A report from The Blog That Ate Manhattan:
The Problem : Lost Face Time = Lost Joy
One day, about 5 years into using the electronic medical record in my practice, I came to the realization that I wasn’t having fun anymore. I was sitting throughout most of every office encounter facing a computer screen, my back to the patient on the exam table across the room. The joy of face to face interaction with people, the real reason I went into medicine in the first place, had been replaced with the more pressing urgency of data entry.
My revisit routine went something like this – I’d enter the room, briefly greet the patient (undressed and sitting on the exam table) and then, apologetically saying “Let me just open your chart”, I’d log on and begin interacting with the more immediately demanding presence in the room – the EMR. I’d turn around as often as I could to look at my patient, but mostly I listened but kept my back to her and I typed. After which I’d rush over to her side, do the exam, then head back over to the computer to make sure I got all her orders, refills and charges in as required. A brief goodbye, and I was on to my next patient.
As more and more mandatory clicks were demanded from the EMR to prove I was a good doctor – smoking history reviewed (click), medication reconciliation (click, click, click,click), problem list review (erase duplicates from ENT , remove resolved problems, add today’s, then click that I had reviewed what I just did) – the actual moments of face time with my patients had became smaller and smaller, till they were almost an annoying distraction from the real task at hand – finishing my charts.
I found myself spending office hours longing for them to be over, and even more sadly, wondering just how many more years I needed to do this before I could retire.
Something had to change. Since the EMR wasn’t going anywhere, it was going to be up to me to make it work.
Renovating the Exam Room was not the anwser
My internist has a patient chair next to the desk in the exam room – I talk with her there, then she leaves the room while I change, then she comes back and does the exam, finally wrapping things up at the desk while I wait in my gown. Then I dress after she leaves.
I thought about pushing for our exams rooms to be renovated, but realized that I probably wouldn’t adopt my internist’s workflow. It just ties up an exam room for too long.
Advance chart prep was not the answer
I tried doing what some of my colleagues do – reviewing the charts of my patients the night before, creating a presumptive note based on her history and the scheduled reason for her visit (when I knew it) , even entering charges and orders for mammograms and birth control pill refills, all of which I could quickly edit and sign tomorrow when I saw the patient, freeing up the encounter itself for more personal interaction.
That idea lasted about a day. While it may work for surgical sub-specialists who hold office hours twice a week to prep charts the night before, it’s impossible for a doc like myself who sees between 15-24 patients a day, 4 days a week. I had to find a way to get today’s work done today (and not at 4:30 am today, which is when another colleague does his chart prep).
Changing office workflow was the answer
I realized that my private office, which sits between my two exam rooms, is arranged so that I can type and look at my patient at the same time. So I decided to reserve all my electronic charting to my office, and leave the exam room to do what it does best – exams.
My patients now come to see me in my office before and sometimes after they’ve been examined – a workflow previously reserved for new patients. It’s a little more complicated for the office staff, but it’s working really well for me and for my patients. We’re both more relaxed and can both look one another in the eye while we talk and I type.
Its not just the office staff who’ve had to get used to the new workflow. Long-time patients can get thrown, despite my staff explaining that this is the new routine. One patient told me she felt like she was being called to the principal’s office. Another was convinced I had bad news for her. Once I explain my rationale, however, my patients are more than pleased with the new arrangement. Some have remarked on how much they like my office, and how its decor and wall art has allowed them to get a better sense of who I am.
Other pluses – I’m no longer wasting precious time logging in and out of the EMR, since my office computer isn’t used by anyone but me. I’m physically more comfortable, and so is my patient. Our wrap up after the exam is that much more personal because I am able to enter her mammogram and refills and even her charges while she changes instead of in the exam room. I remember more of the visit later because I’m more fully present with the patient in the exam room. Finally, there’s less down time for me, since I’ve effectively added a third room to office hours and can see a patient in my office while the other two patients are either dressing or undressing in the exam rooms.
But the biggest upside to my new workflow? I’m having fun! It’s like falling in love with medicine (and my wonderful patients) all over again.
The down side
The down side to my new workflow is that I’ve got to hold everything in memory between the time my patient leaves my office and when she is ready in the exam room, during which I may have seen another patient or two. It can take me a second or two to ascertain who’s behind door number two, and sometimes I get it wrong. Which has led to an embarrassing moment or two when I opened the door with a comment related to a prior conversation in my office and realize the person behind it is not who I was expecting to see. I’ve since learned to keep my mouth shut until I’m entirely in the exam room.
