Contrary to what you may think, most doctors do want to make eye contact. They aren’t antisocial. They want to engage. But they can’t. They’re too distracted by one of the worst computer games ever invented—the electronic medical record (EMR).
You may be surprised to see the EMR compared to a computer game, but there are many similarities. Both offer a series of clicks with an often-maddening array of tasks to solve. There are templates to follow, boxes to fill in & scoring. However, unlike most electronic games, the points accrued in the EMR often translate into payment—real dollars for either your doctor or the hospital.
Although these clicks and boxes may be necessary to document your visit, it’s distracting. And your doctor begins to feel more like a librarian cataloging information rather than, say, a historian capturing your story.
So, why weren’t EMRs designed to wrap around physicians rather than the other way around? Because contrary to what you might expect, EMRs aren’t primarily built to care for people. As hinted at above, they were built as medical accounting software. For example, if you are treated for pneumonia, the doctor will click on a box that triggers a charge for that. However, if you are treated for pneumonia and you also have diabetes, the additional checked box results in a charge that is almost double.
Because contrary to what you might expect, EMRs aren’t primarily built to care for people. As hinted at above, they were built as medical accounting software. For example, if you are treated for pneumonia, the doctor will click on a box that triggers a charge for that. However, if you are treated for pneumonia and you also have diabetes, the additional checked box results in a charge that is almost double.
Tracking treatment and the long list of possible associations lends itself to structured data collection, a series of ever-expanding check boxes and blanks to fill in. The problem here is that human conversations—the kind of interaction most of us would prefer when meeting with our doctor—tend to be unstructured.
If you are not happy with the situation, neither is your doctor. Most physicians feel that the electronic medical record is an unwelcome stranger in the exam room. So, what’s the solution?
Things that work well—true solutions—require humans and machines to combine forces effectively. After losing to Big Blue, an IBM super computer, the then-reigning world chess champion, Gary Kasparov, proved this point when he sponsored a unique tournament. The competitors were, respectively, men, machines, or a combination of—get this—lesser man and lesser machines working together. The tournament winner was not the best man nor the best machine but rather a group of amateurs with computer assist.
That outcome makes more sense than you might first assume. Machines have been described as brilliant idiots, masters of repetitive tasks and organizing data, but lacking in creative insight. Humans are relatively poor at repetition, but are superior when creative problem solving is required. Ideally the strengths of humans and machine should be combined to offer a solution.
There is hope for the future. Newer software companies like M*Modal, and Nuance now offer more effective tools. To some extent the software provides real-time prompts based on the data being input, reminding users of key questions to ask. (Think Google where the search bar makes suggestions based on a few typed letters.) Then, after the fact, the transcript of the conversation can be parsed into useful information. In essence such new software gives us the best of both worlds: no confining front end for the doctor and computing power on the back end for analytics.
So, what can you do today and what are the opportunities for tomorrow?
First, when your doctor’s eyes seem glued to the EMR, speak up; engage her. Remind her of the principle of “garbage in; garbage out,” i.e., that the EMR is only as good as the conversation you and she are having in the moment. Second, let your doctor know you are sympathetic to her dilemma, that you understand that a computer game, the EMR, is a necessary but unwelcome guest in what should be, primarily, a human-human experience.
As for the future, EMRs present a real business opportunity for savvy entrepreneurs, especially those that step back to rethink how EMRs could be built from the ground up, emphasizing care while accommodating medical billing.
Bottom line: Medicine should be, above all, a human-to-human experience, supported by information and technology. Only when humans and machines work together will true solutions be available for patients and doctors.
Alan Pitt is the CEO of Avizia
Interesting how you compare EMR to video games. I never thought it in that perspective before. It really depends on the actual doctor. Some doctor really care for their patients and talk directly to you and shake your hands and really show that they are there for you. Some are just there for the money. Sad to say.
Even the worst video game in the world could give me pleasure in playing it. But some EMRs make me want to pull out all my hair. The clinics I cover use different EMRs that don’t talk to each other, and there’s often a learning curve involved (where do I click to add a memo etc). Worse if it throws an error after I type a whole page of patient notes and there’s no auto-save draft.
Rather than developing more EMRs, there needs to be some form of consolidation and increase interoperability.
So, are EMRs the reason for missed diagnosis, improper care, drug errors, drug interactions, patient deaths, hospital acquired infections, continuity of care between practitioners?
