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Do computers interfere with the doctor-patient relationship?

Kevin | Patient | March 14, 2009

Lost in the zeal of those supporting electronic medical records is how computers can depersonalize the patient encounter.

In a nice op-ed in The New York Times, pediatrician Anne Armstrong-Coben talks about how doctors now have to make a concerted effort to look up from a computer screen simply to maintain eye contact with a patient. “I advise teenagers to limit computer time,” she writes, “as I sit before one myself for hours each day until my own eyes twitch and my neck starts to spasm.”

More worrisome, and this has been mentioned here before, is how template-based notes are voluminous, but often say little. A singly keystroke, or click on a box, can fill up the page with paragraphs of narrative, but what’s important is often missed.

There is no question that doctors should adopt digital records, but as Dr. Armstrong-Coben says, “there should be more discussion and study of electronic records, or at a minimum acknowledgment of the downside.”

Because those drawbacks are not insignificant.

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  • Throckmorton

    I have the dubious honor of fielding the comments and complaints about the care at one of our medical centers. I have yet to get a comment where someone wrote that they “are glad their is an electronic record.” I have many that are “the nurses seem to care more about the computers than the patients!”; “the nurses are never around, they are all at the computers!”; and the best “I hope the computer is doing well, because I am F++++ dying over here!”

  • Laura

    There is a delicate balance in focusing on patient care and entering the pertinent information into the computer in a timely manner, but it can be achieved. One of the biggest problems is that many physicians/clinic are not putting the best effort into the change over from paper charts to digital…and only doing it as they are dragged kicking and screaming. I am a nurse practitioner who researched, chose and implemented an electronic medical record in a small rural Free Clinic and now work as an EMR trainer in a 50+ physician internal medicine/specialty practice. I have seen that it is important to find the right record for you as a provider AND the type of support staff you have. Small clinics, that do not have an IT department should go with an ASP/Online based system to make it easier. Also, if the record is implemented properly, with patient information loaded on the front end of the process, you will find that it will indeed be easy to use and helpful. This is undoubtedly a labor intensive process initially, but well worth it in the end. In larger practices it is important to create an EMR committee that steers the clinic with these decisions. Too many clinics are using their fancy EMR programs as word-processing systems rather than taking advantage of the data-specific components of it.

    One of the biggest problems is that many of the products out there are not intuitive to medical practice and actually make it more difficult to chart, and produce horrible, hard to read records that indeed have way too much information. It’s important to build into the record some of the repetive information in the form of templates, to save time, as well as including a mechanism for you to be able to add pertinent patient-specific information.

  • Anonymous

    Kevin, re your statement : “There is no question that doctors should adopt digital records”, I could not disagree more. I feel the downsides are potentially huge and possibly unmanagable – particularly in securing privacy. We cannot safeguard personal and financial info like bank records and social security numbers, so why will this be safer?

    And where is the cost savings unless all the systems talk to each other?

    Another government agency of medical information technology is coming and it will not be small, efficient or friendly.

    I am very afraid of this.

    Peter, Eye MD

  • Anonymous

    Well I am glad there is an electronic record!

    More than once I have been at an appointment and wanted some clarification on my situation. Perhaps I’ve been reading up on it and wonder what my blah, blah, blah value was.

    Instead of getting a – I’ll get your old test and see what it said and get back to you – think about a hot place freezing over, I get, well let me see if I can bring that up — and more often than not it happens!

    We can review old tests and sequences and confidently move on knowing that the worst was ruled out a year or more ago and whatever I have is minor and can just be managed.

    I can go to a specialist referral and he/she can pull up my records. So it’s not a matter of me remembering what my situation really is, or of some courier getting the paper copies there and another clerk matching them up with me in the paper gown.

    As a mother of teens I’m used to people staring at keyboards or playing with phones while communicating with me. I don’t assume they aren’t listening. If I want eye contact and love I should get a dog!

    Overall I think electronic records are a plus, particularly for those with complicated situations.

  • Anonymous

    “There is no question that doctors should adopt digital records”

    I disagree with that as a blanket all-inclusive statement. I think that doctors, like all other professionals and businessmen, have to decide based on their own particular circumstances. I have worked with them and without them, with good ones and bad. I have seen the benefits and the costs, and I think that is some circumstances benefits outweigh the disadvantages, in others, not.