The good old days
In the good old days, I could pick up a chart from the rack outside the door, and in what seems life a few seconds, familiarize myself with with my patient’s history (because I kept a great paper chart if I do say so myself…) before opening the door to greet her. During the visit, I could sit with the chart in my lap, jotting down notes as we spoke, my focus on my patient and my thoughts rather than a user interface. Once the visit was over, a few brief jotted notes and some well-placed check marks on the encounter form summarized the visit, a few scribbles on a prescription pad or radiology order form clipped to the chart finished the orders (the rest taken verbally by my tech), a check off or two on the superbill and I was done. The entire work of a patient’s encounter took place in one room (or just outside its door), and in one allotted space of time, during which I was hers and hers alone. My chart was there, sure, but it was not the dominant presence in the encounter the way the EMR is now.
Is the IPad the answer?
I find myself thinking a lot about the Ipad these days. While initially skeptical about it’s place in healthcare, I’m beginning to think that it may ultimately provide the best workflow solution for me. However, I’m worried about my ability to type into it – something that’s not easy to do standing up. And its compelling interface could be even more of a distraction than the desktop. But its portability could allow me to review a patient’s chart outside the room just like the old days, and things like favorite lists and drop downs in the EMR could minimize typing.
Our EMR vendor at this point only offers a limited version for the Ipad, something that may be useful on call but not robust enough for office hours. So nothing new anytime soon.
That’s okay. I’m happy again. I can wait.
Margaret Polaneczky is a board certified obstetrician-gynecologist and Associate Professor of Clinical Obstetrics and Gynecology at Weill Medical College of Cornell University. You can follow her at The Blog That Ate Manhattan where this post first appeared.
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Who will instruct patients in EMR-speak so that they know words will fit into the fields that are offered? Surely this should be Step 2, at least, in this process, for why fill the air with descriptives and medical conditions that do not exist – in the applications, anyway?
Cut through it all. Narrow it down to 4 or 5 options. Only see patients electronically. (There is one article that states that 80 to 90% of patients know what’s wrong with them).
This all is entirely driven by the lack of jobs. $20 billion or so was issued through the ‘Stimulus’ act for Health Information Technology for Economic and Critical Health.
Health care for people, not for profit. Physicians and all who practice medicine should have the opportunity to do it and get paid well. The good doctor had no intention of being a data entry technician.
It will all work out just fine, however. People will stop going to see the doctor. Many will do better. Some will die, but at least it won’t be because an EMR got fried.
People who decide to continue seeing physicians might wish to record the entire visit. They might also wish to keep paper records, using the POMR system.
The entire concept of EMRs makes a sham of any attempt at geuine health care.
You get the “e-Doctor award” for engaging patients in ways that enforce mutual respect. http://bit.ly/z2FiCM
And to all you EHR designers/programmers who might be listening in – you need to understand that the note needs to evolve both forward (history => exam => diagnosis => treatment) and backwards (diagnosis => history). Much of a “proper” note (both for medicolegal and coding purposes) depends on the diagnosis. The ROS has to be pertinent to the diagnosis and so any prompts for ROS information needs to diagnosis driven, not only symptom driven, i.e. the ROS for “chest pain” is not as relevant as the ROS for “angina.” Likewise “Acute Abdomen” should prompt different questions than “abdominal pain.” Quite often the note is completed after the diagnosis is known, and the prompts for completing the note quickly should take the diagnosis into consideration.
Agree.
BTW,
“Physicians are right to condemn forms of control that involve exclusion of information and power over decision making. But physicians are in denial about the extent to which they themselves impose these forms of control on patients. Physicians are right to reject impoverished, cookbook medicine, but they are in denial of how impoverished is their own know-how. So too are they in denial when they view themselves as “highly skillful,” because their levels of skill would be far greater within a disciplined system of care. Physicians are right that “one cannot separate the decision from its context,” and they are right to reject uninformed controls by ‘outsiders.’“ But they are in denial of how much they themselves are uninformed outsiders to patients’ lives, outsiders whose exercise of control inevitably separates medical decision making from its context. And they are in denial of the need to submit to different forms of control over their own inputs to care—both decision making inputs and execution inputs.
