Y Pritham Raj
Oregon Health & Science University, Portland, United States
“It must be a virus,” I whispered to myself noticing that Miss C, my medical assistant, was not her usual, efficient self today. She was painfully slow – dragging, in fact – while trying to gather the data I so desperately needed to help the patients waiting behind the closed doors of my busy hospital-based clinic. As much as I valued her, my frustration began to mount. Without rapid access to Mr. X’s vital signs, how was I to make even the most basic decisions concerning his hypertension? Without an accurate medication list, how could I address Mrs. Y’s penchant for selective medication adherence? Not to mention that Dr. Z in the waiting area was sure to be displeased at his escalating wait time due to our inefficiencies.
In the two-plus years since Miss C had begun working with me, her role in my practice had grown critical. Truth be told, I was now dependent on her. Without her operating at full speed, seeing the afternoon’s packed slate of patients would undoubtedly prove harrowing and place great strain on my ability to deliver optimal care. Fortunately, on this day reprieve would come. Miss C suddenly found renewed vigor and hummed to life. Data began to flow. A blood pressure here, a medication list there, and then a bevy of patient requests – all cascading with precision and order. It was the power of technology. For Miss C, short of course, for “Miss Computer,” was no longer just a tool for internet browsing, but was now keeper of my all-important, albeit fledgling, Electronic Health Record (EHR), and her role is nothing short of revolutionary.
The word “revolution” has several definitions, but generally describes the struggle towards change. In the case of the French, Russian, and American Revolutions it was violent change that brought upheaval to the geopolitical landscapes of not only each respective nation but to the world at large. Revolutions of other types, such as the colloquial “Rock-and-Roll Revolution,” brought about non-violent, although to some music purists, equally rebellious change. But no revolution, short of perhaps the Industrial Revolution itself, has impacted the field of medicine more than the Internet Revolution.
As recently as the mid 1990’s, completing assignments and reports in medical school required a jaunt to the campus medical library, a search through myriad beige index cards housed in mini-drawers of an oak card-catalog, followed by an arduous adventure into the stacks of books and journals. Now the same information passes at light-speed through a series of fiber optic and wireless conduits from anywhere to anywhere in the world. I can now sit at a computer terminal with a patient in the United States and, with a few keystrokes, pull up an illustration of a nephron from a British website to explain how his diuretic works. I can download Portable Document Format (PDF) copies of key research studies right at the patient’s bedside to foster collaborative, evidence-based medical decision-making. As one of my favorite clothing stores used to advertise, “An educated consumer is our best customer.” So it goes. But the EHR has added a new wrinkle to medicine’s Internet Revolution.
On this day, I log on to my computer and see the names of 15 patients listed neatly on my electronic clinic schedule. Forty-five minutes before my first patient checks in, I quickly click on each name, reviewing his or her recent chart notes and lab data to remind myself who needed what tests and interventions today. No paper, no hunting, and no hassles involved in this preparation. And so, clinic begins on time. In between patients A and B, I break to electronically refill several medications that have been requested by area pharmacies or patients themselves, all with a series of simple clicks of my mouse. I also stop to send electronic responses to two patients who have sent urgent queries to me using a feature of the EHR that allows them to correspond directly with me. This feature also grants them access to their personal medical record, facilitating transparency. However, this “time-out” between patients proves costly as I now find myself behind schedule.
My next patient, Ms. D, is a pleasant, middle-aged artist who is here for follow-up of several metabolic concerns. She is in room 14, a newly renovated room with large windows and panoramic views of the city. I am grateful for the room’s impressive views, which help mitigate the frustration felt by patients who are sometimes left to wait for extended periods when I get backed up. Fortunately the EHR comes to the rescue yet again, and I feel pardoned today when Ms. D says, “I’m so glad for that computer. It lets you know which medications I’m on because I haven’t got a clue.”
