How an EMR makes connecting with the patient more difficult

I have the great privilege of being a medical educator. Everyday, I have an incredible time working with  internal medicine residents at their continuity clinic, teaching the art of ambulatory medicine. Our working environment here is academically rich and fulfilling. The name of the legendary Dr. Martin Leibowitz (an iconic figure in ambulatory medicine here) stands outside our conference room as a constant reminder of how medicine is practiced and taught. There is a large oval table at the center of the conference room, constantly surrounded by venerable attendings, interspersed with curious residents, discussing all the difficult cases of the day. There is the constant buzz of organized chaos like a stock exchange that is addictive and keeps things fun and enjoyable.

Although this positive vibe has never changed, the working environment has transformed since I first joined in 2009. The conference table used to be littered with text books like Harrison’s, Netter and a variety of dermatology books. In between the people and books sat  heavy, tattered orange colored paper charts. Some were just a few pages, some hundreds, all documenting a litany of complaints, physical exam findings, test results, insurance documentation, medication lists and well thought out plans by generations past of neophyte doctors. Blue, black, red, green ink on yellow oxidized pages, all fascinating yet often illegible. My intrigue with these historical documents quickly faded, and the burden of having to flip through hundreds of abstruse pages became quite frustrating. The sight of these bright orange charts piled on my desk at the end of the day, became a nauseating reminder of the inefficiencies and dangers of paper documentation. Our electronic medical record (EMR), slated to be release 6 months after my start date, could not come soon enough.

When our  EMR era began, it was a cataclysmic event. The process of seeing a patient with the computerized elephant in the room was a culture shock for some the attendings and residents. But we integrated slowly, utilizing a light schedule, and a lot of one to one attention for our residents. In 2 years we overcame a lot of the initial technical problems and are on our way to making this a very successful transition. The hardest part of this change for me, had nothing to do with my personal battles with the EMR. Rather, the presence of the EMR created an entire new domain of education I have to provide for my trainees. In addition to medicine, I find myself teaching how to create macros or imbed digital pictures into the electronic record. I’m teaching how to incorporate a myriad of digital tools to better care our aging complex population. It’s become clear that my role as an educator goes beyond teaching classical medicine. It also involves teaching how medicine will be practiced in the future utilizing technology such as social media and an EMR. As an advocate for the advancement of technology in medical practice, I feel fortunate to have an audience of bright trainees to share my enthusiasm about the future of medicine.

But this technological leap in our practice has had a price. Although the placard of Dr. Leibowitz remains steadfast, the working environment has drastically changed. The conference table often sits empty, replaced by several desktops sitting at the periphery of the room. All the textbooks stand neatly stacked in a corner, collecting dust, as Google images replaces dermatology books, and online resources replaces most texts. The sound of vibrant debate and chart perusal has been replaced by the clicking and clacking of keyboards. Whereas in the past, 50% of my encounter time would be spent discussing each case, and the other 50% seeing the patient, my attention is split in three ways now. 33% each , for patient, trainee and EMR. Now I have less time to get to know and personally connect with each patient. Now there is less time to discuss medicine with my trainees. For new doctors, I wonder if its more important to spend a few extra minutes to discuss how to manage a COPD exacerbation in the outpatient setting, than it is to teach how to multi-click and renew 14 medicines using “E-scribe”. With this whole new domain to teach, given the same time constraints, I’ve had to bring home work quite often, which  is begrudgingly easier now with an electronic record.

Despite these difficulties, I continue to love my role as a medical educator. The day to day issues are minuscule compared to the greater problems in medicine and society. I continue to stay motivated by the idea that my tutelage in medicine and how it interfaces with modern technology will prepare them for a future that will need doctors that are comfortable and successful in the both the real and digital realms.

Shabbir Hossain is an internal medicine physician who blogs at  Shab’s Sanatorium.

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  • caduceusblogger

    Very interesting observations and very well written. I think one of the central problems of adapting to the EMR is just that, you must adapt to it. There is a misconception that computers will make life easier, and in many ways they do, but one must adapt how we take in and document information to the way the EMR does it and not the other way around. I think physicians (and patients) who are “trained” in an era where everything is electronic will have an easier time of it, as for us our whole system has been centered around a paper chart leading to difficulties.
    You also bring up an interesting point of teaching residents how to chart. It’s interesting because I don’t think that most residents in the paper era were every really taught this. They are taught WHAT to chart and the general SOAP note format, but not really HOW to chart. Thus every physician’s note looks different with different physicians and residents documenting labs and other data in different parts of their notes. EMR will help to some degree as hospitals and offices will have a uniform way of charting, however variability will still likely exist among different EMR systems themselves.

    • southerndoc1

      I disagree.

      Current EMRs are designed to facilitate data mining and to advance the financial interests of what Ms. Gur-Arie calls “the all powerful American Medical Industrial Complex.” Those who use EMRs for these purposes are finding them very efficient, and are not having to adapt in any way.

      What these EMRs were not designed for is to improve patient care in any meaningful way. No amount of adaptation on the part of physicians will change this, and EMRs will remain an obstacle that we need to work around in order to provide care to our patients.