Its not that they are the cause, its that they were promised to help when they don’t. Poorly implemented interfaces (that’s the part they could learn from video games) distract from instead of augmenting care. When you have something that doesn’t work well (paper charts) then implementing something that is nearly equally dysfunctional isn’t a step forward. There is this argument out there that says basically that we physicians should be happy that we are the beta testers for the future generation of docs who will have software that is actually useful. It is an admission of the failure that is the EHR and it is time the issues were addressed by all the technophiles taking their collective heads out of their
Dr. Mike, someone has to enter the data, either on paper or EMRs. When the system has 1000s of interactions daily and there is a need to store, retrieve, analyze and bill for those interactions, electronic is the only way to go. The mistake that has occurred is no law to standardize and force interpolation between systems has been implemented, which I believe would allow more competition to improve the people/EMR interfaces.
Blind adherence to believing competition without rules will solve all our problems just does not work.
Here is an example from the auto industry. Pre-1996 vehicles used OBD-I diagnostics, each was preparatory with each manufacturer using their own connectors and software. Small repair shops could not even come close to affording all the equipment (and special knowledge) needed for engine analysis. The government standardized the software and the connectors to OBD-II so now every shop has the potential to fix your car, and there are many choices for OBD-II software/hardware. Even weekend DIYs can afford basic code readers now.
I don’t think EMRs ever promised to replace competent caring caregivers, which is the cause of what I listed in previous post.
I took a look at your site. You clearly have spent a lot of time on this subject. Thank you for the comments. The real issue will be getting on one the current vendors to explore improved data management- yes, getting the necessary information, but not imposing their application on the clinical visit. Alternatively, there are opportunities at the margins, smaller opportunities for boutique systems, to be built differently. Finally, as we see the cash pay economy grow (see an earlier post on alanpittmd.com), in part through concierge services, I hope the requirements for the visit will shift towards care and less so billing.
In terms of controlled studies, an earlier post- really?
“As for the future, EMRs present a real business opportunity for savvy entrepreneurs, especially those that step back to rethink how EMRs could be built from the ground up, emphasizing care while accommodating medical billing.”
Alan, I completely agree. There is a huge opportunity for systems designed to support clinical work.
Current EHR systems are doing what they were designed to do. The problem is that the design focus is primarily on storing and accessing data, which is not the same thing as assisting in patient care activities.
We have to do before and after studies, before the before doesm’t exist anymore. A little evidence-basing please.
Before EHRs, accuracy in diagnosing polymyalgia rheumatica, et al
After EHRs. “. ”
Before EHRs, office costs per 1000 patients /year
After. “. ”
Before EHRs, patient satisfaction as new patients referred by old patients
After EHRs, “. ”
So, what credible evidence exists to indicate that physician-patient eye contact was/is significantly greater (and more effective) under paper charting conditions?
“EMRs aren’t primarily built to care for people. As hinted at above, they were built as medical accounting software.”
I recommend spending some serious time over at Dr. Carter’s voluminous EHR Science.
“Representations of the many types of interactions that characterize clinical care are notably absent from paper charts and their electronic cousins. Clinical care covers a lot of territory, and clinical software should be able to handle the full range of activities…”
“…here are two questions I have been pondering: 1) “What are the underlying principles that tie all clinical systems together within a common theoretical and computational framework?” 2) “How can those principles be applied to determine optimal designs for clinical care systems?”
The average patient has no earthly clue what EMRs are doing, and that it’s not often up to the physician on if they want to use it. The “if you’re not happy, the physician isn’t happy” is spot on. In fact, physicians are probably more unhappy than their patients are in the situation, considering they’re the ones dealing with that input of information. My PCP actually has a scribe that comes in and does it for him now, which I personally don’t have a problem with. His eyes aren’t glued to the screen, meaning his focus is on me. And if there’s any piece of information the EMR is needing that he didn’t cover, the scribe (usually one of the nurses) will make up for the missed data at the end of the consult.
The part of the new system that automates that process isn’t necessarily having the physician read scripts from the computer screen, it’s helping them get used to the required information in an order that’s not so…sporadic and messy.
The irony here is that designers should probably make EMRs *more* like video games, not less.
At the moment, a lot of people feel like the government and their employers are forcing them to play a really bad video game all day, every day.
We should at least make them playable.
“the software provides real-time prompts based on the data being input, reminding users of key questions to ask”
So having the doctor read scripted questions off the computer screen is an improvement?