EMR In PCSM

What is this alphabet soup I’m offering up today?

EMR, here to stay.
How does it impact
patient/doctor relations?

I wanted to discuss “Electronic Medical Records in Primary Care Sports Medicine.”  In other words, “EMR in PCSM!”

I’m just wrapping up a busy Friday clinic and finishing typing up my notes as I transition to typing up these thoughts on the WordPress blog site.   Doctoring these days involves a lot of typing on the computer! Here at Sports Medicine, Nationwide Children’s Hospital, we use the EPIC EMR system.

I was prompted to write about this issue today, and find out who out there in the sports medicine world is using EMR (or perhaps in 2013 the pertinent question may be who out there is NOT yet using EMR), by a  fine article I read in the L.A. Times:   “So much data-gathering, so little doctoring.” 

I began my career in medicine in the early 90’s:  six years after finishing up my undergraduate education, I started medical school in September 1991.  I recall having an email account in medical school, but it wasn’t until my final year in school that I heard about hypertext or the world wide web.  And there certainly was no EMR, at least for me, in the 90’s.  I was writing in charts or, better yet, dictating my notes.  This is how medical documentation remained for me until 2005, when I spent a few months doing locum tenens work in New Zealand.  I recall showing up my first day at the GP clinic in Matamata, on the North Island of NZ, and the clinic doctor whom I would be working next to asked me if I had ever used EMR.  I said no, and was hoping I might have some option to chart on paper.  He smiled and very civilly told me, more or less, to keep a stiff upper lip and just get on with it.  There would be no paper for me, I’d learn on the fly.

As an aside, now having worked in NZ twice in my professional career, may I say that that country is a leader in the field of what EMR implementation can achieve.  NZ continues to work on EMR integration.  I found in my time there that the song and dance of the American medical system–having medical records faxed from the clinic 10 miles down the road; the MRI transferred to a disc that then must be shuttled hand to hand, trying to read an illegibly written note, etc.–was a rare occurrence in NZ.   It was much easier to take care of a patient ‘out of network’ in NZ than it is in the USA.

The view from the
University of California, Santa Cruz campus.
Yes, it really is that beautiful.

On my return to The States, I discovered my clinic at the University of California, Santa Cruz was ready to implement EMR.  While my colleagues mostly moaned and wanted to drag their feet, I had, I believed, already seen the light.  No more need to track down a missing chart, no more need to decipher a doctor’s handwriting, EMR was the way to go.  And from that point on, for the last 8 years, I have only used EMR in the various positions I have held.

But there is a dark side to EMR.  Getting back to the L.A. Times essay, I found this piece to be, overall, an insightful, provocative and short essay exploring this side.  Many things stood out for me, most especially this paragraph:

“….the electronic medical record.  That’s the note your doctor is probably busy pecking away at while you’re trying to explain what ails you.  In theory, an EMR should make care better and more efficient.  It’s falling pretty far short of that goal.”

For me, the author of the essay identifies the chief problem with EMR, that needs to be put in the balance with its manifold advantages:  as it is often used in clinic, EMR can be a barrier to a quality, healing experience between the clinician and the patient.

Though I know I am ‘less efficient,” my practice is to rely on my speed as a typist to do my notes outside of the examination room.  I will infrequently turn on the computer in a patient room, and if I do, it is almost inevitably to show the patient their diagnostic imaging:  the tear I’ve identified in their ACL, the Salter-Harris II fracture they’ve sustained, the spondylolytic defect I can see on SPECT scan.  A picture is worth a thousand words:  I like patients to see their pictures.  I think it enhances their experience.

What I don’t do is write my note in front of them, or fill my orders out in the EMR in front of them.  I think it borders on being downright rude to the patient.  I most definitely do not think it enhances their experience; conversely, I think the computer screen, and the focus we clinicians place on it, takes away from the potential for the experience to be more completely healing for the patient.

We clinicians have all been patients too.  If I sound like a cranky middle aged man as I share the following vignette, please forgive me, but I think it is reflective of what the L.A. Times essayist is describing.  I went to a urologist a year ago (don’t ask, I told you I’m middle aged!) and I was amazed that the young resident (that’s registrar to you folks in the UK!) spent perhaps 30 seconds of a 10 minute intake looking at me.  The rest of the time she was pecking away at the computer, looking at the screen, asking me questions; but I may as well have not been physically present for all the attention she paid me.  The person.  I found the experience dreadful.  I’m sure the computer must have enjoyed the attention.

There was a time in the bad old days of paper charts where one could lay the patient history on his/her lap while looking the patient in the eyes, jotting down occasionally some of their pertinent history.  I think this did not intrude as much on the patient experience.   Pen and paper in many ways were conducive to a more humane patient experience.

There exist ways of solving this problem.  Electronic tablets might more resemble those old paper charts, and allow a physician to make more eye-to-eye contact while making the charting techonology less of a third, distracting entity in the exam room and more what is is supposed to be:  an important, but subservient, component of the visit.  Another solution:  I favor still being able to dictate and use voice recognition software to chart the visit note than typing away in front of the patient.  If I had such technology, I could more quickly dictate my notes than type away, typically, after all the patients and staff have left the clinic.  I’m all for efficiency, but not when it comes at a cost to the service we are supposed to render to a patient in need.  The Journal of the American Medical Association, JAMA, just ran a viewpoint piece, “Refocusing Medical Education in the EMR Era,”  in which the authors discuss some solutions to be introduced at the very beginning of the medical education of a budding clinician.

EMR is here to stay, and that’s largely a good thing.  But we need to keep working on its ‘dark side’:  its potential to be an impediment to a healing, as well as an efficient, clinical visit.  I’m very curious to know what your thoughts are on EMR; how you might be using it; what challenges you to see to its implementation.

Do any of you in the blogsphere have thoughts on these issues? Do you see EMR as a potential problem, the way the essayist and I do?  Do you have strategies for personalizing the EMR experience, for making it more user-friendly for the patient?  Please share your thoughts with me in the Comments section or tweet me @cjsmonline