patients are there regardless of EHR. Does EHR make them worse?

I think technology is a great magnifier. This applies to both good and bad. So, I expect in many cases EHR does make the patient interaction worse. Although, in other cases I think EHR takes the physician patient interaction to a whole new level of collaboration and patient care.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

2 Comments

  • Sounds like the issue is not whither EMR, but one of physician competence, not merely social skills. I suspect many (if not most) family doctors are neither broadly trained nor have the interest and time to continually keep up with new (or old/forgotten) medical findings that would help them better diagnose and properly treat a given patient that does not fit their narrow template. These doctors offer boilerplate “status quo” recommendations as found on WebMD (eg: Cholesterol levels should be below 200 and higher levels have any bering on a patient’s health).

    The medical educational establishment simply does not understand or teach doctors to assess a patient’s real health before or after an affliction set in. And the pharmaceutical industry offers very few remedies that actually cure an illness; most drugs merely mute the effects of a problem, while often creating secondary problems requiring yet more drugs. This can be quite profitable for all parties except the patient.

    Question: Is it easier to find a good doctor or a good auto mechanic?

  • I know I don’t see things the way a doctor does, but a visit several months ago to a hand surgeon was a window into the good and bad of an EMR and what a doctor does with it – and with his patient. The EMR did some strange things, like ask the pregnancy status of a male patient. And it was not well organized, asking questions out of order, forcing the doctor to go in and out of pages, back and forth. But he used the EMR – telling me what he was doing at all times, using it (with PACS) to view xrays taken minutes before, older xrays, older notes, far more quickly and effectively then doctors going through paper charts and putting up films on the viewer trying to make out vague shapes and shadows.

    It’s not just that he was a true believer – despite the problems. It was that he used the EMR to draw in the patient, help the patient understand what was going on; it was part of his flow and his patient communication. His way of doing this is a big part of what drew me into the world of the modern EMR. Now just imagine how this doctor would do if and when he gets the problems with the EMR worked out!

    An internist I know is trying to get used to the EPIC Ambulatory system. Again, not customized for her work, she has to pop in and out of multiple pages just to do basic exams. EPrescribe still has issues; it picks items that are not formulary and therefore extremely expensive, for instance. But she understands the potential for it to help her pick the best choice of meds – if it ever works the way she hopes, and she understands that if she puts enough detail on signs and symptoms and lab results into the system it may point out problems or illnesses that may be rare enough she wouldn’t normally think of them – this in a patient that has an array of difficult to pin down medical problems (past cancer, sort of dealt with cardiac issues, plus a fairly rare variety of an autoimmune disorder that hits the category of orphan disease. Or so she hopes – because the lab integration pretty much isn’t there or doesn’t work well, and because for whatever reason decision support isn’t being used… Etc. But first the system (and I’ve no idea what EA is capable of if properly configured) needs to be ‘fixed’ and the doctor needs a lot more training in both the usage and in using it with patients.

    BTW, in regards to David’s comments, there are lots of problems with meds, and their side effects and interactions with other drugs is a huge issue. It would be nice if EMRs were smart enough to spot some of these problems from the symptoms; for instance, certain gastro intestinal problems that wouldn’t happen from just one med might be set off by years of use of multiple meds that used long enough with high enough doses that side effects seldom seen pop up. Put the symptoms into the EMR, and if its diagnostic abilities regarding medication side effects are good enough, it OUGHT to be able to use the history and current data to come up with a diagnosis in a way that most doctors – including specialists, never could. But even if the EMRs could do this, and the EMRs had a deep enough detailed history, the doctors would still have to be willing to consider the results. And few doctors have the time, energy or knowledge to go through years of meds and odd symptoms to come up with a diagnosis of what the patient’s problem actually is – and then come up with a treatment plan.

    To me, the need for EMRs to be used, and enhanced to do what people actually think they can do, and for them to be properly configured and installed, and the users well trained, is absolutely essential.

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