Execution inputs were the primary focus of the Institute of Medicine’s To Err is Human. That report highlighted the need to protect patient safety by exercising tight control over execution of medical procedures. When we turn from execution to decision making, it is best to think in terms of not controlling but defining inputs, that is, making explicit the inputs that form the basis for decisions.
The basic inputs to decision making are (1) medical knowledge, (2) patient data and (3) the processing of that information. All three of those inputs are undefined and uncontrolled when they originate from the unaided minds of physicians. No one can know exactly what information physicians take into account, nor can we know how they take it into account, nor can we reliably improve the cognitive processes involved. All we know for certain is that medical decisions are enormously variable. The outcome is that patients have no assurance of reliable decision making…
In contrast, a system of defined inputs means first that the knowledge and data taken into account, and the processing of that information, are explicitly defined. Second, it means exercising some degree of control over the manner in which the defined elements are combined. Defining inputs to decisions in this way does not dictate those decisions any more than defining the elements of writing (an alphabet and standards of spelling and grammar) dictates the content of writing.
The need for tight definition and control over inputs goes without saying when the inputs are drugs and medical devices. An elaborate regulatory scheme controls entry into the marketplace and ongoing manufacture of drugs and devices. Yet, nothing comparable exists for the most important medical devices of all—the minds and hands of physicians. Graduate medical education, state law credentialing and board certification purport to regulate the entry of new physicians into the marketplace, while various ad hoc interventions (such as malpractice litigation and licensure board disciplinary proceedings) purport to regulate ongoing performance. Yet, no one trusts these forms of control. Epidemics of medical error, unnecessary care and irrational spending confirm that trust is not warranted. The reason is that existing regulation fails to define and control inputs to care comprehensively.
This means continually optimizing care at every step of decision making and execution. Optimizing care means not only enforcing high standards of care but also continuously incorporating feedback and new scientific advances. This continuous and comprehensive improvement entails a constant assault upon the status quo—upon the habits and roles and economic claims that take root from established practices…”
Weed MD & Weed JD, “Medicine in Denial” pp 44-45
Agree! We docs are under constant barrage of change in workflow. It becomes impossible to ever find one’s groove in such a rapidly evolving system of documentation. And distracts from the task at hand, which is patient care.
Am going to have to read that book.
Peggy
Dr Mike
I still rely on my patient to complete family and social history and a brief review of systems on a paper intake form, and then I use the form as a jump off to my history, so I can focus on the rpoblem areas and not just spend all my time transcribing. I then scan that form into the chart. I’ve been using that intake form for decades, and giving it up was impossible if I was ever to keep up the volume of patients I see on a daily basis. I envision a day when patients can log on and complete these sections in the EMR themselves.
Thanks for your thoughtful comments.
Peggy
I too envision the day when the patient is handed the tablet in the waiting room, interacts with it in a meaningful way, and then hands it to me in the exam room and I complete the note on the same device.
Thanks for starting an interesting discussion
Mike
It’s better than that. You don’t need to have the same device. You can see what they do in real time on your device and take it from there.
Try Google documents sharing. It’s pretty nifty.
Great re-cap!In rpeosnse to the first Q&A – The cost of moving to ICD-10 for small practices may seem minimal as compared to the government or large healthcare agencies. However, I’m not sure I would call purchasing new servers, software upgrades, and the cost of training minimal for small practices. They need to plan for these expenses and they are incurring them now as most of this money is being spent with the 5010 transition. Taking providers and staff out of productivity to do training is an expensive proposition even if its done in-house.
Ah, a victory for EHR proponents – a real life example of a doctor enjoying life with their EHR. Except that’s not the take home message here – the disruptive technology has forced a compromise that leaves the doctor less productive and still less engaged with the patient than previously. These are unacceptable compromises that physicians all across this country are making because they are otherwise made to feel guilty for not embracing the “quality” and “savings” of a modern EHR. These products are clearly inferior to the technology that preceeded them – inferior in so many ways that outweigh their benefits. It is hard to think of any other industry in which the end user is so completely ignored by the companies that profit from them. This is truly a case of “the emporer has no clothes” – we collectively continue to believe the lies the industry and government are telling us about the benefits of EHRs. Thankfully my EHR is free – there is no way I would ever pay the fees that some of these companies think their product is worth. I have used a number of these products and have yet to find a company that appears to have spent any time thinking about how a doctor thinks and arrives at a diagnosis. They make poor use of modern technology and instead are just pretty front ends on a database that requires the doctor to become a date entry clerk.