Later, during the break between my morning and afternoon sessions, I take a few moments to review laboratory and imaging test results that have trickled in from patients seen earlier in the day. As I write electronic “result notes” to these patients, my mind wanders. It could have wandered to any number of clinics that lack an EHR. But this day I am transported to an urban primary care clinic on the other side of the globe – in Pune, India. This clinic is much busier than my own, and thus, its physician staff must typically focus on one or two complaints, maximum, in order to meet the volume of demands. In my mind’s eye, I see a frail day-laborer come in from a crowded waiting area for evaluation of a persistent cough. A nurse brings in a small paper card with the patient’s demographic information typed neatly at the top and hands it to a consultant physician. After taking a brief history and completing a physical examination, the physician hand-writes a few sentences summarizing his findings and treatment plan and returns the card to his nurse. A handwritten prescription is issued to the patient who leaves with a beetle-nut stained smile on his face – grateful and optimistic. The process is simple and efficient.
My daydream is interrupted by a text message on my pager: “1:00 patient is ready…”
“But my notes from the morning session are not complete,” I mutter. As efficient as I thought I had been, completing my detailed electronic clinic notes would likely have to wait until tonight, after the kids are in bed – yet again. Before going into the next room, I am stopped by my assistant who informs me that Mr. E, one of my newer patients, who happens to be an employee of the hospital, is angry and eager to speak to me. I quickly call him.
“I was looking at my medical record on-line,” began Mr. E. “Why did you list Obesity as a diagnosis on my clinic chart?”
As I explained the criteria for obesity and how the term was not intended to be derogatory but rather serve as a diagnostic label for his elevated body-mass index, my mind wandered back the simplicity of Pune. No, none of the Pune physicians were having the conversation I was having this day. Patients would not be electronically downloading any medical information from their charts – small, paper cards are immune to such investigation. But for better or worse, the revolutionary EHR is here to stay and is on the rise internationally. The paper chart is vanishing, going the way of the phonograph record. Government and private hospital systems alike view EHRs as the way of the future, and are willing to spend a king’s ransom for the technology in the hopes of improving care through better communication, efficient follow-up, and increased billing capture (not necessarily in that order). Awaiting the right infrastructure, even the Pune clinics doubtlessly stand ready to embrace it.
But for all of its advantages, the EHR is changing our medical practice in ways that may inhibit good patient care. Some have questioned the quality of record-keeping in the EHR era, where “cut and paste” applications allow for prolific but minimally informative notes. For the sake of efficiency, most users of the EHR type in the examination room. The effect this is having on the patient-physician dynamic is of some concern. For one, the “clickety-clack” of the keyboard can be distracting and downright impersonal to patients divulging the most intimate details of their lives. But of greater concern is the impact that computer-based recordkeeping is having on non-verbal communication in the exam room. Classic data suggests that 55% of all communication is non-verbal, and, thus, important information can be missed when providers train their sights on computer screens rather than their patients.
Recently, during the aforementioned renovation of my hospital-based internal medicine clinic, I helped design a medical observation room with a two-way mirror, like the ones used in psychiatric settings. Using this tool, I have gained incredible insight into how physicians conduct patient interviews. Tragically, I have seen countless physicians sit nearly completely with their backs to their patients during office visits in order to type progress notes. I write not just as a critic, but as a penitent offender of the same, knowing that these “computer-centered” evaluations send the wrong message in this era of patient-centered medicine.
In a rush to establish EHRs, many hospitals, clinics, and health systems have failed to properly address various emerging concerns. What about the physicians in our ranks who have difficulty adapting to new technology? What about patients who are not prepared to handle what is written about them in their easily-accessible electronic charts? What about the non-reimbursable hours spent communicating with patients via the EHR? What about the incompatibility between different, often competing EHRs? What about viruses and system crashes?
So you say you want a revolution?
Y PRITHAM RAJ, MD is an internist-psychiatrist who currently lives and practices Internal Medicine and Psychiatry in Portland, Oregon. He is the Medical Director of the Oregon Health & Science University (OHSU) Internal Medicine Practice and spends a lot of time in his institution’s electronic health record. His primary focus as a clinician-educator is the novel med-psych teaching clinic that he established in 2006 to train the OHSU Internal Medicine housestaff on the importance of integrated mind-body medicine. Yet, his most defining roles are as husband and father to three small children.