Don’t take the damn EMR into the exam room

Do you believe that I have to mention this?  I can’t believe it either but since the advent of the EMR, this seems to be an issue; a really big issue.  Amazingly enough, you are there, as a doctor, to treat the patient and not the computer.  You would think it was the other way around with all the bogus quality indicators, meaningful use baloney and pay-for-performance nonsense being stuffed down our throats, but don’t let those who are now in charge of healthcare fool you.  It really is about the patients.

I am on my third EMR system but I never let the computer enter the room with me.  In other words, I preview the chart and then go in naked.  Ok, I wear a stethoscope but that is it.  Why?  Because I want to look the person in the eye.  Yes, you read that right, look at the patient.

Human beings are interesting animals.  They kind of like to interact with other humans, which includes their doctor.  Staring at the computer screen interferes with that.  Patients want to feel important.  They want to feel listened to. When you look at the patient, you acknowledge that.  You also listen better.  When you turn to the EMR screen, you don’t.  You may try to listen to them, but you are obviously searching the chart or typing in some information or prescribing a drug and guess what the patient is doing?  He is either still talking or he is getting his own thoughts interrupted.  This is not good care no matter how you rationalize it.

Maybe you are better than I am.  Maybe you can bring your laptop into the room and really isolate the interview part of the visit by truly listening fully to the patient and not turning to the EMR, who, by the way, is screaming at you inside his or her head, “Look at me!”

If you can pull this off then good for you.  It does not work for me.  Most of you, however, are like me and will succumb to the temptation of turning to the damn computer too early.   Sure, you will promise yourself you won’t.  You will fight the pull as hard as you can and maybe you will succeed for the first few patients of the day.  Unfortunately, your willpower will weaken and you will start cheating.  Trust me, once that happens there is no going back for anyone else on your schedule.  Been there, done that.  Listen to me, don’t take the damn EMR into your room. If it is already there, shut it off.

Yes, we all need EMRs.  Yes, with my way of not bringing the EMR into the room makes me leave at times to check on things but it also allows me space to think, time to look up stuff that I don’t know, and also stops the patient from interrupting me with more complaints that just popped into his or her head.

Lastly, if you would ask an old-time doctor whether looking at the patient was difficult to him then he would probably answer no and wonder whether you were an idiot.  And he would do this the whole time while … looking at you.

Doug Farrago is a family physician who blogs at Authentic Medicine.

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  • Dr. Drake Ramoray

    I practice the same way you do. That being said I have often thought that I shouldn’t. I should take the EMR in with me. Enter everything and do everything that requires the EMR while in the room. When the patient complains then I can direct them to call their Congressman or Senator to stop this stupidity. The powers that be won’t listen to me and the AMA is useless.

    I suppose if I billed for face to face time including the time entering pregnancy status on 80 year olds that I might not go broke. Watch out for those patient satisfaction scores though. /s

    • buzzkillerjsmith

      Well, maybe if you treated their PCOS better, your 80 year olds wouldn’t have such a hard time getting pregnant. That might be what your EHR is thinking.

      • Dr. Drake Ramoray

        Amenorrhea in 80 year olds. Serious business.

        Did have a consult once for galactorrhea, amenorrhea, and minimally elevated prolactin once in a 20 something year old that turned out to be pregnant. Whoops. Endocrine consult is a very expensive pregnancy test. Guess that EMR didn’t save any costs

  • southerndoc1

    “Yes, we all need EMRs.”

    Nope.

    But good post.

  • buzzkillerjsmith

    If EHR in room, go home 1.5 hours late with a mild to moderate headache.

    If no EHR in room, go home 2.5 hours late with a moderate to severe headache.

    If win the lottery, retire the very next day.

  • southerndoc1

    So, let’s see . . .

    One short year ago, this office was so disorganized that they made you fill out complete demographics and medical history forms at every visit (no wonder your chart was two volumes), no one had ever thought to put a stack of lab requests in each exam room, and the doctor couldn’t be trusted to carry a scrip pad in her pocket . . .

    And just twelve months later, this same chaotic office has transferred all their records into a new EMR along with demographics and prescriptions (including the records of everyone like you who had left the practice and might never return), and every one is using the EMR masterfully . . .

    Sorry, I’m not buying it.

