Neglecting the patient in the era of health IT and EMR

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In advance of their annual User Conference, the social media team at athenahealth was able to talk about modern medicine with the event’s keynote speaker, Dr. Abraham Verghese. A physician and Stanford professor, Verghese has also authored several books, including the New York Times bestseller, “Cutting for Stone.” Here he talks about the importance of being present during the exam, in an era with so many distractions threatening to erode the vital relationship between doctor and patient. This interview was introduced by CEO Jonathan Bush and then appeared in two parts on the athenahealth blog.

 What are some of the promises and dangers of EHRs and HIT in the exam room?

I’m glad that we’re in the electronic medical record era whether it’s cloud computing or on a computer. The great danger is that in the process of recording this data we can neglect the patient.

In the hospital there’s been a study suggesting that in a 10-hour hospital stay, four hours are spent charting and recording. I think all of us agree that that’s probably too much time and so the great challenge for us is to find ways to be more efficient in charting. I think what athenahealth has done has really elevated that to a level where one can really focus on the patient and yet document, which is still very important.

The great danger in terms of the patient is taking an individual who’s already feeling vulnerable, perhaps even disembodied changing into a paper gown and making them feel even further disembodied. To the degree that the physician can focus on them and use the computer as an ancillary tool, it succeeds in keeping that patient-physician relationship vital and sacred without it feeling like the real focus of attention is the computer.

In talking to physicians, we find that so many of them are overwhelmed. Because of the many demands thrust upon them, they often can’t focus on care as they would like to.  Besides choosing the right technology and using it well, what can doctors do about this? 

I think I’m in exactly the same position as the doctors that you’re describing.  I think we’re all challenged by time constraints, by urgent but not important things that pop up and important things that are not urgent that get overlooked for that reason.

I think that I’m always struck by the fact that there’s always one moment in the day where your entire attention is required and you’re required to forget about what’s coming or what’s gone past.  Sometimes you need to recognize that moment, that one patient who really requires you to change your schedule, requires you to push everything back or change things around. You can’t necessarily do that for every patient every moment of every day and not everybody needs it.  But recognizing that one moment when it is needed and being available I think is the key.

One of my heroes is a physician who trained at Harvard and came from a small community in Laredo, Texas. He trained at Harvard and went back to Laredo and practices now, even in his 80s.  And he has this ability to walk into a room and sit on the patient’s bed and create the illusion that he has all kinds of time and nowhere else he needs to be.  And paradoxically by being so completely in the moment he manages to spend less time with patients than many of us who are hurrying to get on to the next thing.

To me I think the most important thing we can do for ourselves is to live in the moment or as William Osler once said “To live each day in day-tight compartments.”  This came to Osler because he was on an ocean voyage coming back to America from England to deliver a commencement speech.  When he was walking on the deck of this giant ship, he heard the sound of big metal doors clanging shut.  And he asked the captain what that was and the captain said after the Titanic they had designed ships now so that they had individual watertight compartments so that if something hit the ship it wouldn’t flood the whole ship, it would just flood one compartment.

Osler was so impressed by that. And he connected that episode with a famous saying of the Scottish historian and critic Thomas Carlyle, who once advised “not to see what lies dimly in the distance but to do what clearly lies at hand.”

Osler melded the two and talked about how physicians should live each day in ‘day-tight compartments.’  And I think that many of us in medicine too often are with our heads partly in what is to come and our heads partly in what’s gone before when really what our patients require is us to be fully present in the moment. It’s less about time than about the quality of your presence.  Recognize that one moment where you need to give both the quality and the time to that one patient.

What is your experience with care coordination–including possible limitations and a vision for how it can be executed better? 

We’re all aware of wonderful examples of how care coordination doesn’t work well.  You know [there are] so many opportunities during transitions of care for information not to be communicated.  I think that too much of the conversation about hand-offs and transitions of care is focused on the health care provider when really the focus should be the patient.

If we put on the patient’s perspective and view how it feels to go from hospital to home to outpatient visit to hospital, I think some of these conversations about transfer of care become colored differently. Too often the conversation is about hand-offs and sign-offs and those are all from the doctors’ point of view.

The short answer would be that we have, in most systems, a long ways to go in coordinating care. It’s perhaps the most difficult thing we do.

Some systems (yours it sounds like) do it very well.  Certain systems are completely focused on the delivery of care to patients. The clinic model can do it very well but when an institution like mine, for example, has a mission that is two or three-fold, we’re teaching, we’re doing research and we’re doing patient care.  Sometimes those tripartite missions wind up actually being in conflict with each other because you are being drawn away from this to do that, from that to do this and there are three different missions.  So I think it’s a continuing problem and I think we all marvel and look to athenahealth and other organizations to see how you do it.

It’s an important issue for us all.

Abraham Verghese is Professor for the Theory and Practice of Medicine at the Stanford University School of Medicine and Senior Associate Chair of the Department of Internal Medicine.

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