The following is a reader take by Paul Ravetz.
Does the “Art of Medicine” really exist, or perhaps more importantly, can it do so in the computer age?
Computers are both the boon and the bane of medicine. Electronic medical records (EMRs) are excellent for retrieval of information about labs, medications, and past medical history of our patients. These records are much easier to access than our old paper charts. However, I feel that the Achilles Heel of these advances lies in the fact that physicians are so busy inputting information into their computers that they do not spend enough time communicating with the patient.
Communication with your patient is the epitome of the Art of Medicine. It is vital that physician and patient understand each other. This includes not only what the patient says but what they mean. This takes time, a commodity which is in short supply in the age of EMR. One should always remember a basic caveat about computers, which is, “garbage in, garbage out.” If wrong information is fed into the computer, it doesn’t matter what algorithm that you use because you will be following a false trail.
Computerization of medicine will lead to great advances if it is implemented properly. However, the way things are presently being done cheats the patient out of the most important part of the doctor patient relationship – time to communicate. I always remember the precept advanced by Sir William Osler, the father of modern medicine, “Listen carefully doctor, the patient is giving you the diagnosis.”
The combination of the computer age along with the time to listen to the patient and to accurately define their problem will indeed lead to a new age in medical care, but to ignore one or the other is not to fulfill our obligation to our patients.
Paul Ravetz is a family physician.
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Patients have complained to me many times that some physicians are so busy entering the data during a patient physician visit that the do not even look up. Physicians are usually late adopter of technology – and themselves have trouble managing their busy schedule and learning the new system simultaneously.
The introducion of EMR will lead to new sets of etiquettes during a patient visit.
I don’t think entering information into an electronic medical record has to take any more time than entering it into a paper chart. I have had problems at times with accessibility which have taken time away from patient encounters, because the program wouldn’t come up or I couldn’t log in, but otherwise, I type as fast as I hand write. I try to do the same things I do when I’m writing – look up to make eye contact, summarize what they’re telling me, and other efforts to let them know I’m listening as well as recording.
The benefits can be pretty significant. I’m still only a med student, but at institutions that still use paper charts, there have been patients that I only have information from some random nurse’s progress note, because it was legible. Lots of specialized physicians probably put some pretty essential information into the chart, but if it’s completely unreadable, it might as well have been thrown in the trash. Pretty sad.
I realize that many practices have successfully implemented EMRs. We have had one for several years now and they are all slightly different. Many of the core features are similar, though. The problem we have with the EMR is data input. The ability to retrieve information at your fingertips is great. However, with data input, there is a tendency to create “templates” for commonly seen diagnoses. When this happens, the note generation is quick but still has to be edited for the specifics of that patient. If the patient doesn’t have a diagnosis for which a template has been created, then you end up having to type in an entire note, essentially being your own transcriptionist. This is a waste.
I say all that to say that I have found that the best “hybrid” scenario is to use the electronic health record as a tool to quickly retrieve data but to still dictate notes and use a transcription service with fast turnaround and have that note scanned into the chart. This enables the physician to spend more time with the patient, do more complete notes and documentation. If we are relegated to assign patients to either “templatable” or “non-templatable” diagnoses, we are not doing what we trained to do.
I have read that EMR put to many items so physicians are too busy. Basic concept to make computer really help is making them as e-assistant, a system which doctors can ask for help like working with other medical personnel especially for information flow. Developing country like mine still have basic “silly” problem like late-adopter and not-yet-ready-to-type EMR, it’s better to let our conversation recorded and analyzed better after face-to-face meeting.
“These records are much easier to access than our old paper charts. ”
I would say that this claim is, at best, disputed. Have you been around when the system goes down? Or, heaven forbid, try to find useful information in the sea of data that is the EMR? Paper has advantages: among them, simplicity, reliability, maintenance costs, and ease of implementation.
I recognize the desire of some for EMRs, but that desire is far from universal. I would urge you to understand the reasons for reluctance to depart from a standard before you go about instituting a new standard. In doing so, you may increase your understanding of what is needed in that new standard.
Iffy issue. I do use an EMR, but patient’s routinely tell me I’m good at listening.
I think it’s an individual basis. Some docs are technophiles, and put that first. That ain’t right.
Some docs are so intent on listening, that they may forget a detail, and then it doesn’t get entered later. That can also lead to problems.
The key is a happy medium. Sometimes you just instinctively know when you shouldn’t be typing away.
I put routine info into the computer on the fly- like allergies, a medication list, etc.
But for their current story (why they are there) I try to keep good eye contact and listen. I have a notepad in front off me, and while listening scribble stuff down so I don’t forget details, while they talk. For some reason patients don’t object to jotting down notes while we’re talking, but would get irritated if I did the same on the computer. Maybe they assume I’m actually surfing or sending email.
EMR is only a small part of the problem, and can be overcome as more tech-savvy people become clinicians. What is more problematic is the increasing reliance upon tests over the word of the patient. Clinicians don’t know their patients, and they don’t see them long enough to get to know them. Yes, patients don’t report perfectly, but neither do tests.
HealthVault is one solution, which enables patients to send health information to the doctor. The Omron HEM-790 IT can connect to the computer, and can upload the data, enabling the doctor to track blood pressure more easily than during appointments.
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