EMR-centered care

A new study in the Journal of General Internal Medicine revealed that doctors spend substantially more time with their computers than they do with their patients.  Reflecting on this study, physician Danielle Ofri argues that “we need to rethink the role of technology in medicine, especially the EMR.  The new mantra of ‘patient-centered care’ needs to apply equally to our computerized systems.  With each new iteration of the EMR, we need to ask ourselves how patients are benefiting, as opposed to whether we are merely satisfying administrative documentation mandates.  The EMR needs to exist in service to patient care, not simply as an end in itself.”

I first became aware of the challenges of EMR use while rotating through the VA in my third year of medical school.  After meeting a pleasant physician I’ll call Dr. Smith, we began our first day together seeing patients.  Following handshakes with patients and their family members, Dr. Smith face turned to his computer screen for most the remainder of the clinic visits.   Asking patients questions about their conditions, Dr. Smith typed away as they responded, recording the relevant data they produced.  After a brief physical exam, patients were handed their prescriptions before being ushered out to the nurse or clerk.  I remember thinking that the encounter seemed more like a business transaction than something to do with healing.  The patients had completed a necessary errand and were moving on with the rest of their day.  The following morning, it was my turn to take over patient care and be supervised by Dr. Smith.  As I negotiated the demands of computer data entry and providing care, I began to sympathize with and adopt his approach.  To listen with eye contact as patients talked and then afterward type what they had just said while they continued to talk and present more information was not practical.  And if I gave the patients my undivided attention during the visit and tried to document afterward, I found myself getting quite behind schedule, to the chagrin of Dr. Smith, the staff, and patients.  Soon I too was shouting out questions as I furiously typed away, rationalizing that this was the only practical way to get through the day.

My story echoes many doctors’ experience of EMRs as a hindrance to effective physician-patient communication.  As pediatrician Anne Armstrong-Coben writes in the New York Times, “Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up.”

Why is recording data often more difficult and time-consuming using an EMR than it is utilizing paper charts?  Part of the problem is that the EMR documentation format is not designed solely for the purpose of providing quality care.  It also aims to ensure that adequate data is provided to justify payment for services should an insurance company or the Center for Medicare and Medicaid Service (CMS) audit the chart.  Since incentives and other forms of reimbursement from CMS are affected by Meaningful Use (MU) of the EMR, EMRs must also ensure that they meet MU standards. This may require physicians to enter data and perform EMR tasks that are not necessarily germane to helping the patient address their health issues.

How can physicians effectively respond to the greater time demanded by EMR documentation?  One approach is using staff to do some of the data entry work.  For example, some physicians have hired scribes to enter data so that the physician can concentrate on being fully attentive to the patient and responding to his or her health issue.  But the expense of paying for a scribe is not an attractive option for many physicians, particularly those in primary care.   There is also hope that as dissatisfaction with the current EMR data entry technology becomes better recognized, software engineers will work with physicians to develop more functional systems.  Already, some EMRs are using improved voice-recognition technology to recover some of the greater efficiency that traditional dictation delivered.

Has using an EMR enhanced or hurt your ability to communicate with patients? Does entering data in the EMR take away time from the other parts of patient care?