Electronic medical records obstruct patient interaction

A version of column was published in USA Today on January 19, 2014.

Over half of physicians today use electronic medical records, thanks to the federal government spending more than $22 billion dollars incentivizing providers to transition away from paper charts.  Supporters of digital records, including President Obama, say they improve patient care and reduce health costs.  Having navigated a transition from paper charts to electronic records in my own practice, I wonder whether those claims are really true.

I’m not alone in feeling this way.  A Rand Corp. survey released last fall found that many doctors were unhappy with their digital record systems, saying they interfered with face-to-face patient interaction.  During the initial phase of my conversion to electronic charts, some patients commented that I often spent more time typing on a computer instead of talking to them. I no longer bring a laptop in the exam room because of that feedback.

Relative to intuitive touch-based smartphones and tablets commonly used today, electronic medical records are generally antiquated programs that are cumbersome to use.  Most force providers to spend more time than ever staring at a computer screen and clicking checkboxes with a mouse to satisfy onerous billing and administrative requirements that do little to help patients. For instance, it takes me over 50 mouse clicks, all while scrolling through dozens of screens, to document a straightforward office visit for a sinus infection.  Refilling a single prescription electronically, which I do over a hundred times a day, takes over 10 clicks.

In fact, more time in front of computers means less time for patients.  An American Journal of Emergency Medicine study found that emergency physicians spent 43% of their time entering data into a computer, compared to only 28% of their time spent talking to patients.  During a typical 10-hour shift, a doctor would click a mouse almost 4000 times.

Doctors in training have it worse.  Researchers at Johns Hopkins University School of Medicine found that medical interns spent just 12% of their time talking to patients, or about 8 minutes a day per patient, but more than 40% of their time on a computer filling out electronic paperwork.

Such hurried interactions not only impede medical education for trainees, but also have real world consequences, such as diminishing patient satisfaction and increasing the rate of medication prescriptions.

And what about the promised cost savings?  Such assertions were largely based on a 2005 Rand Corp. analysis which predicted that electronic records would save $81 billion annually.  Last year however, Rand backtracked, saying those numbers were overstated.

More recently, a January 2014 report by the Office of the Inspector General warned that electronic medical records could even contribute to Medicare fraud, by making it easier for providers to duplicate documentation and make it appear that they performed more services than they actually did.

To be fair, the transition to electronic medical records has had some successes, most notably, a reduction of medication errors. And I’m not advocating a return to paper charts. But let’s curb the enthusiasm for electronic medical records. Today’s systems too often obstruct medical care, and threaten to monopolize providers’ time at the expense of talking to patients.  Until they evolve so that direct patient contact isn’t compromised, the true potential of electronic medical records will remain unrealized.

Electronic medical records obstruct patient interactionKevin Pho is an internal medicine physician and co-author of Establishing, Managing, and Protecting Your Online Reputation: A Social Media Guide for Physicians and Medical Practices. He is on the editorial board of contributors, USA Today, and is founder and editor, KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • jimmyquin

    Great column. Thank you for educating the public on the reality of how EMRs currently work. Do you think the problem is the billing requirements that EMRs have to accommodate or that the design is not just not good enough yet?

    • buzzkillersmith

      Design not good enough, maybe it never will be–unless we can dictate the concise notes we used to and have the EHR automatically put the diagnosis and the billing code in and so on.

      The problem is that physicians should not be entering text data. It is a waste of our time and a morale killer.

      Some docs are using scribes to document. There was a recent NY Times article on this. It takes about 20 days to train a scribe, at least according to the article, and it takes a minimum of 7 years after college to train a physician.

      Why doesn’t every doc have a scribe? Costs too much for small practices, at least for some. And docs who are employed by CorpMed simply have to stay around a couple extra hours and input the data. They’re on salary, so CorpMed doesn’t care.

      The article noted wryly that in most industries computerization leads to increased efficiency whereas in medicine it needs another person in the room.

      • LeoHolmMD

        Can you reference that article? Good point.

        • doc99

          More Docs Get EHR Help
          http://www.modernhealthcare.com/article/20130824/MAGAZINE/308249958

          Hospitalist Marek Filipiuk is working the room like a master of the bedside manner. His smiling audience is a hospitalized 70-year-old female patient who’d been admitted through the emergency department the night before with respiratory problems.

          An electronic health-record system is documenting the encounter, but the doctor never touches a computer.

          Dr. Filipiuk is free to focus on questioning his patient and listening to her without distraction, because his hands and mind are free from typing into the EHR. Matt Restko, a medical scribe who is positioned across the room, laptop perched on a window ledge, is doing the computer entry work for him.

