Monthly Archives: August 2013

Are EMRs making healthcare more or less patient-centered?

EMR-centered care

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?


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Do Omega-3 fatty acids cause prostate cancer?

Do Omega-3 fatty acids cause prostate cancer?

Omega-3 fatty acids have long been one of the most commonly used medical supplements.  In the 1970s, researchers studying the Greenland Intuit Tribe noted that while they consumed large amounts of fat from fish, they displayed virtually no cardiovascular disease.  This finding was attributed to the high amount of omega-3 fatty acids in their fish-rich diet.

The main reason I prescribe omega-3 fatty acids is to lower triglycerides, a type of bad cholesterol that can inflame the pancreas if their level in the blood gets too high.  But omega-3s are taken to treat many other conditions, including dry eyes, depression, and attention deficit disorder (ADD).  The evidence of their efficacy for these other indications is not robust.  But since Omega-3s occur in nature and are not thought to have many serious side effects (aside from possibly fishy breath!), many doctors and patients ask themselves “why not try them?”  Many people take Omega-3s not for any specific reason, but as a general measure to maintain good health.  Such an attitude seemed validated by a 2010 study published in the Journal of the American Medical Association (JAMA) which showed that people with a higher concentration of omega-fatty acids in their blood seemed to be aging slower. The ends of chromosomes, called telomeres, are shortened with aging.  The telomeres in people with higher serum levels of omega-3s were shortening at a slower rate than others.’

With all this omega-enthusiasm, it came as a surprise when a recent study in the Journal of the National Cancer Institute suggested a possible downside to the fishy pills.  Studying men over age 50, it found that those with the highest levels of omega-3 fatty acids in the serum had a 43% higher risk of developing prostate cancer, and a 71% higher chance of developing high-grade prostate cancer, which is more likely to be fatal.  The study did not examine whether the men with higher omega-3 levels had them due to supplements or their diet.

Does this mean Omega-3s cause prostate cancer?  Not necessarily.  We would need a different kind of study to answer this question.  One possible partial explanation for the association between prostate cancer and higher omega- 3 levels is that men who ingest more omega-3 fatty acids may be the kind of guys who get regular check-ups and are screened for prostate cancer.  More prostate cancer was detected in men with higher omega-3 levels, but maybe men with lower levels had prostate cancer that was never screened for and detected. A similar kind of study bias accounts for why taking hormone replacement therapy was long associated with a reduced risk of coronary artery disease in women after menopause.  It turned out that women receiving hormone replacement therapy were more likely to being seeing their doctor and taking other steps (exercising, eating healthy, controlling blood pressure) that reduce heart disease risk.  It was not until a later prospective, interventional trial (the Women’s Health Initiative) that we came to see that taking hormone replacement therapy actually increases the risk of coronary artery disease.   We would need a similar type of study to see if ingesting more omega-3 fatty acids really increases men’s risk of developing prostate cancer.

One important take-away from this study is that nutritional supplements are not always as safe as they seem.  It is wise to have a specific reason for taking a supplement that is supported by strong scientific evidence.


Acknowledging Death is Scary

fear of death

By diminishing the taboo around discussing and studying death, the fields of hospice and palliative care have lessened the isolation of dying and in other ways helped people die better deaths. On the other hand, there is a tendency among those of us who regularly work the very sick to lose sight of just how terrifying death can be. For instance, death-and-dying pioneer Elizabeth Kubler-Ross wrote that ”I always say that death can be one of the greatest experiences ever.” Indeed, for some people the prospect of death prompts them to be fully present to life, to take in each moment of our precious and fleeting existence.

But I have also observed people be consumed by a sickening dread and despair when they face the reality of the mortality. Consider a poignant passage from Tolstoy’s Anna Karenina, in which Levin sees his brother sick with consumption. “Death, the inevitable end of all, for the first time presented itself to him with irresistible force. And death, which was here in this loved brother. . . was not so remote as it had hitherto seemed to him. It was in himself too, he felt that. If not today, tomorrow, if not tomorrow, in thirty years, wasn’t it all the same! And what was this inevitable death–he did not know, had never thought about it, and what was more, had not the power, had not the courage to think about it. I work, I want to do something, but I had forgotten it must all end; I had forgotten–death.” If we do not acknowledge death’s power, we will likely remain befuddled at why people go to such burdensome, costly, and sometimes futile lengths to have the chance at just a bit more life.

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Posted by on August 13, 2013 in Death, Palliative Care

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