Does an EMR impact our bedside manner?


Category : Medical Rants

I received this excellent question this morning.  Many physicians are Luddites.  They see the downsides of technological advance (yes EMR is a technological advance) and do not see the upside.

As an academic hospitalist, the EMR has no impact on my bedside manner.  I work in 2 hospitals, one with a full EMR (the VA) and a community hospital where I hand write my notes.  My bedside manner does not differ, because being at the bedside is a separate job from recording our visits – or at least it should be.

Some critics have argued that EMR impacts the outpatient visit, because the physician is looking at the computer rather than the patient.  Those same physicians used to keep their nose in the paper chart!

What impacts bedside manner is our desire to interact with the patient?  We must always remember that "it is all about the patient".  I find EMRs give me quicker information, so that I can spend more time with the patient. 

My answer is certainly colored through my own tinted glasses.  I like patients, interacting with patients, educating patients, etc.  Nothing will prevent me from that activity.

Perhaps the EMR is an excuse for those awkward physicians who do not really like interacting with patients.  Perhaps the world has changed, and I have ignored the change.

Comments (12)

Disagree the "many physicians are Luddites."
Very few physicians want to go back to the days of lab techs writing the serum sodium on a multi part carbon form and having one filed in the chart, one put in a box at the nurses' station to be pawed through on rounds.  Very few physicians want to go back to the days of physical films for images, to be unearthed by the xray tech, or lost by the resident, or sequestered in the consultant's office.
IT has been nearly universally embraced by the medical profession where it works, where it helps us do our job.
EMRs do not help us do our job enough to justify their existence on their own.  They have benefits.  They have costs.  Under current circumstances (need to get bullets to get paid, bribery/reimbursement to install an EMR that meets government criteria), physicians are grudgingly adopting EMRs.
Do not misinterpret that begrudgingness for Ludditeness.  
It's just that EMRs are being crammed down on us, and we are less enthusiastic about using EMRs because they are high cost, low benefit.  Get us a system that on net helps more than it slows us down, and we will buy them on our own, and use them enthusiastically.  We will adopt them as quickly as we have adopted computerized lab and imaging results.

Dr. C:
While I appreciate the value of EMRs., I often review medical records for law firms. A disturbing trend is evolving. Recently I saw a 3 week hospitalization with 4500 pages of records.
That works out to 200 pages/day (an average, not a day by day figure) or an average of a page every eight minutes of hospitalization. Not only that but the key notes and sequences either weren't present or comprehensible. Reams and reams of checklists that mean nothing to anyone for any purpose..
Other charts like 6 hour ER charts with fifty pages. 3 day hospitalizations with 500 pages. 
How can this possibly be a good thing? Is anyone aware of this trend?     

I'm going to side with the "physicians aren't luddites" crowd. The same politicians who accuse them of that also blame them for ordering too many new cutting edge technologies that aren't proven yet in favor of cheaper, older options because they're suckers for new flashy technology. Which one is it?
I tend to be anti-current-generation EMR, which always seems to be taken as anti-EMR in general but really just means the current offerings are not very good.
Actually, I like the VA EMR, CPRS, a lot better than the other EMRs, like Epic, I use. If EMRs were as functional as other electronic services I use (,,,,, Google Apps etc.–some luddite I am) then you wouldn't have to be twisting our arms to adopt them.

EMRs are great for templates and simple illnesses. That said, I have specialist sending me 5 to 7 page notes with 1-2 pages of nothing but ROS and P/F/S hx that are more extensive than med school but contribute nothing to the care of the patient. It is questionable how much of the excessive documentation really is performed. EMRs also are encouraging higher levels of coding which are starting to draw Medicare audits.

As stated in these comments, many (most?) of the EMR notes are gibberish with important medical information buried in the noise (if there at all).  This clearly violates the principle of endorsing "patient centered care" in what we do. 
Why are the administrators who are usually the strongest EMR advocates usually silent on this issue? 