          Filipiuk is a member of Best Practices Inpatient Care, a 65-provider hospitalist group in Long Grove, Ill. He is rounding this day at Advocate Good Shepherd Hospital near the Chicago suburb of Barrington, Ill., part of the nine-hospital Advocate Health Care system based in Downers Grove, Ill. Filipiuk’s group uses scribes at two Advocate hospitals. Restko, 27, is a University of Iowa graduate with a degree in biochemistry. He’s an employee of ScribeAmerica, Aventura, Fla., a provider of scribe services that has contracted with Filipiuk’s group.

          Their collaboration exemplifies the migration of scribes from their initial beachhead in hospital emergency departments into hospital medical wards and office-based physician practices.

          More at the link.

        • buzzkillersmith

          I’m really bad at that, sorry. But you’ll find it if you google nytimes medical scribes.

  • Ron Smith

    Hi, Kevin.

    Good article. Here are some thoughts (though not brief). It will be important to know that I’ve been a Pediatrician for thirty years and I’ve been a database programmer for that length of time also.

    Re: “To be fair, the transition to electronic medical records has had some successes, most notably, a reduction of medication errors. And I’m not advocating a return to paper charts. But let’s curb the enthusiasm for electronic medical records. Today’s systems too often obstruct medical care, and threaten to monopolize providers’ time at the expense of talking to patients. Until they evolve so that direct patient contact isn’t compromised, the true potential of electronic medical records will remain unrealized.”

    I deployed my current EMR in 2000 and it has been updated and improved greatly over the years. It is a complete solution managing everything from managing credit payment, claims and EOB procession, vaccine administration and stocks with sophisticated bar coding, and all the usual EMR functions.

    There are several things that are different I think about my interface that highlight the difference between what I consider good EMRs and bad EMRs.

    First is that I use the standard H&P format for all exams. That doesn’t mean that every field needs to be filled out, but one interface gives you a complete range to cover everything that you need to say about the exam.

    Each discrete (that mens you have a specific field such as for the left ear) has a list of choices that popup for each specific physician and for a specific template choice. So for example, if I had specific things to say about a well-child exam in the early teen years, I could choose that choice list template.

    I don’t have to go through every discrete field. I only pick the abnormals and the specific choice I want. So if there is a normal left ear with a PE tube in place, I can pick that for the left ear field. I can alter, or add to it, or even put in something that is not on the choice list.

    All the things that I don’t pick get the normals inserted automatically. This is called a negative finding fill-in. This is very fast. When I’m seeing a patient, I can quickly make the correct entries in the exam items that have positive findings.

    The key to the speed is to avoid checkboxes. Choice lists are far superior in my opinion.

    But the really muscle behind the choice list is having the multiple templates of choice lists. I have about 5 or 6 choice list templates. I go though one time per template and create the choice lists for each discrete field in the H&P. Each template of course has its name and each exam as I said can use any one of the templates to do the negative fill-in.

    Each provider creates their own fully customized template selections and choice lists. This takes about 30 minutes or longer if you are as obsessive compulsive as I am about them.

    The time savings are tremendous!

    But the EMR is more than even that. It is a communications tool. At the end of a checkup for example, while in the patient’s chart I simply click the screen button that notifies the nurse assigned to that patient that they are ready for shots. I don’t go looking for her, but trek on to the next patient. I have multiple communications shortcuts built in to the EMR like this.

    There’s much more, but not enough time or space to discuss. The second thing that is so important is that the entire office flow and function is mated to the design of the EMR. This is why canned software is so pitifully inefficient. Our software is designed around carefully thought out patient and care flows and not the other way around.

    This is the part that is so disappointing to docs I think, even if the interface is satisfactory to them. EMRs will not do much to make poor patient and care flows better. These must be addressed primarily. I’ve heard of practices paying $100,000 plus for a system only to scrap the entire thing three months into deployment!

    Now the last thing I think is probably the most important thing to say. Physicians have to remember to get their noses out of the computer screen! I generally am not picking choices of things as I’m talking to a patient. I’m talking to the patient focused on understanding every thing I need to clinically. Granted that after thirty years, I’m pretty efficient at drilling down to the information I really need to treat a patient, but I don’t let the computer drive the examination.

    I may refer to it especially when I am trying to show parents a growth chart or checking an old scanned in paper document from a fax. But I try to immediately put this away until I’m ready to do prescriptions. Everything is sent to pharmacies by fax while the patient watches. Occasionally I will need to get information from their pharmacy. That is part of their chart and a push of another button, I’m Skyping a call and talking to their pharmacy in the exam room with the patient listening.

