In a provocative piece in the Journal of the American Medical Association (JAMA), Elizabeth Toll, MD pens a powerful portrait of what the Electronic Medical Record have brought to the doctor-patient relationship, describing both its benefits and its limitations (be sure to see the 7 year-old’s precient drawing as well).
Perhaps most disturbing was this passage in her essay:
There is a certain irony to all this. For years, we’ve been hearing that focusing on our patients as people, improving communication, admitting mistakes, and creating patient- and family-centered care will make us better physicians, gratify patients, and prevent lawsuits. In fact, professionalism and communication are core components of the residency training curriculum. Medical schools have begun to insist that applicants demonstrate proficiency in the humanities and social sciences, as well as the traditional hard sciences. So, to watch these directives shift with the mandate of the EMR seems a sad reversal of progress and common sense.
All this is not lost on our patients. In addition to the young artist, whose drawing speaks volumes, wherever I go in or out of the medical world these days, I hear patients’ observations: “My doctor hasn’t made eye contact with me since he got on that computer—he’s not a very good typist.” “Our visits are rushed. My doctor used to have time to listen to my concerns, but now she spends a lot of time complaining about how hard her workday is.” Physician colleagues pour out similar comments: “In the past I would see a patient, write a note, close the chart, and spend a moment reflecting on the visit. Now my time goes to fighting with the computer and chasing down my colleagues to get them to lock their notes, so we can submit bills.” “I feel pulled in so many directions, like my brain is scattered. I went into medicine to work with people, but now I’m in front of a computer screen all day, managing systems. I still love my patients, but I hate how I’m spending my time.”
This essay has not been lost on the Electronic Medical Record industry. They are feeling the pushback of doctors who are insisting not just more information, but better information and better efficiencies. In a phone interview, Dr. Toll took some of these concerns further:
The EMR was designed to demonstrate the pieces of the record that you have to attend to in order to bill at a certain level. If you just enter a few questions and you only enter part of the exam, and you only add medicines and you only do this or that, you can only be reimbursed a certain amount. But if you asked about, for instance, the family history, the surgical history and the social history, then you have all the elements to charge more. So there’s an incredible temptation to just push, push, push and bring forward everything from the previous notes without re-asking the questions.
This creates a huge problem: The records are full of lies. They’re full of things that [physicians] have said they’ve done but truly haven’t. The patient has been in eighth grade for three years. The patients are divorced, but in the record they’re still married. The patient used to work as a nurse and now works as a librarian, but it hasn’t been changed in the record because people are giving quick, push-button answers to save time, and they don’t update the info. You can see this as you go through small things in the social history but also in [clinical histories]. Yesterday, someone sent me a letter about an amputee patient he sent to a podiatrist. He got a report back on both the patient’s feet. This patient only has one foot.
Cut and paste has its efficiencies and its downfalls. When audits happen to justify billing and innacurate copied paragraphs are found to fill the doctors’ note, how will hospital systems respond?