    • Shawn Huecker

      I don’t know all of the answers to the issues you’ve raised, nor am I selling anything that I’m aware of (no hidden lobbying agendas, no job as a software vendor), but here goes…

      The practice was in mid-implementation of the EMR when I had to change providers. At that time, the system was not fully live and patients still had to complete a good bit of paperwork with each visit. Providers had PCs in the exam rooms, but didn’t do much with them. I was told during my last couple of visits that the conversion of paper charts to electronic data was extremely time consuming and I would be notified when my content was in the new EMR and available via online portal (as well as during office visits), but as I changed providers before that, I don’t know when the migration was completed. I also do not know the actual EMR development and implementation timeline, so it may have been a number of years in the making before I had even learned that the data was being migrated. I didn’t mean to imply there was a magic wand here, only that in the year that passed between my visits that my experience changed significantly due to the full implementation of the EMR. That is, in my experience EMRs can work and work well from a patient perspective. I am certain the development and implementation processes took well in excess of a year, but I cannot tell you exactly how long that might have been.

      I don’t know why lab forms were not present in every exam room. Issues with sequential forms? Stand alone lab system with a dedicated printer in a common area? All I know is my doctor would excuse herself to get the lab request when one was needed, and it was already completed when she returned.

      Prescriptions previously were not hand written, only hand signed. They were computer printed on some sort of standard prescription paper then signed by the doctor, which again necessitated a trip out of the exam room for preparation and retrieval.

      As for the practice having imported all of my history into the EMR after a year’s absence and being with another provider, I was as surprised as you are skeptical. All I can tell you is that lived it. I was told when returning to the practice that though my doctor is not accepting new patients, she would see me as the clinic keeps patients on their active patient list for 2 years after their last appointment. Perhaps this was the criteria used for importing the historical data.
      In any event, I’m not advocating for EMRs, I’m advocating for use of technology (including EMRs) in a way that that works for the patient and is best suited to her/his care. Patients who are put off by a physician at a screen and keyboard should be accommodated – there should be a process for the provider to print an overview document for reference during the visit, and for charting in the EMR after the visit. For those who find technology compelling and helpful, the provider can be at the screen and keyboard, charting live and using the EMR as another tool to make the visit productive.

  • Arby

    I have been getting checked in
    electronically for a long time now, so I don’t know where your doctor is
    located. It just seems odd to be a surprise after only one year.

    Anyway, the following are a few vignettes about the current state of EMRs, and though it may sound like I am against them, I am not. A medical records degree is what I am going to school for right now. In addition, I love to use EMR portals as a patient to check my records, request refills and view upcoming appts. It bothers me that my doctors do not get paid for emails, and I am careful about how many I send, but this is one of the biggest benefits to me from the online portal.

    I visit my doctor with a piece of paper with my symptoms on it and the staff struggle with what to do with it. I don’t know if it ever gets scanned into my chart. The EMR makes him step through every medication (most are prn) and vitamin and mineral I take even though I say that nothing has changed. [It forced a neurologist, who can't type, to go through the same exercise while I was there for muscle testing, and not two weeks after a prior visit had confirmed all my meds/supps were correct. A good ten minutes wasted there.]

    I visit my PCP and he types away as I talk. My doctor is a great typist, probably 100 wpm. But still he is distracted with the EMR and I can tell. [Where I last worked I used four monitors, 2 keyboards and 2 PCs to manage content for 2 different companies. I could easily have 2 IM chats, an email thread with someone else and be on the phone while editing html in between replies. An egregious example, yes, but it illustrates that I know what distracted is when I see it.]

    So, I ask him the results of the endoscopy I just had and he says that my h pylori test was negative. But, the gastroenterologist said it was inflamed during the exam [I don't take sedation; I was awake through the whole thing], so I directly ask him about this. He then has to dig to find out I was Dxd with Grade C esophagitis. I go home and later decide to check my chart. I see from my intake exam that three of my deceased family members had Hearing Loss, but that isn’t what they had. They had heart disease. It is obvious that drop-down list disease occurred there.

    For all the EMR designers out there:
    1. Why can’t I confirm my medications in the system while in the waiting in the exam room while I am bored to tears after the nurse leaves, but the doctor is not there yet.
    2. Barring that, why is my compliance with medications the foremost thing my doctor has to struggle with at the start of a visit, yet a recent, pertinent specialist report is buried somewhere.
    3. My PCP should have been more careful with the drop-downs but most any user has issues with them. The software should mitigate this risk, not increase it.
    4. Why does my doctor have to be a great typist. Mobile apps are way ahead in this respect and most can be bought for a dollar. I don’t mean touch screens only; they have been slapped on lousy user interfaces all too often. But, the good ones demonstrate that the technology is there. Why isn’t it used.

    I do not want to get rid of EMRs. Rather, I desperately want them to
    improve greatly before they are shoved down physicians throats. And, things won’t get better if you shut down their critics. The current state of
    the EMRs I’ve seen are nothing but clunky billing databases covered
    with a craptastic shell of a user interface that is calling 1995.