    This is not only helpful, but patients sort of get the feeling that this is the way it should be.

    So to recount my recommendations:

    1. Use choice lists with negatives filled in and develop specific templates for the type of examinations you are doing.

    2. Develop efficient patient and care flows in the office. Think outside of the traditional one nurse per one physician staffing. You’re going to need more than that. A top notch practice manager (not just an office manager) is best for me personally.

    3. Physicians need to focus on the patient and keep their nose out of the screen. Try to always speak face to face until you’ve formulated your conclusions and plan of action. Then you can document the positives and chart a course of action.

    There are many, many other things I could talk about, but this is plenty to chew on for now.

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

    • http://briarcroft.wordpress.com/ Emily Gibson

      Dr. Smith, I thoroughly agree. Our EMR is a tool that has improved communication between staff and with patients as most of our information sharing with the patient is done via the EMR secure patient portal, no redundant documenting what was just said in a phone call. I’ve learned to not focus on the computer screen either while with the patient. I would not go back to paper records for any reason.

  • http://www.chrisjohnsonmd.com/ Chris Johnson

    Like many hospital-based physicians, I share the patient chart with colleagues. My major complaint about the current crop of EMRs is that it is very difficult to read a patient’s chart and get a narrative of what is happening, what people are thinking, how things are going with the patient. There is a wealth of extraneous data automatically blown into the progress note, much of it based upon documentation requirements. But much of it is not helpful at all.

    Also like you, I began practice with paper charts. At least then one could flip to a consultant’s note and read something like this: “here is what I think is wrong, and this is what I think we should do about it.”

  • NewMexicoRam

    Amen. Amen. Amen.

  • buzzkillersmith

    So, EHRs annoy ( and worse) doctors and patients, don’t save money, and don’t improve care. Yet advocating returning to paper is taboo.

    It is simply not politically acceptable to follow the data and draw the correct conclusions from the facts in the above paragraph.

    I am advocating a return to paper. EHRs are failed technology.

    Paper is not perfect, but it is much better than EHRs. Want to curb prescription errors? Use a tiny little simple program to do escripts. Easy done. Want to have notes legible? Dictate and transcribe.

    I have no illusions here. EHRs are here to say, at least for the near future.
    But I hope most of the docs and pts here realize they are trash.

    • Ron Smith

      Hi, Busskillersmith.

      Re: “don’t save money, and don’t improve care”

      I have to disagree.. Perhaps most EHRS don’t save money and don’t improve care, but I can honestly say that well designed EHRs can do just that.

      When I designed the EOB processing I used a novel technique that reduced the paid claims processing astronomically. When my practice manager gets a lengthy EOB from just one insurer that she tells me would take two to three hours to process by hand, she does it in 15 seconds.

      She estimates that this one feature saves $75,000 a year.

      One specific advance with my EMR is with status alarms. Status alarms for specific individuals and specific dates. So if I have talked to a parent and want my nurse triage to follow-up at any time in the future, then I set an alarm for her. I can set multiple alarms at any date I want. Anyone in the office can set a these status alarms for anyone else.

      This improves care tremendously and cannot be duplicated with paper charts.

      Look, my father was a natural gas pipeliner, which means he dug ditches for a living. I grew up learning how to use all the equipment. I could drive a bulldozer and dig with a backhoe before I had a license to drive a car.

      The backhoe was much better than the shovel. But it wouldn’t have been if I hadn’t taken the time to practice using the controls and fine tuning my skills by practice.

      Look some makes of backhoes were not as nearly easy to use as others, and the controls sometimes were markedly different. But I learned them because I really wanted to. Human nature is to do what it wants.

      Despite EMRs as a rule being poorly designed, it should still be an encouragement when I tell you that they can be well done, that you should not give up on what I’ve proven in my practice can be good for both patients and practitioners.

      Warmest regards,

      Ron Smith, MD
      www (adot) ronsmithmd (adot) com

      • southerndoc1

        1. Processing EOBs isn’t really an EMR function, so that’s kind of irrelevant to this discussion (and I hope someone in your office is going through them line by line, or you’re leaving a lot more than 75K on the table. We still find that, if we look closely enough, about 30% of our claims are processed incorrectly, always to the benefit of the insurer).

        2. Status alarms: sounds like an old-fashioned tickler file. Every doc and nurse in our office keeps one, and they work great.

        Enjoy your posts.

