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EMR: A reflection
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Billy on his way to school
Didn’t care too much about the teachers and rules
He would rock in the kitchen and roll in the hall
And Billy’s mother said you got no sense at all.
— “Learning How to ‘Rock ‘n’ Roll,’” Cliff Richards, 1984
“Upon young men just starting [in private practice] I would like to urge particularly to take careful notes of their cases, and to study each individual patient intelligently. Experience in any disease is not a measure of the number of cases seen; it is not a matter of mere accretion, of the adding of fact to fact, this is knowledge. True experience brings more than knowledge; it brings wisdom, and this is a question of personal mental development.”
— Osler W. On the study of pneumonia. St. Paul Med J. 1899;1:5-9.
You can be who you want to be
Just remember that me and you
Ain’t all there is to bein’ free
People need love
People need trust
People need one another
And that means us.
— “Sugar Babe,” Stephen Stills, 1971
As I write this column, I am several months into the implementation of an electronic medical record in my office. I feel like an eighth-grade boy at his first dance, seeing only the superficial and missing the meaning. Unsure, I don’t know where to put my hands, and even if I know the tune, I just don’t quite have the rhythm. My own trouble, as Billy, is I never could dance, let alone rock ‘n’ roll.
I know that most of you already have begun to use an electronic medical record (EMR). My office has resisted until now. While not convinced of its superiority, we were moved by a sense of inevitability wrapped around a core of trepidation, dipped in a layer of sorrow.
Unavoidable because of legislative fiat and bureaucratic complexity tied to reimbursements, fearful of the difficulties structural change brings to a small office practice and sad over the loss of a way of professional life, we finally moved to a paperless world. Unfortunately, that world — at least for now and at least for me — has lost a texture that was an intimate fabric of medicine. For the first time in my professional life I have caught myself thinking I was going to work in the morning.
I hope the effects are temporary, but I fear that is likely true only at a passing level, somewhat similar to that eighth-grade dance. I will adapt, my office will adapt, and even my patients will adapt. But the loss will erode the core of what medicine has meant to me. However, I am amazed at how quickly, even in my office, we have substituted electronic communication for face-to-face speech. Perhaps the issue truly is only superficial — an absence of a “user interface” that duplicates the traditional model of care, and that if only someone could recreate that mystical interface in a software product, all would not be lost.
William T. Gerson
Unfortunately, the game is rigged and always has been. Those in power, health information companies, hospitals, and government have no interest in accomplishing such a task, no matter how noble it may appear. Worse yet, there is neither an acknowledgement of the loss nor a reasonably linked approach to provide the least obnoxious intrusion into my clinical space. Rather, there is a self-gratifying and self-perpetuated belief system that the process itself will lead to better and better products and improved quality of care.
The entire enterprise is first fallacy and foremost folly. Acknowledgement of a more limited goal and achievable result would perhaps have led to the utilization of the VA EMR system by all of medicine — established, tested and, best of all, already paid for. Instead, we are left at the mercy of commercial and institutional interests with the inevitable corruption of the process by profit, greed and distortion. Driven by a perceived failure of medical care, information technology was designated the savior, and powerful interest groups have taken that construct to the bank. We are left with a passionless prototype that, at its worst, may be thoughtless, as well.
The essential aspect of an EMR, as it currently exists, is the importation of the thought processes of others — in this case from the IT world — into my clinical note. Worse yet is the substitution of that thought for my own. As Osler reminds us, the essence of medical practice is wisdom, and wisdom is achieved by careful notes in addition to knowledge and experience. Current EMRs hide their inefficiencies in the fabrication of thought bundled to effective billing and improved opportunity for nonphysicians to monitor process. Leadership by suppression of critical thought — we should be taking up arms. Or perhaps just hire a scribe, like the 0.1% equivalent in medicine use.
I would be the last to argue that the American health care system was or is without fault. Nor do I want to pretend that information technology is not critical to quality care, or that improvements cannot be made to current software/user interfaces. What I do want to emphasize is that the practitioner in the office setting was never given much consideration, let alone invited to the rock ‘n’ roll dance. That is a failure on our part, but primarily by those institutions and organizations that we felt represented our interests in our work on behalf of our patients.
Although disappointing, the medical industrial context of the debacle is at least understandable. What is more wrenching is the hit the art of medicine takes. Neglected and ultimately undervalued, the practice of medicine is left to be defined by others — ultimately not in our patients’ interest. And we are too busy entering data (not wisdom) into our EMRs to fight back. To paraphrase Stephen Stills, to accomplish our goals to be what we want to be, we not only need love, we need trust, we need each other, and that means you and me.
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William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.