      • http://twitter.com/PathcareNow Pathcare Now

        True
        There are 3   issues with the current generation of EHR/EMR systems.EHR (Electronic Health Records) systems address the business IT needs of government agencies, hospitals, organizations and medical practices, not the healthcare needs of patients.
        PHR (Personal Health Records) systems are not integrated with the doctor-patient workflow.
        EHR systems are built on natural language, not on patient-issue.EHR – Systems are focused on business IT, not patient healthEHR systems are enterprise software applications that serve the business IT elements of helthcare delivery for healthcare providers and insurance companies; things like reducing transcription costs, saving on regulatory documentation, electronic prescriptions and electronic record interchange.1This clearly does not have much to do with improving patient health and quality of life.EHR systems also store large volumes of information about diseases and symptoms in natural language, codified using standards like SNOMED-CT2. Codification is intended to serve as a standard for system interoperability and enable machine-readability and analysis of records, leading to improved diagnosis.However, it is impossible to achieve a meaningful machine diagnosis of natural language interview data that was uncertain to begin with, and not collected and validated using evidence-based methods3.PHR – does not improve the quality of communications with the doctorPHR (Personal Health Records) on the other are intended to help patients keep track of their personal health information. The definition of a PHR is still evolving. For some, it is a tool to view patient information in the EHR. Others have developed personal applications such as appointment scheduling and medication renewals. Some solutions such as Microsoft HealthVault and PatientsLikeMe allow data to be shared with other applications or specific people.See http://pathcareblog.com/healthcare-fashions-and-trends/

  • http://twitter.com/KarenSibertMD Karen Sibert MD

    I agree completely!

  • buzzkillersmith

    Yup, EHRs pretty much suck.  Nearly every doc and nurse knows this, as it is posted here and elsewhere incessantly. Do we really need more posts on this?

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    Having used EMRs in my practice for the last seven years and having just been challenged by switching from one system I loved ( MediNotes) to another I am getting used to ( All Scripts My Way) , I fully understand the challenges involved in adapting to EMR.  I do not understand why instruction in use of the fine points of the EMR has become the responsibility of Dr Hossain or any other teaching faculty. The discussion of each case should be the same as it was. There should be IT educators within the program teaching the EMR to the staff who have the responsibility to learn how to use it as a tool on their time not teaching rounds.  I expect the use of the EMR adds time and angst to all our patient contacts but should not change dramatically our evaluation and thought process on a patient. Yes it takes me longer. I admitted a patient to my local hospital ICU last night in acute renal failure with hyperkalemia and a severe bradyarrythmia requiring pacing. I still use the old hand written order sheets to organize my thoughts and be thorough and complete before I transfer my orders to the hospital computerized order entry system. It takes extra time but being able to read everyone’s orders without going through the angst of deciphering differing hand writing styles almost makes it worth it.  In my office setting , learning to touch type allows me to maintain eye contact and not appreciably change the doctor patient encounter.
    Maybe learning touch typing should be a new pre requisite for health care training. That plus requiring typing of notes rather than hand written notes might make future doctor patient encounters and teaching sessions easier and more traditional?

    • http://twitter.com/ShabbirHossain Shabbir Hossain

      I totally agree about touch typing. I think it’s an absolute must have skill, that doesn’t get talked about enough. Voice recognition/dictation software is really trying to alleviate the pressures of typing and talking to patients

  • MarylandMD

    It is truly sad to hear that medical educators are passively allowing the administration to dump EMR training duties on their backs, and thus take time away from patient care and student/resident education.  You would think that as physicians they would vigorously oppose such a clear degradation in their ability to provide quality care to the patients.

    Why doesn’t the medical school faculty have the wherewithal to advocate for better EMR training for the students/residents and for available IT staff to help with “teaching how to create macros or imbed digital pictures into the electronic record” and “teach how to multi-click and renew 14 medicines”?

    • http://twitter.com/ShabbirHossain Shabbir Hossain

      Our residents and faculty all got training. But no matter how many simulated sessions you go to, the real world is always different. The ebb and flow of a patient visit can take many different twists and turns when you throw in a 3rd party like an EMR. 

      Unfortunately, even in academia, the bottom line is still the all mighty dollar and it keeps getting stretched further and further (especially in primary care.) Corners have to be cut. After a designated amount of training, we were expected to simply run with this EMR, figure it out as we go along and keep seeing lots of patients , oh and by the way teach some of these kids how to be good doctors.

      Our IT department is great, but they can only hold our hands for so long.  

      • MarylandMD

        Again, I think it is sad that the teaching faculty at your institution have allowed their time for teaching and patient interaction to be cut by 1/3.  From what I gather by your response, it seems you have given up and accept that cut.  That is unfortunate.

  • katerinahurd

    Do you think EMR draws a line between technophobic and technophilic physicians?  Do you think that EMR is representative of a generational gap between older and younger physicians?  Finally, do you believe that EMR depersonalizs medicine, and thus, weakens the interaction between physicians and their patients?

    • http://twitter.com/ShabbirHossain Shabbir Hossain

      I think being “Technophobic” is a choice.EMR’s aren’t going anywhere, so their advantages have to be embraced. The generational gap is merely representative of the amount of time my generation has spent on computers (which is alot more). But as I alluded to in the post, even though younger doctors are more comfortable using computers, practicing medicine with an EMR is still a learned art that’s difficult for many of my technophile residents. I think “depersonalization” is relative. Geriatric patients still remember doctors who made house calls and stay over for dinner, whereas many more younger patients would consider doing a doctors visit over skype. I do believe many of my older patients feel the computers take away from the visit. 

      • katerinahurd

         Don’t you think that patients on multiple medications might appreciate EMR, since their records could more easily identify potential side effects of drug interactions.

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