        • Ron Smith

          Hi, SouthernDoc. You might not think so at first, but everything you do in your EMR is associated with a procedure and diagnosis code for which you are responsible. The diagnosis in particular is what you assign.

          In our EMR the exam has all the financial side associated with it as well. Those who do the coding and claims filing need your information so that they don’t leave any of your money on the table.

          Not only that when you get a Medicaid audit (which I have been through) you will be very, very glad the two are associated. They came with their hands out for $450,000 which they would have gotten without the proper documentation associated with the charges.

          To say that these are not related is simply not true and will affect your bottom line.

          Most EMRs do not integrate these and if they do they do so poorly I’m afraid.

          Warmest regards,

          Ron Smith, MD
          www (adot) ronsmithmd (adot) com

      • buzzkillersmith

        1. If you like EHRs, use them. No one here is interested is proscribing them. The real issue is whether they are useful in the aggregate. I submit that, if they were, they would not have to be shoved down doctors’ throats. Moreover, most docs can’t choose their own freely. They are often employed by CorpMed or are technological babes in the wood preyed upon by vendors. Not exactly a free market.

        2. 75 k per year. Shall we trade anecdotes? The other local FP group says they lose 100k per year. I’m ahead 25k.

        3. Status alarms. Come on, doc. Everyone at this blog, doc or not, knows that EHRs improve some things. TYhe question is whether they improve or worsen things overall. What if those EHRs keep docs from listening to pts and cause them to miss a diagnosis? What if fooling with the EHR decreasing the number of pts docs can see, thereby having more pts wind up in the ER and increasing costs?

        The issue here for whether EHRs should be mandated is their overall effect. If you have data proving they are good overall, please share it.

        4. Backhoes. Don’t take for fools. Everyone at this blog understands the difference between labor-saving devices like backhoes and labor-complementing technology like EHRs. The former almost always save money ( properly designed) because capital is cheaper than labor. The latter
        often does not. Think modern medicine. Think elite education. Think

        • http://www.ronsmithmd.com/ Ron Smith

          Hi, Buzzkillersmith.

          Thanks for your reply. I want to address each issue but I would also like to say that your response seems to show personal antagonism and bias more than anything factual I believe. Your experience seems to be bad I gather?

          1. I think that I have found especially since becoming a frequent commenter here, that the general feeling is that the the intention and goal of EHRs is good, but that the implementations are often bad. You cannot say simply because a particular software is an EMR that it is like all EMRs. There are hundreds of solutions out there to choose from. How is that not free market? It seems you simply wish to live in the days of paper rather than assault the deficiencies of that poor tool.

          2. I only mentioned the one savings of $75K per year. There are more. The perception of a well designed software tool by my parents, most of which are very tech savvy, has had an even greater, though not so measurable, increase in the financial status of the practice. Parents are drawn to these technological pluses because they see the advantage. But simply buying an EMR as though that will solve the ills of a poorly run business is foolhardy. That’s why we don’t sell our software. We market the whole solution that we have created as an office. We want others to succeed like we have. But I digress and this was not meant to be a plug.

          3. You can do all those bad things equally as well with paper. Paper or digital records themselves do not make us better or worse physicians.

          4. If you can’t see the EMR as any different a tool than the CBC lab instrument or the backhoe that makes for a quality result then I wonder if you will ever enjoy anything new in medicine? Why practice anyway it seems if we can’t hope to do better?

          With warmest regards and deepest respect,

          Ron Smith, MD
          www (adot) ronsmithmd (adot) com

  • southerndoc1

    “I no longer bring a laptop in the exam room because of that feedback”

    Do you really go into the exam room with no information about the patient?

  • sleeperagent

    Just had first appt. with new GP–the “nurse” came in first and had her back to me the ENTIRE time as she asked me questions and entered them into her laptop. It was a laptop, and she could have easily turned around. Having spent the last few years accompanying my mother to many physicians and hospitals, this is unfortunately the norm–rarely did any provider look at us; it was always the back. If they were turned to us, they never looked up from their screen….

  • swatdoc

    As one of the older Docs I miss being able to go from one part of the chart to the other without 6 delayed clicks and although I carry the laptop into the encounter try to put aside and look/interact directly with the patient and try to teach my med students that as well. Many patients complain they don’t feel the focus of the doctors attention and compete with the computer for attention of the doc. There are many things that the EMR gives such as outcomes data and to be able to pull out lots of data out as well . But the costs and trouble of EMR is being oversold as the best thing since sliced bread. Costs for a struggling practice especially in someone over mid 50s is in most cases another added expense I did not need

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