See the works of Lawrence Weed, MD
http://xnet.kp.org/permanentejournal/sum09/Lawrence_Weed.pdf
I have his new book “Medicine in Denial” — and have actually read it, cover to cover. Just starting to review it in detail on my REC blog.
Not to dismiss your criticisms out of hand — unlike the way you reflexively dismiss all things HIT a priori.
“…pretty front ends on a database that requires the doctor to become a date entry clerk.”
It doesn’t have to be that way. Read the works of the Weeds.
Why would someone who dismisses all things HIT use an EHR? HIT includes more things than just the EHR. The ability to access the community database of labs and imaging results has been nearly revolutionary.
“It doesn’t have to be that way” but it is. Why are there so many apologists for the EHR in its current state?
Dr. Weed’s work may very well lead to something very useful, but will have to be tested extensively in the real world. I don’t think we want a medical world in which every diagnosis suggested in the algorithm has be excluded – that is not as unlikely as it might seem when you imagine the first court case in which the doc is crucified for not listening to his computer. Medicine will suddenly become a whole lot more expensive – it is statistically impossible for it to be otherwise because the vast majority of symptoms represent no significant illness.
Thanks for pointing out this book.
This is a case of micro-regulation. Companies that build EMRs must comply with regulatory requirements because otherwise nobody would buy their product. Would you have signed up for your free EMR if it was not “certified”?
It is almost impossible, and contradictory, to build an EMR that pleases you and pleases the regulators, just like it was impossible to build an EMR that was fit for clinical duty and also supported billing regulations.
I do agree that EMR vendors are profiting from the EMR mandate, but I’m pretty sure that most would much prefer to please their users than the regulators. Software vendors are in an impossible position, not much different than doctors find themselves in.
More here:
http://onhealthtech.blogspot.com/2012/01/commedia-dellarte.html
Yes, I would have signed up for my EHR even if it were not certified. At the time, meaningful use was not in play and I could have cared less about CCHIT. I must disagree that the Vendors are in an impossible situation. I admit that they have had to divert resources to MU instead of making their products more useable, and this will be an ongoing challenge, but the two are not mutually exclusive. Without even trying very hard I can think of dozens of ways that would make the user interface better. I will be very interested in the first EHR that is designed from the ground up for a capacitive touch sceen – if it can be made to work with a pc, it would not qualify.
You do understand that if it cannot be made to work on a PC 90% of the market will not buy it, right?
I have had the opportunity to conduct these types of conversations with countless numbers of physicians, and I can tell you that within the first 30 minutes, you usually have at least 3 diverging opinions on what it should do and how it should do it. There is no such thing as a perfect EMR.
Unlike common mythology, EHR vendors consult heavily with doctors, but they cannot consult with the plurality of doctors, therefore any one product may satisfy those most similar to the consultants and nobody else. This, by the way, is the reason that specialty specific EMRs are better received – the pool of preferences is much smaller.
Going back to the original post for a moment, the issue here seems to be that “more and more mandatory clicks were demanded from the EMR to prove I was a good doctor “.
Touch screen or not, you will have to click, or touch. You cannot click without looking at the screen and you cannot touch without aiming exactly at what you touch, or even enlarge it with a two finger gesture. It is this need to pay increasing attention to the screen which is becoming a burden.
Some folks can write short notes while partially looking at the paper and partially looking at you. Can’t do that on a computer.
Paper will accept whatever goes through your mind at that moment. Computers have preset needs and you have to fit to your thought to the form.
Paper will instantaneously adapt to changes in the situation in the room. Computers will require that you add/change/modify templates.
Also paper does not run out of battery power.
I can go on for quite sometime here, but I think that the essence of the problem is that paper is passive and analog, which is making it a perfect mode for capturing random thought processes, while computers, with any screen, are designed to collect things in codified, preexisting boxes. It prescribes a way of thinking.
The challenge is to build an interface that dynamically adapts itself to the user’s unique thought process for each different situation. It is not easy.