Perhaps because the most important reason for EMRs is facilitated billing?

Don't know if you saw Abraham Verghese's essay this weekend in NYT, but he's got some wonderfully eloquent passages on how docs are trying to figure out how to utilize EMRs. A choice excerpt:
This computer record creates what I call an “iPatient” — and this iPatient threatens to become the real focus of our attention, while the real patient in the bed often feels neglected, a mere placeholder for the virtual record.
I would vote "no" on MDs being Luddites (especially the younger generation), but I get why the comparison's being made. Just a guess, but I think it's a little easier for inpatient doctors to separate computer screen from patient since most hospital computers are still desktops, while outpatient docs often have their computers right in the exam rooms & they look at them to review the patient's notes while they sit there–whence Verghese's brilliant "iPatient" moniker. Though once those computers move into laptop mode and can go from room to room like they use in our ICUs these days, watch out.

It’s not hard to understand why many physicians don’t like EMR.  It has nothing to do with being a “Luddite” or being “awkward” with patients, or ignoring the fact that “it is about the patient”.  This characterization is easy, because it fails to look at how physicians operate.
For outpatient physicians, EMR
1)   has taken a complex process- the evaluation and treatment of patients- that was easier to document using freestyle entry (i.e. dictation or hand writing) and tried to “digitalize” it into boxes, checkmarks, and drop down menus which not only limit the descriptive aspect of it, but takes longer
2) taken that data and made the EMR companies “stewards” of that information (data migration is next impossible), which now marries the physician to that software company
3) has made physicians into public health monitors for the government and third party payers without appropriate compensation via  “clinically meaningful use” of EMR (which is mostly about creating data sets for outside parties to mine)
4) created vast amounts of useless documents (Cory’s description of thousands of sheets for a 3wk admission is not surprising) that interferes with medical care. 
EMR is different than lab computer systems that call up results, or radiology programs that call up reports- these are separate programs that have existed for years, without the need for government mandate, and have existed alongside paper charts.
BTW I am a young physician, enjoy patient care, carry a smart phone, use social networking, use UpToDate, E-mail my patients, have a notebook, tablet, and desktop, and I still find EMR to be junk.

Every doc I know has a smart phone. The majority of those docs think EMRS stink. Are they Luddites?

No question the computer can get between the doctor and patient. I dont think doctors are any different than they used to be – if you don't like personal interaction with patients you go into radiology, anesthesia, pathology or laboratory medicine. If the sytem you are working for demands that you fill out checklists of clinical reminders that's going to take up part of the patient visit and require interaction with the computer as much as the patient. The patient's concerns may get lost in the performance measure/clinical reminder/billing documentation shuffle.
In high school I had to read a book called "The Art of Plain Talk" which pointed out that communication was best served when it was brief and phrased in the simplest terms.  We've lost this. An office note for hypertension 20 years ago might have read something like this:
"Pt here for BP check. Feels well. BP 160/90. Lungs/cor neg. Will increase atenolol to 50 mg daily. RTC 1 month."
Now the same visit will generate a 10 point ROS, a lengthy physical exam which is usually a templated cut-and paste item, etc. and be a yard long.  No more significant information is communicated but the above note doesn't satisfy anyone other than the doctor seeing the patient a month later. Certainly not the billing people or legal dept.
I use an emr system and find it great for bringing up old lab data, radiology reports, discharge summaries etc. Most of the notes in it are like cotton candy – lots of volume and little substance.

I want one thing from EMR notes – the real documentation can come in bold and capital letters or some other font so I know where to read; the rest can be used by bean counters and global warming police.
I think overall, VA EMR is better than other EMRs. There is no uniformity in EMRs out in the real world. I have seen 5 till now in my short career – either they are not good enough for me or I am not good enough for them.

[…] what’s really happening in a person’s life.  They ask us to quantify things that cannot be quantified, and distract our attention from what might be truly significant in the patient’s life at the […]

Post a comment