Shirah Vollmer MD

The Musings of Dr. Vollmer

Electronic Medical Records: Do You Want Fries With That?

Posted by Dr. Vollmer on January 16, 2012

  The Affordable Care Act, the digitization of our world, and the changing delivery of health care all comes together to roll out electronic medical records, now active at Kaiser, and soon to be active in almost every primary care setting, certainly by 2014. To be clear, I think that this will be a net positive for patient care. Medical information will be helpful to emergency room visits, doing health maintenance, and tracking prescriptions. I am optimistic about the benefits for the vast majority of patients who now have fragmented care, or no care at all. My concern is how will electronic medical records change the joy in the practice of medicine. Will taking care of patients retain the fun, if a menu comes down for every patient, reminding the provider to remind the patient to wear his seatbelt when he drives in his car? Again, I think it is a good idea, and it will help, for the computer to prompt the physician to remember preventive medicine questions, as preventing accidents, for example, is a very important part of health care. Now, though, that conversation, stems from a general concern for the patient, usually discussed, at a visit where critical medical issues have already been addressed. Yes, of course, the computer eliminates the human error, inherent in trying to remember too many things, especially when the provider has too many patients. At the same time, the fun in patient care, at least for me (and I am not a primary care doctor, I understand that) is the spontaneity of conversation, which is based on a deep training of important questions which are well-timed to the moment of most open communication. For example, there is a big difference if you tell a patient to stop smoking in a rote fashion, as opposed to telling them to stop smoking after they just told you that their uncle died from lung cancer. I fear that this art of persuasion will be lost with the advent of electronic medical records. In so doing, I fear the fun of patient care will diminish considerably. Sure, there is an upside. Efficiency is going to make the doctors feel better, as inefficiency, in the current system is degrading and demoralizing to physicians. Balancing it out though, I still fear that this roll out will be a net gain for patients and a net loss for providers. As with so many of my grim predictions, I really hope I am wrong.

10 Responses to “Electronic Medical Records: Do You Want Fries With That?”

  1. Shelly said

    Sorry to disappoint you. We have EMR over here in the middle east and it has done nothing but bring the quality of health care down for the patients. My PCP had said “Oh, I’d be lost without my computer.” I’m sure she would be. But I’ve also been to physicians who have never looked up from the screen, never even looked at my face when talking to me. Is this what you call quality care?

    • Hi Shelly,
      Yes, I am afraid of what you are saying and I am glad that you shared your experience. I realize that the doctor patient relationship may die with electronic medical records and that, to me, is incredibly sad. At the same time, good care can be delivered in an automated fashion and even though it does not feel very comforting, it is a lot better than no medical care at all. The other big concern, that I did not mention, is the huge vulnerability to lack of privacy. That issue is for another post. So, yes, I can see how the visit with the physician is not enjoyable with EMR, and I can see how this will decrease the satisfaction of both the doctor and the patient, but on the other hand, I can also see how increasing information flow will help coordinate care. This is what I referred to obliquely as a net positive. Still, having trained in the 80s when the doctor-patient relationship was touted as a useful tool towards wellness, I share your disturbance that electronics, with all of their excitement in this quickly changing technological world, does not belong in all aspects of our lives. Thanks again for sharing your experience.

  2. I really shouldn’t get started on this topic because I’m probably too opinionated….sigh ;-(.. but I also agree that the doctor/patient relationship of the past will change and become more “digitized and mechanized”, unfortunately. The thing that bother’s me even more is the way insurance companies are dictating “what can or cannot be covered” and are literally telling physicians (uh…”providers”) how to treat their patients…but this is another topic that perhaps you can do a blog post on sometime. My husband and son are physicians (tho not primary care docs) are are seeing the change in our medical system and I have also visited with other physicians that feel the same way and are discouraged. And insurance coverage for quality mental health treatment and care is still in the dark ages.

    • Thank you Eleanor for your comments. One issue here is that change, of any kind, is scary, and so there may be trepidation around that. I want to keep an open mind that EMR may help streamline medical care for many patients who currently go without. I could imagine that with that efficiency will come greater access to care, in that there will be less need for human interaction in that more care can be done electronically, thereby providing more people with needed help. Having said that, the loss of the doctor-patient relationship, does seem to be a potential liability in the change in record keeping. This concerns me greatly, but at the same time, adapting to new ways of doing things is a challenge which is accelerating in every aspects of our lives so we need to find a work-around to accomplish that. Your point about insurance companies dictating care is also important. It is possible that EMR will be the first step to a single-payor system, and as such, this could change the balance of power. The complicated nature of this topic is mind blowing, so it is nice to have a “conversation” about it. Thanks again for your comments.