One way out was, and still is, to give doctors a place to enter free text, write on the screen with a stylus, or dictate, within the note. This of course is a mimicry of paper and does not satisfy regulations.
I do agree with you that much can be done to improve current state of affairs, but do not minimize the enormity of regulatory compliance work, and the effects of “compliance” in general on what should occur.
I suspect the author’s re-found joy in practicing medicine may be short-lived. As you point out, even sitting across a desk from the patient, she has to look at the screen to do all those clicks, and the EHR is still the primary focus of her attention.
The basic problem seems to be that, rightly, she deeply resents being forced to concentrate on clerical work that should be secondary to evaluating and treating the real, live patient sitting in front of her. Not a recipe for a happy doctor.
The comment about 90% not buying it if not available on PC may not be as true as you think – the cost of tablets/iPADs is dropping – if the interface was compelling I would have no problem plunking down $2000 for 4 tablets. When I am seeing patients I need nothing else from my computer other than to enter my notes and access the internet based resouces or text documents that I need for direct patient care, and tablets can do all of this.
There are physicians who successfully used paper templates for years without experiencing any decrease in the overall superiority of paper charts. EHRs have in some cases tried to mimick these forms, but that is where they fail. They need to be able to dynamically respond – i.e. the form you are working on needs to “magically” change in response to what has already been entered. You should not have, at the end of the visit, a stardard “form” that has a bunch of check boxes checked or pull down menus selected or templates inserted. No, instead the “form” should morph before your eyes without any check boxes or pull downs. It should “flow” under your finger. No teenie tiny little buttons. No pages limited to the size of the screen. You should be able to “see” the patient all on one page with relevant information literally dragged into the note visually from the same page, and updated infromation likewise could be dragged from the note into the proper place in the “chart.” The only load screens should be for achieved documents – labs/xray/etc.
There may be EHRs that do it better already, but I know that one area my current EHR (practice fusion) falls down in is in prescribing. It is very cludgy, slow, requiring dozens of clicks just to change a dose of medication. Very poorly designed. Fixing that one area alone would increase my productivity by at least one patient a day (or about $16,000 a year in increased revenue).
“Paper will accept whatever goes through your mind at that moment. Computers have preset needs and you have to fit to your thought to the form.Paper will instantaneously adapt to changes in the situation in the room. Computers will require that you add/change/modify templates.”
You’ve nailed the difference right there.
Margalit – The other big difference is that writing on paper generates personal individualized memories – how that page looked, your handwriting vs the patient’s when you’ve scribbled a few comments onto the intake form, the tactile sensation of a heavy chart vs a thin one, the flipping of a page to view a lab result. That chart becomes personalized to that patient. Not so with EMR’s. They all look and feel the same, and there is nothing about opening up a patient’s record that hints at what may be behind a given tab.
I do miss paper so…
Peggy
Dr Mike –
Agree. And the fact that we have yet to show that EMR improves outcomes means that we may be embracing technology for technology’s sake alone. I sometimes wonder if all the money we are spending on IT wouldn’t have been better spent to improve nursing staffing ratios.
Thanks for your thoughtful comments.
Peggy
Why is it considered acceptable when using an EMR to take time away from the patient’s visit (which they are paying for) to do chart work? With paper, it was assumed that this would be done after the end of the visit.
The paper was solely there to support your work on behalf of the patient. EMR has “secondary” goals….
southern doc. – more and more, we are being demanded to complete our charting earlier and earlier. The need to print an AVS at exit means that most of the fields need to be completed while the patient is still there, or the AVS won’t be current.
So more and more of the patients face time is lost to the computer. I see no end to it.
Peggy
Dr Polaneczky, I like your perspective on how the way in which you “interact” with your EMR has impacted your patient exams and discussions. Too many IT professionals including those with clinical backgrounds have sold EMR’s while downplaying the upheaval it causes in this important element of patient care. The EMR folks need to do a better job of helping manage this change!
BIll – thanks! I agree on all counts. I think we need to start identifying best practices among EMR using md’s, have more end user groups, continued training on systems as they evolve. Usually once the go live is done, support for ongoing use falls off as IT staff are diverted to putting out fires. MD’s who have gotten some experience with and EMR need advanced training to learn to maximize it’s power. Instead we continue with our early use habits and miss the chance to find ways to use the system better.
Thanks for your comment.
Peggy