Elec­tronic records a bur­den to doc­tors

Baltimore Sun - - COMMENTARY - By Cyrus Hamidi Dr. Cyrus Hamidi is a solo fam­ily physi­cian in Sparks. His email is cyrushamidi@hot­mail.com.

The prac­tice of medicine to­day is hob­bled by some of the very tech­nol­ogy that is sup­posed to im­prove it. The main cul­prit is the in­ter­fer­ence of the com­puter in the pa­tient­physi­cian re­la­tion­ship. Elec­tronic med­i­cal records (EMR), re­quired by all health care pay­ers, were in­tro­duced with the prom­ise of low­er­ing costs, and in­creas­ing ef­fi­ciency and rev­enue through more ac­cu­rate doc­u­men­ta­tion tech­niques. Sev­eral years in, the im­ple­men­ta­tion of EMR has over­whelmed many sec­tors of the med­i­cal pro­fes­sion, to the point of wide­spread burnout among solo prac­tice pri­mary care physi­cians, who of­ten ei­ther quit al­to­gether or give up their prac­tices and sub­mit to cor­po­rate reg­u­la­tion and over­sight of their work.

The most se­vere con­se­quence of EMR has been the tran­si­tion of health care from a per­sonal ser­vice-based in­dus­try to one in which the doc­u­men­ta­tion of that ser­vice seems more im­por­tant than the ac­tual de­liv­ery of it. Health payer re­im­burse­ments are based on the doc­u­men­ta­tion of codes that are gen­er­ated for var­i­ous ser­vices. Physi­cians spend an in­or­di­nate amount of time check­ing boxes and think­ing about the most ef­fec­tive code to choose. In ad­di­tion, the sys­tem is in­ef­fi­cient and un­re­li­able, mak­ing it more dif­fi­cult to ac­cu­rately re­trieve and un­der­stand pa­tient records.

The trans­fer of med­i­cal in­for­ma­tion used to con­sist of a phone call fol­lowed by a con­cise, com­plete let­ter, re­sult­ing in greater col­le­gial­ity and trust. Now this in­for­ma­tion con­sists of com­puter gen­er­ated chaff, with a small bit of clar­ity re­vealed at the end of many clicks. The trans­fer is par­tic­u­larly prob­lem­atic in an era of mul­ti­ple, non­com­mu­ni­cat­ing EMR sys­tems. (There are days when I work on four dif­fer­ent EMR pro­grams, of­ten con­tain­ing re­dun­dant and in­ac­cu­rate in­for­ma­tion.) Many of­fices have to print out the of­fice visit doc­u­men­ta­tion, then fax it to the re­fer­ring of­fice, which then scans it into their own sys­tem. My of­fice uses more pa­per now than be­fore EMR.

Be­fore EMR, I spent about 85 to 90 per­cent of my time with the pa­tient, and the rest doc­u­ment­ing the visit. Now, two years into EMR, it’s about 60/40. Early on, I spent the first few min­utes of the pa­tient visit apol­o­giz­ing for the com­puter and its stand, jok­ing about the new pres­ence/ bar­rier in the room. Lately, I’ve no­ticed that I just walk in the room, fire up the com­puter, and get on with the visit, with­out apolo­gies. This de­spite a re­cent study in­di­cat­ing that eye con­tact im­proves pa­tients’ sat­is­fac­tion with the visit.

Be­cause of EMR, I con­sis­tently run later than be­fore, which means that pa­tients have to wait longer than they used to, and I spend more time af­ter­ward in the of­fice on the com­puter, not see­ing pa­tients. A re­cent study in­di­cated that physi­cians spent 38 ex­tra hours each month on EMR. This is likely a fac­tor in many ex­pe­ri­enced physi­cians re­tir­ing a few years ear­lier than planned. The pri­mary health care trade jour­nals re­cently fea­tured ar­ti­cles on cop­ing meth­ods for burnout as­so­ci­ated with EMR, off­set by ar­ti­cles on the in­creas­ing in­ci­dence of physi­cian burnout. Over half of pri­mary care physi­cians re­ported symp­toms of burnout in one re­cent sur­vey.

There are some ben­e­fits to EMR. I can write more com­plete and leg­i­ble notes. The elec­tronic trans­fer of pre­scrip­tions is im­pres­sive and use­ful. I can’t imag­ine that it will be very long be­fore we get the tech­nol­ogy to di­rectly trans­fer in­for­ma­tion be­tween sys­tems, with­out wast­ing so much pa­per. As I’ve grown used to us­ing EMR, I have to ac­knowl­edge its po­ten­tial. I have come to ac­cept the idea that this is early in a big, on­go­ing tech­no­log­i­cal change in the prac­tice of medicine. How long be­fore these tech prob­lems don’t ex­ist — 10 years? 20?

An­other sil­ver lin­ing on this cur­rent cloud of tech­no­log­i­cal change is ex­pe­ri­ence of younger physi­cians who have a life­time of com­puter ex­pe­ri­ence. In15 years of teach­ing med­i­cal stu­dents, I have seen a pro­ces­sion of in­tel­li­gent, strongly mo­ti­vated in­di­vid­u­als with the won­der­ful car­ing at­tributes that fu­ture physi­cians should have. While some in my gen­er­a­tion ab­hor the idea of con­vey­ing test re­sults through tex­ting, this gen­er­a­tion rec­og­nizes an ap­pro­pri­ate way of con­vey­ing sen­si­tive in­for­ma­tion. While my gen­er­a­tion of con­trol freaks sweats it out at the prospect of “por­tals” in which pa­tients can ac­cess their own health in­for­ma­tion, this gen­er­a­tion shrugs. While my gen­er­a­tion of old fo­gies shud­ders un­der the over­whelm­ing vol­ume of in­for­ma­tion on the EMR, much of it in­ac­cu­rate noise, this gen­er­a­tion has de­vel­oped skills to or­ga­nize it to their own ad­van­tage.

New gen­er­a­tions of physi­cians will be more em­pow­ered to in­tro­duce pro­gres­sive change in EMR, to de­crease waste and in­crease clar­ity, while my gen­er­a­tion will be re­tir­ing and telling sto­ries to the kids. How­ever, as my peers and I chafe un­der the tech­nol­ogy, and as we burn out and re­cede and re­tire, there is one thing that we can do. Be­fore we hand over the sci­ence and art that is the prac­tice of clin­i­cal medicine to the next gen­er­a­tion, we can teach the up­com­ing co­hort of doc­tors how to re­tain the essence of med­i­cal care: the per­sonal con­nec­tion to their pa­tients. If they can re­tain the spirit of the pa­tient-doc­tor re­la­tion­ship and truly use tech­nol­ogy to en­hance it, then it will be a ben­e­fit to the physi­cian as well as to the pa­tient.

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