More than a decade ago, when one of the larger hospitals in north Mississippi was transitioning from paper to electronic medical records (EMRs) in a quest to meet “meaningful use,” their administrators posted a large sign at each nurses station with a terse warning: “All nurses MUST remember to see their patients at least ONE time during their shifts.” This statement in one sentence captures the serious distraction of the computer screen and the entering of data and notes in our EMRs. Meaningful use often meant eliminating hands-on interaction of medical staff with the patient. Old time nursing care, which once involved the nurse sitting on the bed talking with the patient, establishing a relationship of care, has largely evaporated. Now, our nurses and clinical staff spend the majority of their time sitting at the nurses station staring at a computer screen entering information which will never be read again.
The brilliant physician writer Danielle Ofri asserts that the EMR has “decisively realigned how doctors and patients connect. The twosome is now a threesome. As with any ménage-à-trois, there are always consequences.” She wrote in a recent essay: “Patients were frustrated by the inevitable slowdown of an already overburdened medical system. Clerks, medical assistants, nurses, doctors, phlebotomists, social workers, billing specialists, and others labored over their computers, struggling to fit the human patients standing before them into an unyielding electronic pegboard.” Although she acknowledges benefits for population health macro management, EMR has shown less benefit for individual patient care. “Studies focused on diabetes, sepsis, and advance directives have shown mixed results— certainly not the exponential improvements that EMR evangelists promised.” She relates that the EMR has decimated clinical staff morale and has had a negative consequence on patient health. She describes the impact EMR has had in making medical care “data-entry drudgery.” Primary care doctors spend an average of six hours daily on data entry, which is twice as much as they spend on direct patient care. She also asserts EMR as a major cause of clinician burnout and medical error.1
An international study concludes that EMR largely improves quality of care of patients, asserting that retrieval and entry of patient information are more accurate, access to the system is more efficient, and that the EMR reduces medical errors, tracks data over time, monitors quality of care, and enhances work productivity which allows typing instead of writing. Similar arguments push our health systems towards the rapid adoption of paperless systems, although many continue to remember fondly the efficacy and dependability of paper records. Most patients express a dislike for physicians working with a computer in the examination room. Reduced attention and lack of eye contact have frequently been criticized by patients. Patients negatively perceive the physician’s shift of attention away from them and towards the recording of digital entries.2
There is no doubt the genie is out of the bottle, and our future in medicine will involve substantial use of EMR. Hippocrates, as he divorced in ancient times the supernatural from the natural in medicine, stressed the importance of physicians writing down their observations about patients, what he called the “clinical history,” in order to formulate our diagnostic thinking.3 Hopefully, physicians and AI (called “augmented intelligence” by physicians instead of “artificial intelligence”) can create a “digital thriving” for both physicians and patients which accomplishes diagnostic thinking rather than secretarial redundancy. The system must remember always: We are scientists. We are not secretaries. Such would satisfy the requirement for EMR to heighten the patient-physician interaction rather than surrender to insurance and third-party maliciousness.
Contact me at drluciuslampton@gmail.com. — Lucius M. Lampton, MD, Editor