Unintended consequences of standardizing physician practice

Turns out there is an unintended consequence of many of the current efforts to standardize the way doctor’s practice medicine.  It is called de-skilling.  De-skilling can occur when physicians and other providers try to adapt to standardized, new ways of doing things.  Examples of such standardization include clinical based care guidelines, electronic medical records (EMRs), pay for performance (P4P), patient centered medical home (PCMH) requirements and so on.

Examples of physician de-skilling were revealed in a recent study which consisted of in-depth interviews with 78 primary care physicians regarding EMR use.  EMRs are all about standardization – what data is captured and recorded, how data is reported, how data is used, and so on.

Over the course of the interviews, physicians in the study described significant examples of de-skilling behavior.  Most indicated  that valuable patient information was being lost given how physicians adapted to using the EMR.  Why?  The physicians believed that the EMR forced them to change how they “fed their clinical thought processes into a patient’s record.”

The majority of PCPs interviewed reported situations where they or specialists “cut and paste the same exact language and statements, sometimes consisting of entire narratives across different patient records” where patients had the same condition (usually a chronic condition):

The net result was that PCPs believed they were increasingly getting less patient-specific information from specialists via the EMR which hindered their ability to make informed decisions around diagnosis and treatment.

According to these same physicians, this situation did not happen with paper records.  That is because paper records forced clinicians to dictate a certain amount of unique verbiage for transcription into a patient’s record:

Time pressures also contribute to physician de-skilling relative to EMRs.  Most EMR systems use templates that physicians must modify for each patient.  Physicians in the study complained that there wasn’t enough time to edited the EMR templates and then enter the proper patient information.  The conclusion, according to researchers, was that “some of the docs just do the bare minimum in terms of putting stuff into the EMR. When you read what’s in the record you’re kind of like, what is this?’’

In other words, some physicians simply didn’t bother to tailor EMR templates to the needs of the patient choosing instead to simply get through the standardized template.

The bottom line is that physician de-skilling has serious implications for patient outcomes and quality of care.

Patients need to be aware of and protect themselves from instances of physician de-skilling.  How can patient do that? The best way is to ask your doctor to review the patient notes section of your electronic patient record to see what you doctor entered about your condition.  Is what your doctor entered accurate? Is it complete? Given that others providers will be relying on the quality of your record for treatment decisions, this is something that everyone, patient and physician, need to be aware of.

Steve Wilkins is a former hospital executive and consumer health behavior researcher who blogs at Mind The Gap.

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  • Anonymous

    This is a critical point but unfortunately the control that the government has on issues like billing and cost reduction trump good patient care.  Very few methods and procedures in medicine have true strict evidence to support them which is why the art of medicine is as important as the science.

    EMR’s must has free form sections for the clinicians opinion to be noted loud and clear,  Otherwise these notes have no use.

    Thank you for this important article.

  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    Great article! I loved this. I believe that the Art of Medicine has been completed muted from the exam room as doctors scurry through handing out prescriptions. This makes sense that using EMRs shape the behavior of doctors. I use an EMR but I free type the subjective and plan portions. The Objective and Assessment portions can be templated much more easily, but the conversation between me and my patients can never be templated. The loss of connection between doctors and patients is destroying medicine and the use of EMRs in this standardized way is contributing to that. Thanks so much.

  • http://twitter.com/livewellthy Stewart Segal

    As protocols and EMR drive behavior, modern medicine loses it heart and soul.  The “Art of Practicing Medicine”  is dying at the hands of “Evidence Based Medicine”, guidelines and the background drone of key strokes and mouse clicks.  I fear that “quality care” and “outcomes” will be measured by the “Art of Practicing Template Medicine!”

  • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

    Medicine is a wonderful career when it involves creativity, constant learning and innovation and ample room for individual growth. Medicine is a horrible career when you clock-in, clock-out, follow the cookbook, do things according to protocol instead of common sense, focus on filling out paperwork more than on communicating with the patients. It makes sense why doctors in some specialites love what they’re doing and doctors in other specialities feel jaded and burnt out.

  • http://pulse.yahoo.com/_VM5ZKYTEEAO4KZZG23W3HL2ERQ marc

    This is just a rant against poorly designed EMR systems and not about deskilling. There are all sorts of ways of digitally capturing rich patient records that will hopefully consign paper records to the dustbin of history (and also handwritten scrips – which kill rather a lot fo people). 

  • Anonymous

    This is just another version of “the computer says NO”. Physicians are not obliged to abdicate their skills and put the demands of an EMR system ahead of their patients’ interests. I agree with marc, physicians should demand a redesign of the system if they regard it as inadequate.
     As for the argument against evidence based medicine  maybe Stewart wishes to revert to quackery?! I am sorry to be sarcastic but I fear this retreat from enlightenment thinking and rationalism towards unsubstantiated mysticism.

  • Anonymous

    Excellent article….as an RN with an IT background as a business analyst in the field of disease management and wellness, I have seen this same issue affect nursing care.  In my past experiences with helping create, maintain and test a nursing clinical application used by a major telehealth corporation, the nurses were constantly requesting more free text fields.  Dropdowns and checkboxes never did justice to the living, breathing human being on the other end of the line.  Unfortunately, all the client (insurance companies) was interested in were those fields that supported clinical outcomes and reducing the bottom line.   I have since left the IT field and gone back to hands-on nursing.

  • Anonymous

    From “The Guardian,” Sept. 21:

    The £12.7bn National Programme for IT is being ended after years of delays, technical difficulties, contractual disputes and rising costs.

