Tuesday, February 22, 2011

EMR - A Patient's Point of View

I like to read the doctor blogs.  It's interesting getting perspective from behind the white coat.  Hearing their struggles managing patients, running a business, dealing with insurance companies and of course, with illness and death has been useful to me as a patient.  Well-written blogs can give us an idea about the problems facing the people who, by virtue of our disease, have become a powerful force in our lives.

One topic that pops up regularly on the blogs is the use of Electronic Medical Records, or EMR.  Apparently, doctors are a bit behind the curve in managing patient health electronically.  It stands to reason that having patient records online, accessible to other doctors,  insurance companies and pharmacies would streamline care.  I've read notes on my charts that are absolutely incomprehensible; once I even had a nurse hand me a piece of paper written by one of my doctors and asking me what it said.   I'm pretty good at reading bad handwriting, but I had no idea, and it was about me and what was supposed to happen to me.  That can't be good for a patient.

On the other side of the coin, different software companies make different solutions, and they don't all interface and talk to each other, so the dream of every one of your doctors being able to see another's notes is just that - a dream.   There are privacy concerns when anything is done electronically, and of course, there are the typical user issues that happen anytime a new system is implemented.  There is fear that the insurance companies will misuse the information and create more work for doctors' offices, or use something said in a note to deny a reimbursement.  And, speaking as a former IT person - people just plain hate new software and often resist.

My oncologist's office implemented a new EMR system when I was in the middle of chemo  In fact, they did training on the system during one of my long infusion days, right in front of my barcalounger,  so I got to see the entire thing in action.  Once the nurses learned the system, once they stopped cursing,  I saw no difference in the care I got from them.

Not quite so with the doctor.  My experience with him changed dramatically.

Before EMR:  I would go to a exam room and sit on the chair, flip through a magazine or play Angry Birds on my iPhone and wait.  Dr. would walk in, make eye-contact, and ask me how I was doing, or  more likely, tell me how I looked to him.  Then he'd sit down and face me, my chart on his lap.   I would put away my phone and describe any concerns I had while I admired the oddball tie he was wearing that day, and he would answer while actually looking at me, occasionally glancing down to jot notes. There was a human connection there, at least as much as you will get with a professional physician whose specialty is people dying of cancer. We had a conversation.  He'd ask a question and my response would bring up another question - or I'd remember a concern and go from there.  We looked at each other.   He was in control, but there was give and take. I'd leave the office feeling like my concerns had been addressed and my needs as a patient met.

After EMR:  I go into the exam room and sit on a chair, play Angry Birds on my iPhone and wait.  He walks in, makes eye-contact, ask me how I'm doing, and then turns to sit in front of the computer - with his back to me. My doctor, with his penchant for humorous ties, could be wearing a dead pig around his neck for all I know.    I hear the mouse "click click click click" then he asks a question.  I answer and then "click click click.... type type type type."  Is he writing down what I said, I wonder?  What is all that typing about when I just said I am taking my medicine regularly?  Since I don't want to interrupt his train of thought while he is typing and clicking through various screens, I go back to playing Angry Birds.  When  he's done with what he's doing, he asks another question.  I answer, and the whole thing repeats.  Because each question/answer/type session takes so long,  I continue to play my game while he works.  This goes on for some minutes, and any human interaction or spontaneity  is gone. It's a very stilted experience.  I'm playing a game and he's deep in his computer.

Kind of like my family after dinner.

Because I saw him before EMR was implemented, because at that time I learned he's caring and competent and responsive to his patients, I don't feel slighted or that he's displaying a lack of interest. I don't think he particularly likes this system, in fact.  I feel comfortable enough so that if I did have a great concern, I would express it even with his back turned.  However, had this been my first exposure to him - had his back been turned to me during the early days of my cancer diagnosis, when I was facing the unknown and a bit scared, I might very well have turned my back as well -  right out the door to another physician.