    This software needs to be elegant because the stakes are so much higher than the garbage businesses generally worry about with software. IT CANNOT BE: Let’s cut all the corners we can to come in under our fourth budget that just happened to double the cost of the entire project to meet an arbitrary deadline pulled out of the air so that we can all get advanced in our careers and we will get all this done by pretending there are no issues that aren’t the end users’ fault.

    To all of the providers out there hating your EMR, please do not use what I wrote to encourage you to hate it more. What needs to happen is that you have to find a way to get your concerns and ideas heard. Demand user groups and join them [even if you don't have time, because I know you don't]. There isn’t any other way that I can see.

    • LeoHolmMD

      I just joined civilization and got an iPhone (was on flip, never texted). It had no instructions. Within 2 days I am on texting, programming, etc. Fingerprint unlock (don’t have to log in with 5 different passwords 150 times each day).Can probably flip through a whole year’s worth of pictures in the time it takes me to look up just a few things in a patients chart. The current EMRs are an embarrassment to the tech industry, medicine and government. Physicians and patients could have solved this hundreds of times over before most EMRs get to their first useless upgrade. There is no excuse for this sorry performance other than it came under government mandate from a bunch of fools who had no idea what they were getting into.

    • buzzkillerjsmith

      Good comments on the micro of all this, but I’d like to comment on the macro, which is really the main thing here. EHRs do not save money, improve care, or improve efficiency in many cases. Or at least they have no been shown to do so in studies that meet the standards of medical research. Of course docs and medical groups that use EHRs voluntarily should be free to do so.

      If EHRs do not do those things, they might be a failed technology, even in the long run. They obviously should not be mandated. In terms of improving things to make using them easier to use, it is fine to try small scale experiments on new technology. You can randomize here but you obviously can’t blind.

      Small scale studies, not reorganizing the whole health care system based on what amounts to a combination of theology and profiteering.

      Something not worth doing is not worth doing right.

  • Shawn Huecker

    No apology as far as am concerned Arby, especially as my comment was quite lengthy as well. Your every word was valuable, and discourse can only drive the effort forward.

    • Michael Chen, MD

      Shawn and Arby,

      I very much appreciate your comments especially from a patient point of view and one that I have been championing for alongside with physicians for better EMR user interfaces and usability for years. A forum is a good medium but an even better medium is one where there is a real community based project, an open source project that brings in all of these viewpoints to create a better EMR… Google my project at NOSH ChartingSystem. I’ve also had some of my posts published here at Kevin MD in the pasb regarding my private practice and my current thoughts on EMR design and safety considerations. NOSH was designed from the ground up to envision a truly cooperative EMR system for doctors and patients so it doesn’t look or work like the usual EMRs out there. Unfortunately, it’s certainly a struggle to be different from the Goliaths in the EMR world of today but I believe that the power of unity and cooperation with a shared vision will eventually overcome the power of monied interests and short term goals of forcing doctors to adopt poorly designed EMRs. I’d like to hear more from you about what you envision such an ideal EMR can be so that it can be a beneficial tool for doctors and patients rather that a dreaded tool for CorpMed and un-meaningful use.

  • southerndoc1

    Much appreciated your comments: you really get what docs are having to deal with.
    Most of us are much less optimistic than you are. We know that no one is listening to us.

  • DoubtfulGuest

    Excellent insights, Arby. I really enjoyed your comment. My experience with EMR at the hospital I go to has been mixed in terms of convenience for me. It seems to just add stress for my doctors. So the net result has not been positive, and that matters.

  • southerndoc1

    Health Affairs Blog, 3/11/14:

    “no other industry, to our knowledge, has been under a universal mandate to adopt a new technology before its effects are fully understood, and before the technology has reached a level of usability that is acceptable to its core users”

    • buzzkillerjsmith

      That is a truly stunning statement. Yet the authors conclude their blog post by stating they are optimistic about EHRs in the longer run.

      Stating the obvious, that EHRs are crap and are very likely to remain crap, is simply not acceptable. I don’t even know if those folks can bring themselves to think it. But it’s true.

      • southerndoc1

        Yup. The contortions of the “thought leaders” who see all the ugly naked flesh yet can’t bring themselves to state that the emperor has no clothes is pathetically hilarious. Check out Dr. Sinsky’s blog for a case-in-point.

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

    Hi, Doug.

    Appreciate the tenacity for good patient interaction. I too think that it borders on rude for physicians to keep their nose to the screen while talking to patients.

