Tuesday, June 2, 2009

Doctor Please Look at Me not Your EMR

A recent personal experience with a pediatric office that I have been attending with my children for the last 7 years provides some valuable insight into the effect of an electronic medical record on a typical busy general pediatric clinical practice.

A little history - this practice has been servicing patients in our area for many years. Currently there are 7 physicians on staff and they have regular hours and see patients 6 out of 7 days providing on call coverage at all other times. They are great, my kids like them and my wife and I both love the practice. I have been to the practice and watched the impact of the implementation of an Electronic Medical Record (EMR) over the last 18 months. I was there shortly after they went live with their new system and watched as the clinicians struggled with a large unwieldy tablet using a combination of tablet and keyboard entry that clearly was uncomfortable and difficult for a physician who in previous visit had been highly efficient with a pen and paper based record.

The most recent visit was simple physical examination immunization and paper work for participation in sports programs. What should have been a brief efficient visit was not but it was my 10 year old who pretty much summed up the experience
She (the doctor) spent more time looking at her computer than at me
Practical medicine is about body language, facial expressions and interpreting more than just what someone says. The picture below dates back some years to an implementation of an EMR I was involved with in 1993 - the patient in the bed is ignored by the 5 doctors focused on the EMR screen in the corner:

When you ask a patient if there anything else that's bothering them you don't just listen to the answer but look at their face and the way they behave. There are clear indication if this patient is going to drop some significant additional piece of information on you with the classical line, often delivered as the patient is standing up and reaching for the door know
Oh and by the way doc..."insert interesting/relevant piece of clinical data"....thought that might be relevant"

It's a well known phenomena - part of our general make up that prevents from arriving at the doctors office for a "routine visit" and when first asked if you have any problems opening with
Yes, I have been bleeding rectally for the last 3 days, it's fresh blood
We all dread sharing what in our heart of hearts we know is bad news even though most know that early detection, treatment and dealing with problems is a much better strategy than putting our head in the sand:

To be clear I am not leveling criticism at our physicians - they are doing the best with the hand they have been dealt. Their perception of the EMR has changed over the course of this implementation. Prior to the implementation (which predates the economic crisis and the current rush towards a set of incentives currently linked, albeit with poor clarity, to implementing an EMR) they were not excited by the prospect of imposition of technology. Their decision was driven by their lead physicians drive towards modernization and the belief that current paper based systems were failing them in delivering the best possible care. They reviewed the choices and selected based on their needs. During the implementation the sentiment was very clear - everyone was fed up with the additional overhead required to cope with the new system and the huge change required in their day to day work flow and clinical practice.

Now many months on things have settled down. In the words of one of their physicians - they love the ready access to all the information on their patients when they are seeing them. For the most part the presentation of patient data is helpful and easily navigated..........but the capturing of this information is a burden and interferes with the clinicians/patient relationship.

Clinicians need to look at their patients, they need to interact with their patients and technology should not interfere with this essential component of the diagnostic process. Computers can be part of that interaction but currently in the vast majority of implementations they are a distraction and interfere. As my 10 year old said
Why is the doctor more interested in her PC than in me?
In fact in a recent exchange the story is even more disturbing with the roll out of these EMR's. A clinicians recently shared with me that his clinical interaction had changed since the new EMR system had been implemented. Since the system presented him with a series of choices to questions he would ask questions designed to elicit responses that were featured in the list. If he thought a question might elicit a response that was not featured in the list of choices available he would avoid that question since documenting the response was a time costly exercise.

Dictation has long been tainted as a problem not a solution....but dictation has been the mainstay of capturing clinical information. We moved from hand written notes to dictation and transcription as the volume of information increased. It made sense because off loading the heavy lifting of creating a typed legible note was more efficiently done by someone who specialized in that process and was more cost effective than asking a clinicians to spend more time documenting and less time seeing patients.

Despite the bad rap dictation and transcription is the mainstay of clinical information today - 60% of the data we have on patients is generated by dictation and transcription. Of the remaining 40% the vast majority of this data comes from automated clinical systems including laboratory and imaging systems that generate data - not clinicians who currently generate somewhere in the region of 3-5% of this information input into EMR's today.

But to satisfy the informational needs of the EMR we need the clinical data. This is possible today and the technology is available to make the process of dictation and transcription not only more efficient and cost effective but generating the data necessary to fill the information void in the EMR's. Instead of just accepting the concept that physicians should become data entry clerks ask how you can use existing technology and services to allow doctors to focus on their patients not on an inanimate piece of technology

I'll leave it to my 10 year old to sum it up
I wish she (the doctor) would look at me not her computer
How have your experiences been in any recent visits to your doctors office. Do they have clinical systems and do they interfere with your relationship with your doctor(s)? Let me know - I'll publish any stories people are willing to share


Kristy said...

Yes! Your 10-year-old's experience mirrored mine with a local clinic. My son and I went in for help with a relapsed, hard-hitting respiratory malady that was going around our community. We watched the doctor keyboard information, left with NO help, and a hefty bill.

My friend went to her doctor for the same malady, received traditional face-to-face care, came out with a prescription, and recovered from her bout of illness 2 or 3 times faster than our family did.

Anonymous said...

Thanks for today's blog. I can totally relate to what you wrote in your recent blog and to your child's sentiments. Been there, done that, and promptly switched to a new physician! My current physician pushes her laptop into the room for every patient and enters information into the EMR. However, the difference is that she has also mastered being able to balance inputting information, writing prescriptions, etc., with listening and addressing the issues of the patient. She makes eye contact. She pays attention when you are speaking to her. She really recognizes the necessity of interacting with the patient and showing that she cares and is here for them. People want to be heard and validated. Hopefully more physicians will take notice and apply these principles. And patients need to speak up too.