Electronic Medical Wrecker



I need to say a few things about the EMR (Electronic Medical Record), EHR (Electronic Health Record) or whatever you would like to call it this morning.

Our system in the SC Department of Mental Health has been using an EMR system for several years now. The telepsychiatry program I work in also has a modified version of that same record keeping system. When we talked about the rollout of this system a decade or more ago, it caused fear and trepidation among the thousands of mental health workers in our system who were used to pen and paper, writing process notes and prescriptions by hand, and taking notes on yellow legal pads or in spiral notebooks as they helped those who suffered from depression or schizophrenia.

For some, it was so anxiety-producing that they simply decided to retire rather than face the uphill battle of learning to use a strange new system that to them was nothing short of a career-killer. It was sad for me to watch several caring, seasoned therapists and doctors decide to walk away rather than learn a new way of doing things. They collectively held the institutional memory of our system, and this was a great loss to both the system itself and many of the newbies who were just starting their own careers in the public mental health arena. 

So, one of the first casualties of the electronic medical wrecker was the experienced mental health worker, a dinosaur who trudged off into the mists of time, mumbling about technology and pulling a cart loaded down with thick, fraying medical charts behind him. 

Are there other casualties even now, years after the adoption of this system of keeping medical records? I think there are. Now, let me say, for the benefit of the two of you who are reading this and do not know about my love of all things technological, I am not a Luddite. I love my computers and gadgets and apps and programs. I still feel that the EHR has many shortcomings and puts one more layer between patient and provider, weakening the doctor-patient relationship.  How?

If you have ever gone to see your own doctor and she must pay attention to the screen in front of her (be it iPad or laptop or desktop or iPhone) more than she pays attention to you, you have felt that sense of diversion of energy. The doctor is so fixated on check boxes and lists and forms that need to be filled out that she cannot make nearly as  much direct eye contact with you. She cannot watch for that little twitch of your face, that tell tale movement of your hand because she is entering your current medications as she takes your history. The attention paid to the patient must be sacrificed, at least in part, because of the need for increased screen time. 

Satisfying the demands of the EMR at each visit takes away from the time that the doctor might have to think, process what he has just seen, and come up with innovative responses that would help his patient. If  family practice doctor must see a patient every 7-10 minutes and also included the electronic documentation in that time period, less and less time is being spent on clinical thinking and processing. Even if the note is completed later, a huge chunk of the day’s time is given over to record completion that is prescribed in a very specific way.

Doctors that I have talked to say that because of the new record keeping demands they have less time to relax, regroup and think during the work day. They are usually worried about keeping up, getting medical record tasks done for the day, and do not feel that they can let up until that task is done, even if it means skipping lunch or getting home late for dinner. 

Granted, the EHR makes it much easier to go back later and read a doctor’s notes, as legibility becomes a given. Documentation is much more complete, usually, even though in our own system I see that notes are getting shorter and have less content since time is of the essence. There is no longer that satisfying feeling of being able to physically flip through a paper record, knowing exactly how far back in the record one must flip to get to labs, nurses’ notes or history and physical. Like the pleasant and satisfying feeling of holding a beloved book in one’s hand and turning its pages, the experience of using a paper chart will be one that many a  medical student of today may never have. 

Once again, let me be clear that there are many aspects of the new electronic health records that I appreciate and even like. That being said, I think we as doctors are having to give up many other aspects of the day-to-day physical practice of medicine that I hate to see us lose. 

What has your own experience been with the electronic medical record? Has this been as a practitioner or as a patient? Did you feel slighted or cheated? Did you feel more rushed? Did the record keeping detract from the direct time with your doctor or patient in any substantial way?

As always, I’d love to hear what others think about this latest change in medicine and how it has impacted your own interactions in the world of medical care. 

Have a good Monday, my friends.