EMR – Electronic Medical Records – is a topic of special interest to me because it sits at the intersection of three streams of modern life which are near and dear to my heart: Medicine, Computers, and Writing.
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Atul Gawande is a surgeon who is also a writer. He has written a long long LONG piece about EMR in the most recent issue of the New Yorker. It’s called “Why Doctors Hate Their Computers.” If you have the time and inclination, you can read all about it here. Or, you can read on… if you dare.
My brother-in-law is a former respiratory therapist. He now jets around the country helping hospitals implement an EMR package called “Epic.” He is well compensated for his time. And he has seen the EMR debate from both sides.
When Gawande describes his initial encounter with his Epic “trainer” – this is how he sets the scene:
The surgeons at the training session ranged in age from thirty to seventy. I estimated about sixty per cent male, and one hundred per cent irritated at having to be there instead of seeing patients. Our trainer looked younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut, a blue button-down shirt, and chinos. Gazing out at his sullen audience, he seemed unperturbed. I learned during the next few sessions that each instructor had developed his or her own way of dealing with the hostile rabble. One was encouraging and parental. Another was unsmiling and efficient. Justin Bieber took the driver’s-ed approach: You don’t want to be here. I don’t want to be here. Let’s just make the best of it.
My brother-in-law looks nothing like Justin Bieber. He’s a long long LONG way out of college. But I am guessing – to his credit – he takes the driver’s-ed approach.
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The debate over EMR boils down to a couple of key issues, each of which is viewed differently from the patient’s perspective, from the doctor’s perspective, and from the perspective of the computer guys sitting in the middle. I’ll address each of the issues in turn.
Control.
Back in the old days, meaning back when medicine operated under the “Arrowsmith” model (you can read about Sinclair Lewis’ novel of a callow young doctor’s coming of age early in the 20th century here), the doctor-patient relationship was sacrosanct. House calls were not uncommon. And medical record-keeping was, well, mostly an after-thought. This gave the doctor a tremendous amount of control over literally everything. It gave the patient a close personal relationship with his or her caregiver, but not much else. The relationship was highly asymmetrical. That’s just the way things are – take it or leave it. (And computer guys didn’t even exist yet – more on this later.)
Many docs of my generation got into medicine with the “Arrowsmith” model lodged in the back of their brains. Is it any wonder then that, in an age of Epic and EMR, a lot of them would seriously contemplate early retirement than give up the total control which they see as a birth-right of their profession?
Communication.
From the patient side of things, Epic’s easy access to lab results and ease of communication with caregivers via the Patient Portal are undisputed pluses. Theoretically, access to historical information about a patient’s prior care should be a boon to physicians as well. And sometimes it is. But there are some unintended side effects of this model that tend to drive docs crazy. One of these is the sheer number of notifications and prompts spewing out of the system . These have to be continuously sorted though, prioritized, and attended to. Which ones are significant, or even relevant, in a particular case? Under the weight of this information deluge – and related time crunch – the doc’s temptation to ignore/delete becomes almost irresistible.
A more insidious, and I would say pernicious, side-effect of the computerization of medical record-keeping is what’s known as “the screen effect.” Consider the difference between the following two scenarios:
A patient sits on an exam table. The doc arrives and sits on a stool. In the old days, the doc talks to the patient looking him or her straight in the eye, elicits what’s known as a History of Present Illness and – if it’s an initial visit – a Family History and a General Review of Systems as well. Then the doc examines the patient from top to bottom, again giving the patient full attention. Afterward, once the patient is dressed and gone, the doc either writes or dictates notes of findings and impressions.
In an age of Epic/EMR, however, there’s a big shift after the doc comes in and sits down. Now, instead of looking exclusively and directly at the patient, the doc is looking primarily at a computer screen. (S)He’s inputting data as (s)he goes, responding to prompts, and – maybe, occasionally – glancing up at the patient. Set aside all the things potentially missed in terms of physical diagnosis. It’s the social implications that are most profound. The “system” is now what’s driving the interaction. And, smart as that “system” may be, the trade-off between “record-keeping” and “relationship” has been undeniably altered.
Economics and Time
I mentioned the time crunch before. While there’s an initial promise of time-saving from EMR, the results where rubber meets road are a bit more complicated.
Unlike in the Arrowsmith days of solo primary care, modern medicine is big business first and foremost. The vast majority of physicians nowadays are either part of a group practice or even a vast medical conglomerate that cares as much or more about profit as about patient care. (Those Big Corporations are the ones that can best afford the price tag of EMR packages like Epic, after all.) Talk to docs individually, or examine the statistics, you will find the same thing: The pressure to produce profits, measured as patient-visits-plus-treatments divided by time, is not just the bottom line. In fact, it ultimately drives both EMR lines of code as well as docs’ minute-by-minute decision-making. Do I even need to say, this is not necessarily a good thing?
Not for patients, of course – but especially not for docs. Job dissatisfaction leading to burnout or early retirement. Taking shortcuts – like ignoring those incessant Epic prompts/emails. And of course, facing toward a screen instead of toward a human being in an exam room. That last is perhaps the biggest of all bugs in a system still under construction, a system which is currently being beta tested on the American medical consumer.
Conclusion
So, in the face of all that, what’s an Epic consultant like my brother-in-law to do? Keeping an even keel during training (the driver’s-ed approach) certainly can’t hurt. Beyond that, understanding and attending to the parameters of frustration on each side seems key. To the extent that system customization can cut down on irrelevant and/or unnecessary information-flow to harried medical providers (more than just physicians, btw), by all means: Do it! To the extent that employing medical scribes, for instance, as the effective EMR interface-users – thus freeing up docs to face patients again in the exam room – Yes, Hallelujah, and Amen!
As for the underlying economic forces re-shaping the landscape of Big Medicine these days, I am less sanguine. Just as Henry Ford’s assembly line – and later, computerized robotics – transformed the auto industry, so too with medical care delivery. Given the seemingly astronomical price tag health care carries these days, I’d be more surprised if it didn’t.
As to whether becoming a doc retains its allure in an age long past the extinction of Arrowsmith? Well, that remains very much an open question. Might be better to trade in the white coat for a blue button-down and chinos, become an Epic consultant.
Oh, and don’t forget the early Justin Bieber wave-cut. Details here.