    But I have to disagree with you on the EMR in the room. Here are some examples of benefits from my perspective as a thirty-year Pediatrician.

    It is not too uncommon that there is a typo in a weight or measure that gives a troublesome dip to one of the lines on the growth chart. It is not uncommonly the head circumference that is mismeasured. something which is important for me to know. I can retake the measurement, correct it in the EMR and have a new growth chart image on the screen in about 15 seconds to show parents.

    Another really great feature of my EMR is the ability to do Skype calls simply by clicking the phone number I’m looking at. It is absolutely a game changer for me to confirm the dosing or other drug information, but placing a one-click call to the pharmacy where the prescription was faxed. There I am with the parents in the room talking to the pharmacy in front of them. In no time at all I have the information that I needed to make a decision right then without leaving the room. The parents often seem stunned at first but then relax into “gee, that seems like the way things ought to be.”

    What most doctors hate about their EMRs is the incessant point and click method. I created mine with choice lists, choice list templates, and negative fill-in.

    What that means is I only spend time choosing the positives, which I can modify as needed. Because I cover all the same exam points every time, then the negative fill-in comes from the choice list templates that I have personalized just once for myself.

    Don’t through the baby out with the bathwater. All EMRs are not made the same just as most database programmers are not the doctors that have to use them. Tools are either good tools or they are junk.

    So use good emr tools. You have the experience and knowledge to not be rude to your patient and I wish there was a prerequisite chapter for that in all EMR manuals that taught what we know.

    We have to do the business of medicine in order to practice medicine, but we don’t have to sacrifice one for the other.

    Warmest regards,

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

    • southerndoc1

      Don’t understand. You call in prescriptions after they’ve already been faxed?

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

        Nope. If there are questions about a patients prescriptions, say one that was filled by an ER or urgent care, then I can click once to automatically dial up their pharmacy on my computer in the exam room with the parent and the patient.

        Prescriptions are always faxed in. MUCH faster than paper. Just pick a medication from a choice list, pick the pharmacy from a choice list (the default one for that patient is entered automatically), then click fax. Within a minute or so, their pharmacy has a prescription with all the patient demographics, and legible medication info.

        Warmest regards,

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

    • Shawn Huecker

      Glad to see a positive viewpoint from a provider. Having the right tool would definitely seem to be critical, though it sounds like for some that is an uphill battle. I would be interested to learn how you built your interface out with choice lists, choice list templates, and negative fill-in. Sounds like doing so has had a significant impact on your productivity.

    • Brailleyard

      Nailed it.
      If anything – this thirty-year-veteran (physician) is demonstrating the way medicine will hopefully be practiced by graduates who are not-yet thirty. Tech is an augmentation of, not a replacement for our skills as [future] providers. The fact that Dr. Smith seems to have mastered it gives me hope that innovation won’t have to simply wait-out the doctors that cannot interact with tech and their patients.

  • Sara Stein MD

    I read out loud to them while I’m typing – it is a great way of verifying I understand the problem correctly, and becomes part of the discussion. The issue isn’t the computer – the issue is that doctors stop talking with the patient while they are charting.

    • Shawn Huecker

      My PCP does the same, and I find the resulting conversations to be very informative and inclusive.

    • Lisa

      I’ve had doctors do that and I like it; I get a chance to hear the doctor’s notes and correct errors. Recently, I saw my podiatrists and listen to him dictate his visit notes for the EHR. When he was dictating his summary, he got everything right except that he said I had metastatic breast cancer. Eek! I was very glad to be able to correct that error.

  • Maura69

    Ever since the beginning of the EHR my PCP has had his nose buried in the computer. When it first started I asked him if he liked his new appendage, he stated that it was ridiculous. Now he doesn’t go anywhere without the computer. Recently I brought my boyfriend in because he had lost the use of his legs due to a continuing back problem. The doctor walked in and said, “are we having fun yet” (nose buried in computer) then he stated that, “well now you are getting old to get used to the walker and the wheelchair” (Boyfriend is 68 and this was a crisis). Needless to say I am quite upset with this Dr for many reasons but one of the major is the EHR computer that he carries around like an arm.

    • Lisa

      I would be less upset by your doctors use of the computer than by his comments. They would lead me to believe that he was not taking your boyfriend’s situation seriously.

      • Maura69

        Thank you Lisa and you are so very right. He is not taking the situation as he should. My boyfriend ended up in critical condition due to severe Cellulitis and was hospitalized for 10 days…and is unable to walk yet and we are not sure if he will ever be able to be w/o a wheelchair for the rest of his life.