Fighting the patient-computer attention war

I recently supervised a new intern as she conducted a patient interview. Following procedure, the intern reviewed the patient’s electronic medical record (EMR) and checked his lab results. She noticed that his cholesterol was high, and he told her that he had stopped taking his atorvastatin due to a recent trip to the Dominican Republic.

“It’s no problem,” my intern replied. “We’ll get you back on the medication.” She began to navigate through the online prescription ordering system.

“I had to go to Santo Domingo because my brother died,” the patient said, tearing up.

As she searched the computer screen for the right section to order a follow-up blood test, the intern reassured her patient not to worry; the medication would bring his cholesterol under better control.

Seeing that the patient was in distress, I stepped in. “Tell me about your brother.”

“He was my twin,” he replied.

The intern looked up from the computer screen, startled. “I’m so sorry,” she said.

It was clear to me that lack of compassion was not the issue in this intern’s “miss.” Rather, she was struggling with a problem familiar to more and more physicians practicing in the electronic age: the patient-computer attention war.

The EMR, an online patient information system, has greatly advanced the centralization and timeliness of patient information for physicians. Where once we sifted through paper charts and waited for specialists to call, we can now see test results, check other physicians’ notes and clear patients for surgery at the click of a mouse. Our ability to provide the right documentation to the right place instantaneously has improved, the communication between doctors and staff is much better and there’s a trail for everything. The benefits we have seen in a relatively short amount of time, including an 85 percent reduction in prescribing errors and significant improvements in transitioning care, are inarguable.

As a practicing physician who sees patients regularly in my outpatient practice, I appreciate the efficiency of the EMR. My patients particularly like that I have most, if not all, of their medical records at a glance, even those from doctor visits outside the Montefiore system.

This efficiency, however, seems to come at a cost to the doctor-patient relationship.

The design of most EMRs requires physicians to navigate through multiple templates while hundreds of items come across the screen requiring review, signature and follow-up. I have used our EMR system since its inception, and by now the documentation and test ordering have become second nature. Even so, I find that the EMR sometimes creates a barrier to the empathic presence I strive for with my patients. Even the peripheral awareness of a screen filled with action items creates distraction. As I routinely counsel new and training doctors on the importance of smiling, noticing interpersonal cues and asking screening questions to build authentic connections with their patients, I want to make sure I practice what I preach.

During a recent visit with my own physician, I noticed a marked change in the funny, compassionate man I’ve known for years. His sense of humor and ability to smile had become less spontaneous. His practice had recently switched over to the EMR system. I felt his pain, and wondered whether the electronic elephant in the room has challenged our ability to partner with our patients — the joy of our life’s work, for many of us.

I am proud to be part of an organization such as Einstein/Montefiore, where we are equally committed to leading-edge medical innovation and to continual quality improvement. We have pioneered meaningful use of the EMR, and I suspect that the issue of the doctor/patient disconnect is an inevitable “growing pain” that comes with blazing these trails. As evidenced by our myriad of quality-improvement initiatives, appropriate intervention and support can successfully overcome a host of obstacles in the advancement of medical care.

What those measures will be — whether adaptations to the online system, the hiring of specially trained scribes to assist during the patient interview or other measures — remains to be seen. I look forward to a future where both patients and physicians can reap the new and unfolding benefits of the EMR while preserving their ability to connect fully through meaningful communications.

Sharon Parish is an associate professor of clinical medicine, Albert Einstein College of Medicine. She blogs at The Doctor’s Tablet.

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  • buzzkillerjsmith

    “I look forward to a future where both patients and physicians can reap
    the new and unfolding benefits of the EMR while preserving their ability
    to connect fully through meaningful communications.”

    I look forward to the day when we event perpetual motion machines and evolve the ability to fly by flapping our arms. But I don’t expect to see that day soon.

    • buzzkillerjsmith

      invent, sorry

      • Deceased MD

        OMG another EHR error! LOL.

    • southerndoc1

      And I look forward to becoming a unicorn and farting rainbows.

      Another koolaid-drinking physician, supposedly trained scientifically, who wants to ignore evidence and experience, and base the future of medicine on hopes, dreams, and wishes.
      Just what big corporation health care wants.

      • SarahJ89

        Unicorns and farting rainbows. I totally LOVE it, wish I could like it 100 times.

      • Noni

        This post had me in the beginning as I thought we’d see a nice criticism of gov’t mandated intrusion into healthcare at the expense of the relationships we have with patients.

        Then the message became “EMRs are great! We’ll squeeze in a smile or a few seconds of eye contact. No big deal!”

        Depressing.

  • ssilverstein

    Where is the “inarguable” data that “the benefits we have seen in a relatively short amount of time,
    including an 85 percent reduction in prescribing errors and significant
    improvements in transitioning care”?

    Who has seen it? Are the gains portable and universal? Are there articles refuting such findings?

    The Institute of Medicine itself in its 2012 study of health IT safety (Google it) says the rates of EHR-induced harms are not known due to systematic impediments to knowledge diffusion, as does FDA. The ECRI Insitute reports 8 injures and 3 possible deaths from 171 health IT “glitches” in a 9 week study of 36 ECRI PSO member hospitals (Google “ECRI deep dive study of health IT safety”).

    Finally, many if not most medical malpractice may have nothing to do with documentation, paper or electronic, whatsoever. See http://hcrenewal.blogspot.com/2010/12/is-healthcare-it-solution-to-wrong.html

    I’m tired of grandiose claims about IT glibly or unscientifically made. Critical thinking always – or your patient’s dead.

  • ssilverstein

    Where is the “inarguable” data that “the benefits we have seen in a relatively short amount of time,
    including an 85 percent reduction in prescribing errors and significant
    improvements in transitioning care”?

    Who has seen it? Are the gains portable and universal? Are there articles refuting such findings?

    The
    Institute of Medicine itself in its 2012 study of health IT safety
    (Google it) says the rates of EHR-induced harms are not known due to
    systematic impediments to knowledge diffusion, as does FDA. The ECRI
    Insitute reports 8 injures and 3 possible deaths from 171 health IT
    “glitches” in a 9 week study of 36 ECRI PSO member hospitals (Google
    “ECRI deep dive study of health IT safety”).

    Finally, many if not
    most medical malpractice may have nothing to do with documentation,
    paper or electronic, whatsoever. Google “Is Healthcare IT a Solution to the Wrong Problem?” and see the HC Renewal blog post that references the article “Temporal Trends in Rates of Patient Harm Resulting from Medical Care”, Landrigan N Engl J Med 363;22.

    I’m tired of grandiose claims about IT glibly or unscientifically made. Critical thinking always – or your patient’s dead.

    • SarahJ89

      EMR means you now get to know waay more about the top of your doctor’s head than you ever want to. It also means any misdiagnoses will follow you to your grave.

  • SarahJ89

    EMR has destroyed my relationship with my doctor. It’s nothing but a data-mining tool that usurps his attention and violates my privacy. I no longer tell my doctor anything.

    • Deceased MD

      i can see why. When you don’t actually know where the data is going. Ironically it sounds like you feel there is no privacy. And ironically the same law protecting your privacy is also violating your privacy.

    • azmd

      I agree, but would like to point out that insurance companies have been selling our health information to marketers for much longer than there have been EMRs.

      Sixteen years ago, I was startled to start receiving a large volume of junk mail marketing baby products, a month after my first prenatal visit to my obstetrician. Clearly my insurance company had immediately sold my address to a mailing list for pregnant women.

  • Deceased MD

    Unfortunately at the moment I think we are in it.