Electronic records a burden to doctors
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.