I'm supervising resident doctors-in-training at a family medicine clinic. The resident sees an 80 year-old woman from Pakistan with respiratory complaints but notices one of her pupils is strangely shaped, and asks me to take a look. It is an iridectomy scar -- the aftermath of a cataract operation that cut through the iris, a common surgery that preceded the intraocular lens implants we now do. As I've been in practice for over 40 years, I'm familiar with this scar, although it's been about that long since that type of surgery was routine. What confused the resident is that five previous notes in the Electronic Health Record (EHR), by five different physicians, document normal, round pupils. The patient's son confirms his mother had cataract surgery on that eye, in Pakistan, 40 years ago. Gibberish.
Have you noticed your doctor doesn't look at you much anymore? That's because he or she is using an EHR (also known as an electronic medical record, or EMR), which redirects attention to a computer screen, away from the patient. The widespread introduction of EHR's in the past few years came with a bright promise: legible charts immediately available to multiple providers, computer-driven algorithms to make sure you're doing the right thing, drug-interaction checks, and all the wonderments that computers can provide. Some of this has come to pass, but the reality is that the EHR, as it currently exists, is an impediment to good medical practice.
EHR's were designed to maximize reimbursements, demonstrate parameters for quality of care, and meet governmental "meaningful use" requirements. This is accomplished with many mouse clicks to fill required fields (like "eyes examined"), and data entry. The data entered don't necessarily enhance patient care, and the sheer volume of documentation requirements renders the information into something less than accurate, at best, and made up, as above. No one is trying to be dishonest. But sometimes, there's no other way to have any time to spend on the patient, the one who really should command your attention.
Doctors are not happy about this. A RAND corporation 2013 study (p. 111-112) found that currently used EHR's were cumbersome and contributed significantly to job dissatisfaction. And unhappy physicians deliver poorer quality care. Believe me, most doctors would rather be looking at you, the patient, than at a computer screen. But so much "information" has to be entered that we no longer have the luxury of facing you.
In fact, when the note is finally generated, there is very little space or time left to put in what actually happened during the visit, what the doctor thought, and what was done. I often have to plough through several pages of gibberish data to figure out why that person actually came to the Dr. that day, what the thinking was, and what actually happened.
And medical practitioners these days have little choice but to use EHR's. The government- through its Medicare & Medicaid Services (CMS) began prodding physicians in 2011 to use EHR's, to demonstrate "meaningful use", which are parameters of what the government believes to be good medical care. Failure to do so results in financial penalties. Ironically, the cost of implementing and using an EHR is prohibitive: lower estimates from a government source referencing pre-2011 data put it at $33,000 to get started and $8000 annually to maintain. A more recent look by Medical Economics found the costs much, much higher, with 45% of practices spending more than $100,000 to begin. Although government incentive programs will defray some cost (about $18 billion was earmarked for this), the costs of hiring extra personnel to do all that the systems require, and the attendant drop in patient visits is not covered. Solo and small practices simply can't afford EHR's, and must absorb lower reimbursements or sell the practice to a medical conglomerate, whose focus is the bottom line, not your health.
In "Transitional Chaos or Enduring Harm?" The EHR and the Disruption of Medicine", an October 22, 2015 editorial in the New England Journal of Medicine, some of the utter thoughtlessness behind EHR's as currently used is laid out: how the systems were designed without either doctors' needs or patient care being seriously considered, how projected cost savings and higher quality care never quite happened, how EHR's were designed to document quality care and maximize billing.
As if quality medical care exists merely by documentation. Having spent most of my professional career looking directly at patients, I apologize now when I must turn away from the person I'm trying to help, and toward the computer instead. My patients are sympathetic; they have iPhones, they accept technology. My younger colleagues may never know what it was like to actually look at the folks you're caring for. Soon, the doctor-patient relationship may evolve without eye contact. (Maybe it won't matter- some EHR's have the patient's picture at the top of the record.)
EHR's like iPhones, are here to stay. The legibility and availability of consultants' and hospital notes, as well as test results, save time and contribute to good continuity of care. But the systems are not "interoperable", meaning you can only access records within your own practice or hospital. There are many EHR vendors and they are in competition. They don't share. So one of the greatest potential benefits of computerized records- that they be immediately available to any practitioner who needs them- has not materialized, although there's hope that someday it will.
"Higher clinician gaze time at the patient predicted greater patient satisfaction." This was the conclusion of a November, 2015 study in the Journal of Family Practice. It is as if, by trying to measure quality, we diminish it. Interns spend 40% of their time at the computer, and 12% at the bedside. How can this help? Insurers are paying for mouse clicks, believing this equates with good medical care. EHR's in their current form are more detrimental than helpful. They need to be made simpler, cheaper, interoperable, and less obsessed with documentation of quality care and more interested in enabling a good doctor-patient relationship. They shouldn't have to be padded with unhelpful information in the name of quality. Technology should enhance skills, not suffocate human contact under a sludge of gibberish. We should know what our patients' eyes look like.