Mary McAteer MD FAAP
General Pediatrician
President Indianapolis Medical Society
Indianapolis, IN
One of the biggest failures in health care is the use of the electronic medical record. By proving to be inefficient and unreliable, EMR systems have undermined confidence in the patient/physician relationship. The quality of the relationship is essential to improving our patients’ health outcomes and the health of our profession. Building that relationship involves developing trust by personally committing to creating respectful communication and defining mutual expectations.
Workflows involving EMR distract doctors from practicing the complicated skills involved in treating patients. Using EMR requires doctors to validate, navigate and input data in the system, rather than give personal attention to their patients. This has resulted in dissatisfaction for all involved in the patient experience, a known factor leading to physician burnout. Patients are given the impression that the doctor is not communicating meaningfully with them, which disengages patients from being open, decreases compliance and worsens health outcomes. Patients come with expectations that their health information is valid and complete, like their experiences conducting searches for themselves. Physicians also expect the information to be valid. But with the inefficiencies of data entry and retrieval, that reliance on validity is up for grabs.
I believe our patients trust us to bring it all together for them, and I hope they realize how much we all would like that too. To illustrate the cooperation needed, here is my story about Chris, who came to my office for his wellness visit prior to college. We are in the exam room laughing about the last time he received shots and passed out in his dad’s arms. He swallows hard when he asks about shots he may need this visit, believing that they are necessary and good. I turn to the electronic version of our 18-year relationship, which had previously existed on paper. I am searching his data, still searching, his laughter is getting a little more anxious. I am getting a bit more anxious too, trying to talk about the Colts' upcoming season or something….anything else.
Soon, Chris offers his help. He has rebuilt computers, has programming experience and feels confident with anything electronic. Appreciatively, I show him his EMR and the vast array of possible spaces where his records of past immunizations may reside. He studies the screen and we navigate through some of the options. After a while, he stands up and shrugs saying, “This is a mess. I feel sorry for you, so go ahead and give me any of the shots you think I might need.” My office staff interrupts us with a knock on the door, supplying the old paper records. Upon consulting those, he receives the appropriate vaccinations. The tragedy of this story is the waste of time, precious time, that we could have spent preparing him for this new phase of his life.
I have heard many defenses of the EMR as a necessary evolution in health care. Using an unreliable and inefficient tool will never evolve into better health care. It is imperative to develop better technologic tools to result in more productive and reliable communication, reasonable expectations, and personal commitment to patient care. We need improvements focusing on more efficient workflows and communication that uses valid clinical information. The standard for adopting clinical tools should be primarily to improve the quality of the patient experience, leading to rewarding, trusting relationships with physicians. With tools designed with the goal of serving the patient/physician relationship we will rejuvenate health care.
Thanks for writing this. I think we would do well as a profession to focus on two specific major issues that are related to this, rather than the more-often-heard "EMR" issue. I don't think that the use of electronic records are inherently a problem — in fact, there is an "EMR" I use at a summer camp which is largely simple free-texting that I prefer to paper, because it's legible and I type faster than I can hand-write. And even with the EMR I use in clinic regularly (Epic), I have to say that the clarity and speed with which I can get information about my patient from specialists and (now) even other systems, is incredible.
ReplyDeleteThe issues boil down to two items, one of which is discussed above, and the other is not.
One, the interfaces are horrible. Even the best EMRs seem to have interfaces designed by vandals. The clarity for the end-user appears to have been minimally considered, and most physicians who are involved in the process tend to forget that not everyone spends all their time thinking about EMR usage and have forgotten how to make it work. The care and diligence we put into focus groups and surveys to make sure patient materials are clear and intelligible is completely forgotten when it comes to the interface. This is a place where innovation is sorely needed, and it needs to be demanded by the customers — who are the health systems (since they're paying).
Two, the "death of a thousand clicks" to measure and record all sorts of things is less a problem with the EMR itself, and more around the need and desire of health care systems to record these things for documentation purposes — often for reimbursement reasons, although sometimes it can be for research or QI. If there had been an easy way to collect this off of paper charts, we would have seen it happen prior to the advent of EMRs. So let's be clear — how much of this is because of the inherent nature of EMRs, and how much of it is because of what administration wants/needs?
Let's make sure we're pushing back on the right things. These are decisions made by human beings, and can be changed. I worry that a succession of anti-EMR articles (of which there are many) will sounds like we're happy to throw the baby out with the bathwater. EMRs have some great benefits. Let's demand improved interfaces, and let's demand that administration recognize the burden they're placing upon us.
Thanks Dipesh, I agree as I look at my old hand written charts, that I can read what I wrote much better with typing. I agree with your call for better interfaces, so we can interface with our patients better. By diminishing the administrative goal of documentation for billing sake, we can focus on communicating for the sake of patient care -very rewarding.
DeleteThank you for your story and perspective, but mine is different. With a well-designed EMR, used effectively and efficiently, you would have been prepared to answer your patient's question without having to scroll thru screens in front of him. I don't disagree with you that EMRs are changing the landscape of how we store and retrieve data... but there are EMRs built for pediatrics, from the ground up, that work. We should be using them or demanding that 'generic' one-size-fits-all EMRs function as these pediatric-designed EMRs do, to avoid encounters like the one you describe.
ReplyDeleteEMRs are a work in progress. As pediatricians, we are part of both the problem and the solution. Tolerating inferior products in our workflow is simultaneously part of the problem and slowing our progress toward the many varied solutions.
Dear Gayle, I am so glad there exist some sensible EMR pediatric-related products. It is difficult to advocate for a change to EMR products, if employed by a corporation where pediatrics bring in less than 4% of corporate revenues. Thank you for the call to keep sharing and helping each other advocate, perhaps the squeaky wheels will get noticed.
DeleteDoctor to administrators... "Do no harm!" Let's hope EMR evolves very quickly or I fear we will lose a generation of wonderful, smart, dedicated, pediatricians.
ReplyDelete