  3. Hi Shirah, I agree, this topic is incredibly complex (there are certainly no quick or easy answers) and I think everyone is in favor of increased access to medical care, or at least I hope they are because it is so important. What is scary here is that some of the methods of increased access to care can potentially lower the quality of care for everyone…and the loss of human contact is a given to some extent…the picture of “providers” typing away at computers, filling in lists “boxes” regarding diagnosis from answers the patient gives is becoming commonplace rather than having face to face conversations with patients regarding the intricacies of complex symptoms, etc. In some cases, the EMR computer database wants absolute, either/or, black or white “check box answers” to questions that aren’t always absolute and this puts everyone at risk. Also patient confidentiality is at increased risk with the increased use of EMR systems. Those physicians in training now are of course more prepared for all this because it is the only thing they have ever known. In talking to many medical friends and acquaintances over the years who trained in another time, they are understandably saddened by the loss of human connectedness in the “art” of the practice of medicine.

    • Hi Eleanor,
      It is great to get your point of view. I agree with everything that you said. The issue is a value judgment between quality of care and access to care. If more people have access, but the overall quality is lower, is that better or worse than the current system? I am not sure. My focus in this post is on the doctor’s perspective. As you said, people who trained with paper records are understandably dismayed. My concern is that a different personality will be attracted to medicine that has EMR and maybe that will be OK, but it will certainly represent a major shift in the profession. Technological change is shifting our world rapidly. Medicine is no exception.

  4. I’ll make one more comment then I’ll shut up…smiles… 🙂 I’m hesitant to make analogies or generalities but I’ve give it try here. It’s my understanding that many of the current trends in psychiatry today focus on treating the “brain” rather than the human inside……Medication is easier, quicker, more bottom line cost effective, and can reach far far more of the general population….but is it better? In some cases, yes, but in all too many instances the patient’s soul…their “self” can be compromised in the process. This probably isn’t the best analogy but it’s all I could think of! I totally agree that medical practice today is attracting a different breed of “provider”…not better or worse…just “different”. Lets hope they can be aware of the limitations of the EMR system while maintaining some degree of human connectedness in care and treatment down the road.

    • Oh, don’t shut up. This is fun. Yes, psychiatry has lost its way-sadly. Our new psychopharmacological tools have given way to a less personalized service, but as you say, also a broader service. Hopefully, the pendulum will swing to a middle ground which integrates psychopharmacology with psychotherapy.
      As for the issue of EMR, I think it will be hard for the newbies to appreciate the limitations if that is all they know. Us, older people, need to remind them of what they are missing, and they, the younger folks, need to be open to hearing it. Let’s see how that plays out. We live in interesting times. Thanks again.

  5. OK Ok I won’t! (shut up ;-)….few more recent insights into what we’re talking about here…..Talked to my son about this also…His orthopedic surgery office is completely paperless…everything digital (saving the trees which is a good thing!)…Every patient’s complete history is on hard drives with elaborate back up systems). He is very tech savvy and has also written a comprehensive program for the iPad and iPhone to link up to his patient electronic records …anywhere, anytime through WiFi. This program app is for lease on the Apple App store. The templates his office uses are highly customizable so more of the individuality of patients is maintained…but individuality depends on “how much and to what extent” one customizes the templates. Maintaining digital records takes huge amounts of time…much more time than dictating records, so some doctors customize less than others to be more time efficient. I asked my son if he has computers in his exam rooms and he said “we tried that in a couple of the rooms but it was too distracting so we took them out”. This means lots of time later filling out all the electronic records after hours or on weekends. But the patient gets more human connection with the physician. Conversely, at the just opened half billon dollar, no cost spared for the best of care, Texas Children’s Hospital/Baylor Women’s/Maternity center there are computers in every exam room and every consult room. Because of this many of the doctors fill out the forms and boxes with patients present in both exam and consult rooms…not a good thing. EMC is here to stay, no doubt, but the choices individual physicians make on how to use this system will effect the degree of “personalization of care” in the future.

  6. Hi Eleanor,
    Thanks for your comments and kudos to your son for avoiding the face in the screen “interaction” with patients. It is interesting to hear your son’s experience and that of Texas Children’s Hospital. My fear is that physician productivity is so closely monitored that physicians who work for large organizations will have no choice but to have their face in the screen while taking a history. Only boutique practices will have the autonomy to decide how to interface with EMR. Hence the majority of doctors will be forced to be “data-entry” physicians . Or, as my imaginary New Yorker cartoon would say, “Hello, I am Doctor Vollmer and I am going to input your data.” Thanks again for sharing your experiences and experiences of your loved ones.

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