    Should a solo practitioner psychiatrist who sees private paying patients with primarily in psychotherapy who have a lot of privacy concerns and rarely significant medical complexity adopt an interoperable medical record? Almost certainly not. Few adavantages, lots of disadvantages.

    A PCP or medical specialist who is part of an integrated multisite system with a large volume of patients with complex issues and lots of referrals, consultants, and studies to track will likely make a different calculation if presented with a well designed and affordable system.

    Another PCP with a niche practice may still find paper more efficient.

    Like any other endeavor, if left to multiple free individuals to make independent decisions based on the facts of their particular situation the greatest net efficiency will emerge.

  • Anonymous

    As a patient, I don’t mind computers in the exam room as long as the doctor makes an effort to look at me more than the screen. The best ones won’t even look at the computer until I’m done speaking, giving their full attention to me in the mean time.

    Computer placement also seems to make a big impact on how well doctors seem to look at me. In most exam rooms, the computer sits on a table that’s pushed against the wall, so that when the doctor is using the computer they are facing the wall. This means that they have to make much effort to turn around and look at me. In the best situation I’ve come across, the screen was mounted to an arm that protruded from the wall. This allowed the screen to be placed in a location that made it easier to maintain eye contact with me. And of course, when done, the doctor can push the screen to the side and out of the way.

  • Anonymous

    It is hard to design a good EHR system, but once you’re spoiled with a good one, such as the one at Beth Israel Deaconess Medical Center, you’ll never go back.

    I always maintain eye contact with the patient because I dictate my note at the end of clinic or of each encounter. And if necessary, I can type without looking at the computer monitor or the keyboard.
    The home page of each patient provides a comprehensive overview of that patient’s medical history, which no paper chart could. I could glance at one single screen and know the patient’s home town, medical problems, current medications, name of primary care physician, previous medical visits, most recent labs and studies.
    I can have my own to-do list for each patient on that patient’s home page and have the option of making that list private or public. Patient A needs a colonoscopy by August; patient B’s repeat chest CT needs to be followed up on by the end of this month; patient C needs his A1C rechecked in three months, etc…
    I frequently pull up a patient’s radiology studies and share them with them. Here is where we think the pneumonia is. Look, here’s the rib fracture.
    I am required and happy to reconcile medications with each patient using a single click.
    I encourage all my patients to use Google Health to download their BIDMC medical record and share it with physicians from outside their system. For example, if patient A needs to move to California, she can download her Beth Israel medical record to Google Health, go see her new physician in San Francisco, open up her Google Health and say, “Doc, these are all my labs in the past 10 years.”
    There are many, many other advantages of the Beth Israel electronic medical record system that perhaps Dr. Armstrong-Coben does not have at Columbia. For example, from my iPhone while I’m in conference or walking down the street or even at home, I could pull up a patient’s chart, or put in an order, or page a consultant.

    So please don’t blame electronic medical records in general. They do not depersonalize medicine. The critics should at least check out the system we have at Beth Israel Deaconess Medical Center first.

  • Michael

    The best EMR’s I used allowed to to free type into the record. This really should be done for HPI’s, ROS, Exams…PMH and FH can be clicked on…

    Doing this gives you the best of both worlds. I always found those point and click boxes annoying anyways.

  • Chuck Brooks

    Distractions and excessive focus on a computer monitor is probably about the same as trying to quickly review a volumnous paper chart. In both cases, deciding on what to present is the hard part, and will vary considerably. It can be easier to do a drill down with a computer than with most paper charts, but the organization and presentation priorities will take some tailoring.
    Chuck Brooks
    FutureWare SCG

  • j.

    We have cured the problem by having MAs when rooming patients get certain pertinant facts that pertain to the Reason for Visit, go through Review of Systems, pull down allergies, family history, current medications and diagnosis codes that pertain with what the patient is here to discuss. Then the MAs discuss with Dr before going into room. While in the room the MA annotates EMR language while Dr does exam all the while paying close attention to patients. The only time physician is not looking at patient is when e-prescribing and/or looking at results, which is the same if they were hand writing scripts or looking at the paper chart. Visit notes are done most of the time same day as visit, and Dr/Patient satisfaction is great. When signing off of the chart the Dr reviews the note and makes sure all is noted properly before sending it to biller. This is truly “team” care with every team member contributing to the pateint’s care from the time they call in to the time they leave the visit.

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