  • Anonymous

    Interesting thoughts. Of course, I would conversely wonder how many physicians using “old fashioned” paper charting might also be shown to have fallen into habits of entering a certain minimum amount of information or use standardize language to describe a patient’s H and P
    A significant issue of how some physicians are interacting with the new EMR’s is to sit and ask questions of the patient, enter responses…and rarely if ever look up a the patient. Is the patient blushing at a question, avoidant or detectably lying, visibly bothered…”human interaction and assessment skills that should be present int he exam room.
     I am strongly in favor of EMR, but they are a new tool that physicians need to be taught how to use.
    For patients to assume responsibility for their own health care, pathway decisions, and medical record information, they also need to be taught how to do this effectively.

  • Anonymous

    There are many physician’s who have taken the time to ensure EMR templates are tailored to their specialty by spending the resources to develop logic based formats. If you leave the HPI, Assessment, and Plan sections as free text fields, then you are able to individualize the office note while demonstrating clinical decisionmaking. Each physician can then utilize speech recognition or the services of a scribe during or after the encounter, thereby ensuring great physician to patient interaction.

    • Anonymous

      Hiring a full-time scribe for each physician is one of the most dramatic cost savings brought about by EMRs.

      • http://www.facebook.com/people/Holly-Johnston/1070647546 Holly Johnston

        however, in reality, how many have full time scribes? We have had 2 department based scribes who have been threatened to be taken from us as we transition in to a different EMR. Our facility also was reluctant to use speech recognition for some of the process, thereby delaying the process even more. They were headed to decreasing face to face encounters so that MD can complete and close the chart during clinic.

        • Anonymous

          Seems like a full time doc would need a full time scribe to make it work, but that would be way too expensive for most practices.  The basic problem is there’s no efficient way to get the data into the EMR yet. 

  • Anonymous

    Once again: mission drift. And we bit. 

  • Anonymous

    Utilizing scribes enables real time dictation at a fraction of the cost of medical transcription. We are able to send letters to our referring physicians within hours. Our practice has been fortunate enough to use speech language pathology grad students as scribes, keen language skills & medical terminology. We are 5 years into our EMR & would never go back!

  • http://twitter.com/TheUnorthodoc Doc Cory

    great post!

    These days, being reimbursed by a third party (commercial or governmental) requires translating incredibly complex medical thought and human interaction into binary symbols that a computer can easily say “yes” or “no” to. When the computer is unable to make that distinction, the rejected claim lands in the hands of a human to decide, but it is guaranteed that person is not a doctor. We have a binary choice…grasp this language and become fluent enough in it to persuade our “listener,” be it computer or claims processor …OR…stop being paid through this system and negotiate directly with our patients for payment. Understand, however, that our patients, their computers and mobile devices are coming to expect us to move our language in this direction, too. However we deal with our patients now, we don’t have far to go before we bump into the need to interpret and communicate in this binary language again…think about simply needing to attach a diagnosis ICD-9 code to a lab requisition and you are back at square one.

    Unfortunately our patients need us to understand not only the complex art and science of medicine but the complex art and science of the information age. We’re as much their advocates in the one realm as the other. Physicians who opted to remain privately owned in the ’90′s grasped that the only way to do that was get their hands dirty with this new language. Remaining in charge of our own destiny still requires that. This is not “de-skilling,” its “re-skilling” and we need to reward the IT companies that find make that easy for both us and our patients.

  • andy hunt

    Only way the EMR works with template-driven exam is with a scribe.    Most docs do not have time to do this if they are seeing more than 20 patients/day without spending all night doing their notes.    If they do get this done, their notes suck and and are unhelpful.     To pay for a scribe is the only real solution short of having a dictated note scanned into the system.   
    As it is right now,   a template driven EMR note is a treasure-trove for malpractice attorneys and frankly, useless to other providers.   I am sure it is great for hospital admistrators and insurance companies in capturing charges.

  • Anonymous

    All true, and more sad testimony to the tightening grasp of management on the profession and money on its soul.  I use EMRs but paste my own notes and reports in my own format and language, drawing the occasional compliment but little emulation from the docile mainstream.  One should not become part of the problem, even if one must suffer it.

    Quoting Tennyson’s Ulysses:

    Tho’ much is taken, much abides; and tho’

      We are not now that
    strength which in old days

      Moved earth and
    heaven; that which we are, we are;

      One equal temper of
    heroic hearts,

      Made weak by time
    and fate, but strong in will

      To strive, to seek,
    to find, and not to yield.


  • Susan Root

    If this is an acceptable (if not mandatory) way to document an encounter, what is the role of the physician?

    • Anonymous

      What is the role of the physician?  Isn’t the primary role of any business model to maximize profits?

      • http://www.facebook.com/people/Terence-Ivfmd-Lee/1523282856 Terence Ivfmd Lee

        The concept of maximizing profits is not ethical UNLESS the paying party is doing so VOLUNTARILY and sending a message to the provider that “Yes, what you do for me gives me value so that I’d be willing to pay X-amount for it.

  • Susan Root

    What is the role of the physician?  If this type of documentation is acceptable, a computer could do the entire encounter and its documentation, with no human physician intervention needed!

    • Anonymous

      What makes anyone think that one-on-one advice from a physician is any better or worse than advice from a reputable medical web site. Let’s face it, health care delivery in America has failed about one-quarter of the population because at least 75 million Americans are uninsured or underinsured and can’t participate. Maybe computer assisted primary health care that’s delivered in a network of low cost neighborhood health clinics that are staffed by nursing professionals is better than no health care at all?

  • Jim Jaffe

    compelling argument.  equally so for ripping out autopilots on aircraft because pilots tend to rely on them and allow some of their skills to atrophy.  the role of the physician is changing and the challenge here is to assure that this is change for the better from the patient’s perspective.  as physicians become more specialized, their range of skills inevitably decreases.  this is the basis for the rhetoric about the loss of primary care physicians.  

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