Learning to juggle computers in the exam room can have unexpected consequences for doctor-patient relations.
One afternoon several years ago, I found myself faced with an unexpected challenge while seeing patients in clinic. The hospital had just put in effect an electronic medical records system, or EMR, and along with the dozens of shiny new computer terminals installed in nursing stations on every ward came the promise of fewer missing charts, streamlined information and efficient work-flow patterns for all. By the time the first computers were finally installed in exam rooms, my colleagues and I were already fluent enough in the system’s software that we were creating and trading order sets, progress note templates and clinical checklists like kids exchanging baseball cards and CDs.
For someone who likes to imagine herself as tech savvy, it was a heady moment.
But that afternoon as I settled in to see my first clinic patient, I realized I had no idea where to sit. The new computer was perched atop a desk in one corner of the room; the patient sat on the exam table on the other side of the room. In order to use the computer, I had to turn my back to the patient as I spoke to him. I tried to compensate by sitting on a rolling stool but soon found myself spending more time spinning and wheeling back and forth between patient and computer than I did sitting still and listening. And when my patient did talk, his story came only in spurts because every time I turned my back to him to type, the room fell silent.
My vision of an interaction marked by the seamless flow of conversation and capture of information vanished. Instead, I was spinning my wheels. Literally.
In the years since that clown car moment, I have developed a more fluid, albeit still not hugely efficient, style of interacting with patients while using EMR (I memorize and jot down quick notes when necessary, then leave the room to type everything into the computer). But I have met other doctors, our family pediatrician for example, who do manage to use the system well and efficiently, turning the omnipresent laptop or desktop into the white noise of an office visit.
Nonetheless, for every one of us who is using, struggling with or considering adopting an electronic records system, one thing has become increasingly clear: just because EMR improves information sharing and retrieval, it doesn’t necessarily follow that our communication with patients and colleagues will also be better.
This month, the Center for Studying Health System Change, a nonpartisan health policy research organization in Washington, released a study on the effects of EMR on physician communication. The researchers conducted in-depth interviews with the doctors and staff from 26 small and medium-sized practices across the country that used the electronic system in their offices for at least two years. Few, if any, of those interviewed would choose to revert to a paper-based records system. But all the physicians expressed concerns that EMR had less than salutary effects on the patient-doctor relationship, including difficulties replicating the narrative aspect of a patient’s illness and the constant interruptions from alerts and instant messaging.
“EMRs are a phenomenal contribution to care,” said Dr. Ann S. O’Malley, lead author of the study and a senior researcher at the center. But there is often so much information available — some of which requires a direct and immediate response from the physician — that “some doctors liken the presence of EMR to having a 2-year-old in the exam room.”
As all parents can attest, while a 2-year-old can create chaos in any situation, a setting that is as delicately balanced as the clinical one runs the risk of falling into complete disarray. Doctors often must consider several issues simultaneously when seeing a single patient — all the potential diagnoses and possible treatments, the patient’s history and list of medications, any possible adverse effects or interactions, the limits of that patient’s health care coverage and numerous preventive health issues, to name just a few of those considerations. The addition of an electronic records system can push some doctors into what one EMR expert refers to as “cognitive overload.”
“The whole point of EMR is to simplify the process and to enhance and facilitate communication,” Dr. O’Malley said. “But in order for that to happen, EMR needs to be more user-friendly and more responsive to the clinical needs of patients and clinicians.”
Currently, most systems have been designed not with clinical needs in mind but to meet the demands of the fee-for-service payment system. The software rapidly codifies diagnoses and symptoms, thus facilitating billing. But that shorthand also encourages clinical shortcuts and less face-to-face time with patients. Time-pressed doctors can fall back on the electronic records, which format and abbreviate information in a way that physicians can absorb quickly. And because the data is in the electronic system, it is easy to assume that the information is as reliable as the patients themselves, if not more so.
“There is a kind of reliance on electronic transmission and electronic data which suggests that they stand in a one-to-one relationship with the truth,” said Richard M. Frankel, a professor of medicine and geriatrics at Indiana University School of Medicine in Indianapolis who conductedone of the first studies examining the effects of electronic medical records on patient-doctor communication. In the Center for Studying Health System Change study, one physician recalled the words of a colleague: “This is great. I used the EMR before I came here. I was able to sit down with my bagel and coffee and do my rounds before I even got in.” The system becomes a proxy for the patients themselves.
While EMR can capture certain information like medication lists and test results with mind-boggling accuracy and efficiency, it often fails to relay the nuances of a patient’s illness course. “Physicians think in stories,” said Dr. C. T. Lin, a practicing internist and chief medical information officer for theUniversity of Colorado Hospital in Denver, which has used electronic records since 1994. “How can you possibly point and click your way through a patient’s 10-year history?” To address this problem, Dr. Lin and other experts have been exploring newer technologies like voice recognition that will allow doctors to dictate patient histories, and thus restore a sense of narrative, into the electronic record.
According to the researchers of this most recently published study, many of the potential pitfalls of electronic records can be avoided if doctors and other clinicians are taught how to use the software efficiently and how to communicate effectively with patients when using it. “There is so much money going toward adoption and implementation of EMR,” Dr. O’Malley said, referring to the $19 billion allotted by Congress in last year’s stimulus bill to promote the use of health information technology. “I think it would be wise for us as a society to invest some resources in training physicians to communicate effectively with others in the presence of EMR so that it becomes less of a distraction and more of a tool for communication.”
And that training would include matters as simple as where we place computers in our exam rooms. Just as hospitals and health care providers have learned to place blood pressure cuffs in every exam room well within reach of a patient’s arm, they can learn how to situate, carry, rest or tether their computers in such a way that they facilitate, not block, discussion.
“Many doctors are never taught communication skills in general or, more specifically, that computers are actually a third party in the conversation between themselves and their patients,” Dr. Frankel noted. “We are asking people to take on a new technology that has enormous variations, and we are not providing enough upfront training for them on how to use it appropriately.”
“It’s really important,” Dr. Frankel added, “to value the best selves of the people who are providing medical care.”
Pauline W. Chen, MD • Copyright 2010 The New York Times Company