Electronic medical records worsen patient communication

Electronic medical records are becoming more prevalent in physician offices nationwide, but patient communication is being disrupted by the computer in the room.

An excellent piece by the New York Times’ Pauline Chen outlines the problem.

Calling it an “unforeseen consequence” — I quibble with whether this was truly unforeseen — Dr. Chen notes that, although electronic medical records promise efficiency, in reality, they hamper communication:

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.

That’s a scenario replicated thousands of times across the country daily.

To solve the problem, I do what Dr. Chen does, which is to “memorize and jot down quick notes when necessary, then leave the room to type everything into the computer.” That way, I’m able to maintain eye contact with patients, instead of sharing it with the computer screen.

A poor user interface that plagues the majority of electronic medical record systems is to blame. Streamline the bells and whistles, de-emphasize the importance of capturing insurance billing information, and focus on easing the physician’s workflow. Only then will patients truly benefit from the digital record.

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  • Regina Holliday

    This sounds like poor room design instead of a problem with electronic records. Any time we make a change in technology we need to re-evaluate the space and adjust accordingly.

  • Rhonda Palmer

    Why not envision an i-Pad like interface, and let the patient enter his/her own comments about symptoms. Why must it always be filtered through the clinician?

  • Max

    Totally agree with this article. With EMR, a bulky computer in any exam room hinders communication. A laptop hinders communication. An ipad perhaps would be least intrusive. It is repeated daily in thousands of exam rooms. And then the e-RX continues it with the back to the patient. So rude and all in the name of ‘accurate’ record keeping or more likely, how to upcode. Isn’t EMR wonderful? Sure it will ‘save’ money, just ask a few more questions and get a level 5.

  • http://www.consentcare.com Martin Young

    See my post on this topic on KevinMD at http://www.kevinmd.com/blog/2010/01/touchscreen-computers-future-electronic-medical-records.html

    Why don’t we keep what is familiar to us, i.e. the pen, but do it all digitally? Slate PC’s and touchscreens really are the way to go!!

  • R Watkins

    When using an EMR, the physician is forced to engage with it in a demanding, labor-intensive (physical and mental) conversation: drug interactions, recommended health maintenance, template completion, pre-auths, best practice guidelines, and on and on. A good physician will allow the patient to make an occasional contribution to the dialogue, but the doc is there primarily to serve the needs of the EMR.

  • http://distractible.org Rob

    No! Documenting the visit is the problem regardless of the medium. I’ve seen plenty of docs pouring over paper records and not talking to the patient. We have the exam room set-up so we are looking at the patient and I can type while not looking at my fingers, so I take a history while maintaining eye contact (which I can’t do with a pen and paper). Documenting medicine does detract, but so does searching for lost data (which is far less likely on the EMR). This is a classic case of “PICNIC” (Problem In Chair Not In Computer).

    • Max

      And you don’t feel like a court reporter doing that? I sure would.

  • http://www.diabetesdaily.com/blogs/fadingtogray Christine

    One of the things I’ve found, with electronic charting, is that now, as an RN, interdisciplinary members of our team often have no idea where to find my charting. MDs, NPs, PT, OT, and pharmacy are all still writing in the paper chart, while RNs, RT, and skin care are all charting in the computer. The result? I’ll have an MD or NP come to me and ask me if I observed something or the patient brought up some issue with me. I’ll reply that I wrote a detailed note on the issue. They’ll tell me they have no idea how to find it. Very frustrating for all involved.

  • alex

    Arrghh. How can they write an entire article about this without criticizing the Medicare documentation requirements? Most of the reason it’s so god-awful is the requirement that you document a bunch of crap that may be totally irrelevant to your patient just because Medicare says you need to document it. IT’S COMPLETELY WASTED EFFORT. Thousands of doctors across this country at this moment are wasting hours of their and their patients time doing an activity that has literally NO BENEFIT except that a CMS bureaucrat decided writing about it should be part of every patient encounter.

    • R Watkins

      “Medicare documentation requirements”

      I assume you’re referring to the AMA’s proprietary CPT coding guidelines that they license to the tune of $70 million annually?

      • alex

        Did the AMA come up with the guidelines for distinguishing Level 1 from Level 2 visits, etc or did CMS? If the former, another thing to blame them for, although CMS certainly doesn’t have to engage the jackbooted audits with the threat of massive fines as they do.

        People seem to think doctors love the AMA, but the reality is they are largely driven by a Washington-ized professional bureaucracy that is far more interested in scratching each others backs than representing any interest of doctors. Hence the 75% of US doctors that don’t belong.

  • http://www.consentcare.com Martin Young

    Rob, you are the exception, not the rule!

    I know very few doctors who can touch type!!

