“It’s going to be ugly today” was my colleague’s assessment at 6:30 a.m. Wednesday morning, when the electronic medical record failed to launch, the Internet could not be accessed, pagers and phones could not connect, and a recording on the helpdesk line noted, “Systems are down, and there is currently no estimated time of resolution.” So we waded into fourteen hours of practicing medicine without computers.
This was not good. Patients’ surgeries had to be cancelled. Worried men and women, anxious to learn if the shadow on their CT scan meant cancer, had to wait for another day when the specialist could access their computer images. The safety net crosschecking medicine allergies and drug interactions against newly prescribed medicines was completely absent.
However unintended and unwished-for, a day in the life of a primary care internal medicine clinic without electronics was an experiment worth examining. Here is a case report.
Previous status quo: Patient is roomed by hall staff, answers multiple questions about tobacco and domestic violence, and watches their answers being logged in online. Meaningful use criteria are checked off. I enter and conscientiously try all the studied techniques of effective communication: looking the patient in the eye, letting them talk at least 180 seconds before interrupting, and facing the patient rather than the screen.
And yet — the computer’s checklist must be satisfied before patient and doctor are allowed to leave the room. Order a chest CT to be performed six months from now? Nine clicks, two scrolls and a line of typing. New prescription to the new mail order pharmacy? Nine clicks, two lines of typing, association with new ICD-10 code. Physical exam including orders for a flu shot, Prevnar 13, mammogram in three months, colonoscopy, laboratories, medicine refills, return in a year? Several dozen clicks at least. Every minute spent clicking is one minute less spent hearing the concerns of the fellow human being in the room and considering solutions to their distress.
The EMR can also distract the physician from the patient in the room by offering the hope of finding a definitive answer lurking in their record. The wealth of information can tempt the physician to browse echocardiograms, laboratories, nuclear scans and consult notes. More, more and even more data can be reviewed, but the patient is sitting quietly (or not) during this review, and other patients are in line behind them as the minutes fly by.
On this day, however, the hall staff ask the patient how they are, take a weight, blood pressure and pulse, and write it on a slip of paper. I walk into the room and sit facing the patient — a natural situation, because there is no other pull of distraction — and ask, “How are you, and what would you like to take care of today?” And then, amazingly, the patient speaks, and I listen. We are two adults considering a question, assessing the information, considering the circumstances, resources and philosophies of the individuals involved, and making an assessment and a plan. I jot a few orders on a piece of paper for staff to enter when the computer is up again: wonderful. At the end of the appointment, I give the patient a few lines of recommendations: given the quality of my handwriting, not so wonderful.
At the end of each appointment, there is a sense in the room that the patient has been listened to, their concerns have been addressed, and a plan has been crafted. Twice the positive sense of engagement has been achieved in half the usual appointment time. If this were the case every day, I could see twenty-five patients rather than sixteen without any additional sense of burden. Indeed, this was the schedule I kept before online clinician order entry, leaving the office one to two hours earlier with ten more patients seen and all work done.
What was the difference on this day, without electronics in the room? Certainly there was more eye contact, and the patient did not need to sit watching me typing in orders. More importantly, my entire emphasis and priority in the exam room was changed. While we always strive to be patient-focused, the bottom line is that the computer’s checklists must be satisfied by appointment’s end. By default, data entry becomes the focus and the goal.
The day the computers went down offered a window into truly patient-focused care, not as an add-on but as the essence of the visit. The computer is an invaluable tool, and there were a few times I wished I had access to an echo report to find a prior ejection fraction, or a chest x-ray to look at a nodule.
However, this day showed the need for disruptive innovation to restructure our delivery of care. We have developed technologies to perform myriad essential tasks. Our challenge now is to develop an EMR that serves the needs of the patient and their physician rather than dictating the content and context of their care.
Heather E. Gantzer is an internal medicine physician.
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