I walked into the ICU amidst a chaos of harried residents, chirping alarms, and the whir of the portable X-ray machine. Aromas ranging from old coffee down to vomit and stool mixed together in the usual fashion. In other words, it was a typical morning. I watched as my team gathered into a semicircle around me outside the first patient’s room and I got into my morning rounds stance: leaned against a wall, stooped slightly over with brow furrowed — ready to filter and interpret the onslaught of rambling, disorganized thought about to spew forth from the tired night resident.
“This is a 59-year-old man with a history of …” and the part begins where no less than 17 past medical conditions are listed while I try to figure out why the patient is actually here. But something was wrong; I could hear words, but nobody was actually talking to me. My resident was facing me, but standing in front of her W.O.W. (“workstation on wheels” — because C.O.W. is apparently offensive) with the screen completely obstructing her face. I begin to chuckle to myself until I looked around and noticed that I was surrounded by the backs of computer screens. Out of a team of 7 people, our computer-to-person ratio was nearly 1:1. And — like an unlucky guy in an episode of The Walking Dead — I was encircled with no escape route. I began to wonder, “Is this what it will look like when Watson eventually replaces me?” Probably not. At least Watson would face me, taking my job away while spinning its stupid avatar.
Later that afternoon we admitted a sick patient from the emergency room who was close to needing intubation. I pressed my resident to present the case within 30 minutes so we could make a collective decision. She was admitted as a boarder to another floor, which meant (Gasp!) the W.O.W. wasn’t able to make the trip. Before presenting, he nervously told me he didn’t have his computer and did not have a lot of time to think about the patient. But what followed was an incredibly focused and clear presentation, with a solid plan and only the details that needed to be discussed. I told him from now on he should present without a computer attached to him and his performance improved even further. By the end of the week, he was confidently presenting key findings, occasionally referring to a piece of paper, and we used a computer just for orders and reviewing radiology.
There’s no debating that the introduction of the electronic health record (EHR), computers, and smartphones into patient care has been a net positive for mortality, medication errors, and cost. However, at the point where a trainee feels it’s normal to present a case into a computer screen, we have to wonder if the pendulum has swung too far. Technology seems to have become a replacement and a crutch, rather than an aid to us. It feels more important to have all the data documented (just in case!) rather than understand what’s really important for each patient. When I asked my residents why everyone needed a computer on rounds, the common response was the ability to work on notes when they weren’t presenting. Notes that usually weren’t completed until the late afternoon anyway. Thus, it’s no surprise to see a study showing that residents who were followed on a general medicine ward spent half of their day on computers, with the majority of that time devoted to clinical documentation.
There are many explanations for how we ended up here. EHR note-writing tools are becoming better at dumping in more information from the medical record. Copy-and-paste functions encourage the creation of documents that are added upon more so than edited down from. And as billing becomes more complex, coding specialists increasingly request that notes are “optimized” (structured in a way to maximize billing and minimize penalty). The end result is an assortment of cluttered clinical documentation that, despite your best effort to maintain, only gets worse. Eventually, you resign yourself to just focus on avoiding egregious mistakes that would land you in court. But even that takes more time than it should. It’s strangely like living with a toddler. Even more concerning is that patients are beginning to notice this trend of documentation dominating encounters and are starting to question how effective we can be when we seem less engaged with them.
It’s hard to envision a future where the complexity of patients, the quality infrastructure, and medical billing rules all improve. Therefore, the onus is on us to take a hard look at how we interact with the technology we use and how it affects patient care (or the patent’s perception of their care). Acknowledging that our documentation is scrutinized by many other entities, they nevertheless need to more accurately reflect our own thought. Most importantly, the way we instruct the next generation of care providers—who have lived their entire lives inundated with technology—needs to reflect this new reality. Medical students and trainees should learn how to minimize documentation time by writing short, concise and accurate notes from the beginning. And we should foster and environment where it is understood that an over-dependent doctor-computer connection has the potential to erode the doctor-patient relationship.
Taison Bell is an internal medicine physician.
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