I understand the need for documentation, and am a big fan of technology.  I was rooting for Watson, not Jennings.  I also understand that many exam rooms are not set up so that a doctor can face a computer and a patient at the same time, which is the case with my doctor.    I am guessing that many doctors are not experts at typing and it takes a while to input their notes, time which leaves a patient twiddling their fingers, which is also the case with my doctor.  As a former IT professional, I can't imagine this particular system is well-designed, considering that it takes a dozen clicks to get anywhere but I have not (yet) snooped.

However, these are things that need to be worked out before fully implementing an EMR system, at least for any doctor who cares about making a human connection with a patient.  There are tablets, iPads, laptops.  There has to be a way to return to a bedside manner method of doctoring while still entering the digital age.

So much of being a good doctor, from a patient's perspective, is not only medical knowledge, which (rightly or wrongly) we typically take for granted, but also the ability to relate to us, to look at us and see if our truths are being expressed.  Trust is essential - after all, the physician is about to cut us open, amputate a body part, radiate us, poison us with chemicals, tell us if we are going to live or die.  We need to know that this doctor is a person who will treat us with dignity, who will do the best professional job for us he is capable of.  We need to know he takes our concerns and fears seriously. We want him to want us to live.

It's very hard to gain that kind of information and learn to trust somebody with our well-being and our lives when all we see and hear is the back of a white coat and  the click of a mouse.

EMR may be the future of medical management, but it hopefully won't come at the expense of a true doctor/patient relationship, which we patients really do need.  While I admit I was rooting for Watson to win Jeopardy, the truth of the matter is, I'd much rather have Ken Jennings as my doctor.



  1. As with most things, hopefully the almighty dollar will win this one. Patients who don't know your pre-EMR expereince won't put up with such a (seemingly) cold hearted relationship. Patients have choices these days and those I talk to shop around for a doctor they feel a rapport with. Doctors had better figure out how to provide it within the new constraints...or lose business. Like it or not, cancer IS big business. Just sayin'!

  2. "We need to know that this doctor is a person who will treat us with dignity, who will do the best professional job for us he is capable of. We need to know he takes our concerns and fears seriously. We want him to want us to live."

    Truer words were never said. Patients do not want doctors' backs to us; we want to be valued as people with real concerns and fears. EMR does have a way to go before being very useful in terms of patients feeling good about their care.

    Wonderful posting.

  3. I think I'll mention this to my PCP on my next visit. His relatively large practice implemented EMR within the last few years. Most of the computers are set up so he's sitting perpendicular to me, so at least I can see his face. But it would be a lot better if the exam table was moved to the other corner of the room, so I could be looking at him (and him at me) on the oblique.

    At least I'm not looking at his backside.

  4. Nice post! I enjoyed reading this EMR patient's point of view. We have a now the modern technology where in the EMR has a big role in the physicians daily task. EMR will also protect us if we use the system well and are meticulous about our usage. Anyway, thanks for sharing this post. Looking forward for your next one.


  5. Your experience with EMR is *exactly* what I've seen when I accompanied my parents to doctors' visits at the world-renowned Mayo Clinic. Mom and I are ushered into the exam room, where we wait, and wait, ... and wait. A white-coated doctor walks in, introduces him/herself, asks some perfunctory questions, and sits down at the computer. From that point on, he/she never looks at my mom or me. A brief question is asked and answered ... type-type-type... pause ... another question is asked and answered (with no chance for elaboration)... type-type-type ... We remind him/her of the lab results that should be back by now ... type-type... pause... "Yes, I see. There's "X", and "Y".... pause. Etc.

    Patient contact and interaction is sacrificed on behalf of efficient record-keeping and document-sharing. Pretty soon we'll be doing this virtually, via iPhone. "If you have joint pain, press '1'."

  6. More of our patients are asking for CCR/CCD records to be able to take with them with medical history. The new ACO and PCMH programs will require clinical integration to be successful.


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