Two weeks ago, I did what had to be done. Months of procrastination had to end. Fears had to be put aside. Anxiety and misgivings had to be overcome. Second opinions always confirmed the need to proceed. So, when the excuses ran out, I jumped.
What decision did I make?
(a) Finally have rotator cuff surgery?
(b) Begin electronic medical records (EMR) in the office?
(c) Retire from medicine to be a full time ‘Whistleblower’?
(d) Agree to a family vacation when we will hike up and down the Grand Canyon sans mules?
(e) Agree to become an expert witness for a medical malpractice plaintiff’s attorney?
(f) Apply an Obama 2012 bumper sticker on my car?
Two weeks ago, our office entered the paperless universe. The era of ink on paper was over. The manner that I had seen office patients for 20 years suddenly evaporated. And, I wasn’t happy about it. For our small group of gastroenterologists, even though we are aware of the potential advantages of computerized charts, we adopted EMR because we had to. For me, I was perfectly satisfied seeing patients in the office the old fashioned way, similar to how physicians have treated patients throughout history. Prior to 'point & click medicine', I had lots of time for eye contact and observing patients’ body language and facial expressions. I have previously expressed my concern about EMR adversely affecting the doctor-patient relationship. My written chart notes were in my own unique verbiage, code words and phrases that could convey my precise meaning when reviewed months or years later. True, I couldn’t access patient records from remote sites, but somehow we managed to get the job done without tragic consequences. EMR is a cure, but I wasn’t aware that my practice was diseased.
So, now I face patients with a laptop, loaded with software that I don’t fully understand. I am clicking, pasting, free typing and spending minutes searching for some common term like hemorrhoids to insert into the history of present illness. During the first week, I have sorely tested my patients’ patience, and my own.
Since, I don’t want to communicate to my patients my frustration, annoyance and trepidation, I try to make the experience seem like it's all jolly-good fun. I maintain a fixed smile of delight that must make patients think I administer an hourly Botox injection. Looking deliriously happy when I want to smash my laptop to shards is hard for someone with no acting skill or talent. Therefore, I \prepared some cue cards to assist me. Here’s a sample.
Do Not Say: I hate this system and so will you.
Say: Isn’t this wonderful? I can now search my whole practice for all of my porphyria patients.
Do Not Say: Remember how you used to wait a half hour in the waiting room for your appointment? Those were the ‘good old days’.
Say: My partners can view your medical history even at 3:00 a.m. Try it out this weekend when I am not on-call.
Do Not Say: I wonder who can hack into these records?
Say: Of course, this will really improve your medical care. I already clicked that you are feeling better.
Do Not Say: I can check my email during office visits and patients think I’m looking at their EMR charts!
Of course, it will deliver many improvements for patients and physicians, as pointed out by überblogger Musings of a Distractible Mind . I am excited to have access to my patients’ records from anywhere. It has been vexing to receive phone calls at night from my partner’s patients with stomach pain, when I do not know them, and have no access to their records. E-prescribing will save time and screen for important drug interactions and allergies. Letters can be sent to referring physicians at the time of the office visit automatically, although the software writes them in a robotic fashion. Ultimately, all EMR systems will communicate with each other, so that a patient seen in an emergency room can have medical records accessed from any EMR system. By then, patients should be carrying a flash key or a microchip containing all of their medical history, radiology images, EKGs, etc.
While on balance, EMR is a true reform that will improve medical quality, it won’t make everything better. It will take great effort by physicians to prevent EMR from dehumanizing our personal interactions with our patients. This is a formidable task, and many of us will not fully succeed. We should not simply consider the medical outcome, but also the path and the experience that precede it.
For example, we would sustain ourselves on Ensure or Meals Ready to Eat (MRE) for life. This would save us time and money. But would it be worth it? When we focus only on the medical outcome, then our humanity is at risk. While the nutritional analogy above isn’t a perfect fit for the EMR issue, I hope you will agree that there is a connection.
What do other physicians think about EMR? More importantly, I am interested in the views and experiences of real, live patients. For those who are dissatisfied, how can we physicians do better?
If I do end up at the bottom of the Grand Canyon, and the National Park Service adds WiFi service there, should I take my laptop with me? While my feet are dangling in the Colorado River, I can refill prescriptions.
I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.