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Patient care in the age of the EMR: Which is the cart and which the horse?
In our university-based endocrinology clinic, we have a “swamp” where most of the work attendant to seeing patients is done behind-the-scenes. The comparison to stagework, I think, is apt — I think of it as “backstage in the clinic.” When we go into patient rooms with our eager learners in tow, it is showtime.
On stage, I muster all the positivity and charm that I can to build rapport with the patient and demonstrate for our students that internists (and internal medicine subspecialists) are caring, empathic physicians — in other words, I take that role model thing to heart at least part of every day. On stage, we walk the students, residents and fellows through the subtleties of thyroid nodules, goiters, Charcot feet, cheiroarthropathy and so forth. The feedback we get from our learners is generally excellent, so there are definitely some “feel good” moments to be had. On stage, I still find it generally satisfying and often even fun and exciting to be in “the doctor role,” 26 years after graduation from medical school. On a good day, one can have the feeling that medical education is alive and well!
But not all of one’s time can be spent at center stage — and backstage is a netherworld, an alternate universe, the photographic negative of the “on-stage” world — in short, the seamy underbelly of our operation. It is in our “swamp” where we physicians routinely face up to all the harsh realities of being a physician in this millennium in America.
The ‘backstage’ tour
Each of our doctors has a chart rack for “incidental” business. A random flip through any of the rack’s contents will yield several prescriptions to sign and return-fax, authorizations for diabetic footwear, annual certifications for insulin pump supplies, and requests for “prior authorization” (I consider finding one of these the equivalent of drawing a “Go Directly to Jail” card in the game of Monopoly). Also, because of the rotisserie nature of employer-based insurance carriers, we enjoy daily games such as “Guess the AII receptor antagonist” and “Statin du Jour” on a routine basis.
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But on our backstage tour, I think what you would find most remarkable is the number of laptop computers in the small room. The room itself is about 10 × 15 feet and there are two conference tables, with about 12 chairs (in addition to four attendings, we may have up to five fellows, two residents and two med students at any given time). On each conference table there are between four and six laptops because we are now in the midst of the digital revolution and the transition from a paper to an electronic medical record! You will notice that the temperature in the busy “swamp” is several degrees higher than the hallway — busy computers and human bodies do generate heat!
Allow me a disclosure. I love computers. I loved the idea of a computer before ever owning one when I was helping my wife type versions two through 13 of her Master’s thesis (on a typewriter, not a word processor).
As a fellow, my program director loved for his fellows to write — and he loved to edit in micromanagerial style. It was then that I learned to love and use the word processor. It seemed a very efficient way to do re-writes. I learned that my own style of writing, and my own habit of revising my work as I composed, was well suited to silicon. Since buying my first computer in 1989, I have not written anything long-hand, other than patient charting.
Physician as clerk-typist
But meanwhile, backstage faculty physicians and learners alike are hunched over the laptops, keyboards clattering away. We are deep in the midst of a busy afternoon clinic. There is far less conversation backstage than there was only a few short months ago before we took the digital beachhead. Much of the conversation now is med students giving dictation to a fellow or attending, since we cannot review and sign their notes for billing purposes; much of the backstage time is getting the facts right, rather than talking about pathophysiology or therapeutics.
Backstage, we are not physicians — we are clerk-typists. Well, we could dictate notes, but since we are endocrinologists, we cannot afford the cost of paying transcriptionists, so instead we type. I find that I do a lot of the documentation prior to even seeing the patient. The EMR is a great enabler in that sense it takes less than two minutes to generate a complete normal physical exam with current labs, problem list and medication list, with a cookie-cutter assessment and plan, billable at Level 4, which is completely useless clinically!
As I review cumulative notes on patients from other clinics and from the hospital, I am more and more struck by the overall worthlessness of the documentation (except, of course, for billing purposes). Due to the grafting of cut-and-paste text from entries old to entries new, over time, documentation no longer accurately reflects the evolving reality of the patient. A below-knee amputation will not preclude the patient’s extremity exam being documented as “no cyanosis, clubbing or edema. No skin or nail changes.” Deviating from the cookie-cutter templates, by contrast, to document little details (like, a harsh aortic stenosis murmur or a gangrenous foot) takes time. It slows you down and there is no tangible reward. In fact, taking time to do good documentation often increases patient waiting time, thereby generating patient complaints.
I ask rhetorically: Who is really being served by this tangled cyber-web we weave?
Without doubt, it is the billing-and-reimbursement end of the system: by making it easy for us to document a “normal” (but inaccurate) 14-point review of systems (I have seen that done on comatose intensive care unit patients on ventilators) and a “comprehensive” (but phantom) physical examination, the EMR documentation maximizes billings. In that sense, to borrow a line from a U2 song, the digital representation of the patient is even better than the real thing. But from a patient care standpoint, is it not repugnant?
Which brings me to the point of all this: The status quo of the EMR, from a system standpoint, reinforces a value system that is wrong. It makes it easy to do the wrong thing and as difficult as possible to do the right thing. Good systems should make doing the right thing as easy as possible, and make doing the wrong thing close to impossible. Come to think of it, for most things nonmedical, that is what computers have done for us! My belief is that EMR’s are here to stay. They will in the near future be universal and essentially mandatory — and I do not think they need be inherently bad.
As a profession, I think we should demand that they serve us and our patients — we should not “serve” the EMR and the billers. It is high time to say “no” to false gods, or rather, make that [Control]-[Alt]-[Delete]!
For more information:
- Stephen A. Brietzke, MD, is Associate Professor of Clinical Medicine in the Division of Endocrinology, Diabetes and Metabolism, University of Missouri Columbia School of Medicine and a member of Endocrine Today’s Editorial Board.