  • http://healthymagination.com Healthymagination

    Interesting post. Electronic medical records hold a lot of promise for the future, especially in their ability to streamline information processing. But they have a downside. Digital documenting runs the risk of hampering patient-doctor communications and overlooking important details. Technology can’t be viewed in isolation. Doctors should personalize information by complimenting electronic communications with face-to-face interactions. We talked about this in a recent blog post as well: http://www.healthymagination.com/blog/digital-healthcare-rethinking-the-paperless-hospital/

  • http://www.notebookingdiscovery.org/wordpress Alice Robertson

    When I went to a Minute Clinic you sign-in with all your insurance information via the computer, and your symptoms, comments, etc. The nurse practioner then scanned your insurance card and added some notes about the planned treatment. It was quick and efficient (much more efficient than the list of questions she would have needed to check off, or typing in symptoms. The patient had already did this part of the chore, and if there is an error the patient did it). Most patients are capable of typing in their own symptoms, so a large majority of the patients seem to know themselves and their keyboard well enough to do this by independently (there will be a small majority that can’t, but overall most can). I believe the notes were then sent to my physician electronically and added to my file. When used properly, and allowing the patient more control, about content, and symptoms, this can be an asset to the patient and the doctor.

    You may have read recently about the hospital that opened the complete electronic medical files to the patients and some were not happy about the personal anecdotes added by doctors (i.e. saying a patient was grumpy, or hard to work with). These notes are understandable, but they may become a thing of the past.

    Patients are taking more control and that’s a strength and weakness. With the internet we are all genuises, so it will add to a doctor’s workload when they are forced to debate false information (and proving it’s wrong with a patient whose mind is settled has the potential for some Monty Python moments, or at least teeth-grinding. A doctor wrote in Time magazine about “punting” on a new patient when she declared herself the Queen of Google and even knew his address and traffic patterns on the highway he took home. I believe he sent her to a colleague he couldn’t stand?).

    But, overall, allowing the patient to take some of the workload and fill in forms is a good thing that will be time efficient (I wish I could order my order my own food electronically instead of the waiter trying to mentally get the order right w/o writing it down). Empowering the patient will overall be a good thing, although, I tend to think it will be frustrating. In this era of time being everything in corporate medicine this could be a time saver if most of the paperwork is filled in electronically before the patient/doctor enters the room.

  • http://applied-infosystems.com Robert Wieseneck

    I’ve noticed my doctor uncomfortable with a computer. You could take notes on paper forms or with a tablet computer if that makes you more at ease.

  • http://www.consentcare.com Martin Young

    Speech recognition works well for some UNLESS you have a stutter (as I have) or a funny accent (as you may think I have.)

    Also the software appears to be written with the American accent in mind.

    Medical terms are also a problem. The user still has to check and correct everything he has spoken for medicolegal reasons.

    So, good for some, but not perfect!!

  • http://Www.heartlandclinic.org/plattecity David Voran

    Illistrates the importance of the patient-physician-computer triangle where both the patient and the physician are looking at the INFORMATION on the screen, sitting at eye-level with each other and maintaining eye contact during conversation and exam.
    In this manner both participate in the encounter note and agree that the right information is recorded.
    Takes a little practice but in the same manner we see in grocery store check outs both the clerk and the purchaser have the opportunity to validate a transaction.
    When the old paper chart is for physician only approach is taken bad things happen.

  • Rand Ragusa

    Why write or type when interacting with a patient when technology exist that allows doctors to leverage voice recognition to document patient data? Speech translated into text as come a long way – & the results, though they may not be perfect, give the doctor & support staff the unique ability go back & relisten to clarify. Today doctors waste valuable time (2-3 hrs per day) away from direct patient care doing manual writing & data entry = wasted $ and one of the primary reasons we have a broken healthcare delivery system in America.

    • http://www.heartlandclinic.org/plattecity David Voran

      Why not talk? First, the accuracy (even at 95%) isn’t good enough, it interrupts the conversation with the patient since you can’t record a note AND listen or talk to the patients whereas it’s easier to work with hands and fingers while listening.
      Our note-taking is completed in the exam room before the patient leaves, may add a couple of minutes to each visit that we’re finding improves patient compliance and understanding and then is available to others (including the patient through the we portal immediately.
      In short, changing workflow to parallel processing increases productivity. Dictation (no matter how it’s transcribed) is a linear process and is non-productive.
      Would we all like to eliminate the details we are forced to document for reimbursement? Of course. But in order to do this we need to accept a different payment system. I’m not sure most physicians are ready for that disruption.

      • Rand Ragusa

        In the future, I hope medical voice recognition software vendors will avoid “interrupting the conversation with the patient” by allowing you to record a note AND listen or talk to the patients seamlessly – so that at the end of the encounter, you don’t have to write/type anything – it’s already written out for you. Then it’s a simple click & submit & you’re done vs. jotting down notes & then entering them into the computer. Writing + data entry = the old way. And the old way of doing things is the problem, not the solution.

  • Elizabeth

    Electronic Medical Records are here to stay – it is the only way. Unfortunately, the idea of “choice” in everything in the US permeates into EMR, where standardization is sorely needed for optimal patient care, i.e. each plan or institution or doctor’s office will have different forms, regulations etc.and each computer company wants a piece of the American money pie, hence different software. Where EMS has been in place for some time in large medical institutions – everyone benefits. However, even in such places there is still a high ratio of clerical personnel to doctors.

    Such standardization of EMR already exists – i.e. France as described in T.R. Reids book – The Healing of America – 2009. One card for everyone – NO paper records, no near for clerical assistance, just the doc and the patient, immediate access to info. I am only talking about EMS here. Regardless of how you feel about their “healthcare system” and how it is paid for, and what medical personnel “earn”, Their EMS is a world model that we could learn from.

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