For medical clinicians, our growing challenge is to find ways to reconcile the required use of the electronic medical record (EMR) with efforts to provide high quality patient centered care.  Although unavoidably familiar to clinicians, this transition from handwritten records to EMR is probably not well understood by patients.  However, patients are well aware of the effects of this transition when they see more and more of their doctors staring at computer screens during their clinical visits.  Patients are in fact competing with computers for their doctor’s time.

Why is this happening?

The basis for the shift to EMR relates to obligatory changes in our healthcare system where more specific documentation is required for reimbursement of services.   For example, in doing a physical examination the doctor has to list every organ system evaluated even if normal, whereas with the traditional paper record the clinician will do the same exam, but will only indicate what is abnormal and relevant.  Diagnostic codes are also required for reimbursement and many times those codes don’t fit with the nature and complexity of the patient’s complaints.  In fact most of the issues I see with patients having complex GI problems don’t yet fit existing diagnostic codes.  At this time the EMR doesn’t make clinical care more efficient as intended; rather it serves as an invoice sent to payers to document the services provided.

When this change first began, efforts were made to “translate” paper forms into electronic screens, but these well intentioned efforts were done without understanding or addressing the intuitive processes of the clinician’s judgments.  Clinicians think differently than computers and good clinicians understand the subtleties of human illness in ways that cannot be captured by computers.  As a result clinicians have been forced to retrofit their clinical observations and judgments into categories set up by technicians to meet billing needs. This is further compromised when the EMRs are designed to address the interests of a national healthcare system that is often considered dysfunctional in its own right.

The difficulties of EMR are stated very well from a friend and gastroenterology colleague Michael P. Jones who recently shared his personal concerns in a recent Los AngelesTimes article. Michael addressed his experience when seeing his own internist and stated to him as the internist was looking at the computer while taking the medical history: “…does any of this look like a good doctor-patient interaction?”  The internist responded: “Hell no, but I’ve got to do this now or I’ll never get finished on time.”  He goes on to say that the difference between good clinicians and the healthcare industry, is that the latter is more about industry than health or care. Thus, the EMR emerged as a way to document the doctor-patient care process but in a format that works for billers and statisticians more so than for doctors or patients.  I am hopeful that this is just a transition period.  In time and with better attention to this issue we may eventually have a system that will be both efficient and relevant to the needs of patient care.

What can physicians do now?

A close friend and participant in DrossmanCare,  Dennis Novack, Associate Dean for Education at Drexel Medical School, has spent his career on finding ways through research and education to improve the patient physician interaction.  He states his approach to working with the EMR:

“One method I’ve found useful in overcoming some of the barriers the EMR imposes between Dr and Pt is to take brief notes while the patient relates the history, and then dictate it into Dragon [dictation software] while looking at the patient and checking for accuracy.  I do the same thing with the Assessment and Plan section, and patients seem to appreciate it.  Also, I can then print out the note with the agreed upon assessment and plan and give it to the patients, which they seem to appreciate.  Still, the whole process is clunky.

Similarly I have often consciously spent most of my attention on the patient while scribbling notes to remind me of key points of the dialog..

Since leaving the clinical services in the academic environment, I created a method used now in Drossman Gastroenterology that addresses this issue.  I am part of a clinical team with a superb physician assistant, Kellie Bunn – PA-C working with me and it makes a world of difference.  This is not a luxury; it’s a necessity because it gives me the ability to focus 100% on the patient and the issues at hand during the clinic visit.  In addition, Kellie takes the notes and enters the clinical information into the EMR under my supervision.  As a result she is fully informed of the issues that transpire during the visit, and she can easily handle any phone calls or messages that arrive with full knowledge when I’m not around.  Our experience is that the patient benefits most of all knowing that he or she will truly be heard and understood and will have two resources to help in the care.  Most important there is now adequate documentation that a good clinician patient relationship is dependent on good communication skills  which improves the clinical outcome.