“Send me a note on MyChart” were the last words my doctor uttered as she exited the exam room. I complied with her request 24 hours later and received a prompt and pertinent response. In contrast, six months earlier, I queried a different specialist through MyChart. It wasn’t urgent, but nevertheless, I failed to get a response. The note had been opened. I had a visit six weeks later with another physician in the same group. I asked my question and correspondingly commented on the lack of response to my electronic query. This second physician gently chided me: “Let me tell you how the sausage is made. We don’t get our MyChart notes. Phone our nurse line instead if you need something.” (NB: I’m using “MyChart” generically to refer to the online portal on EMRs).
I was astounded by the response and associated rationalization. I responded to physician #2 that I hadn’t had that experience with my other physicians, let alone an entire group! So that piqued my curiosity. I’ve been an early adopter of electronic patient portals and EMRs at multiple institutions and practices spanning several states over 15 years, including three large hospital systems that use EPIC. I’ve been a patient at four additional small to midsize offices who chose other EMRs. To be honest, I never detected complaints from my doctors nor recall reading the proliferation of EMR-related complaints on AMA or other physician websites. All told, my sample size is in excess of 50 different physicians including PCPs and specialists. Sporadically, I sensed some trepidation from my physicians prior to their respective EPIC launch dates. Prior to this year, I can only count one doctor who routinely badmouthed EMRs at each visit. My impression was that he was a good doc with a bad attitude and found fault with most any change in his practice of medicine. I’d experienced similar attitudes from prior colleagues dating back to my residency days. So, initially, I didn’t process any wholesale contempt for EMRs writ large.
Admittedly, I may have had “blinders.” I partook of MyChart and EMRs for the better part of 10+ years. I loved it! Electronic communication became my go-to. I was no longer a slave to my phone. It was less likely that my message was misconstrued by a well-intentioned staff. I could communicate in “Medspeak.” I could access my detailed lab results in a timely fashion without playing phone tag with the office staff. I no longer collected appointment reminder cards that were invariably misplaced. Now, some systems even allow online access to progress notes. It certainly simplified my life. I learned through my research for this article that an original primary outcome goal for EMRs was to aid patients.1 Mission accomplished! Maybe?
Recently, I’ve been a party to a proliferation of vitriolic complaints voiced by my docs about EMRs. These grievances are mutually disruptive. But worse yet, I have found myself ruminating about these conversations for several weeks thereafter. I’ve also perused numerous articles linking EMRs to the growing “epidemic” of physician burnout. I don’t doubt that physician burnout is a significant issue, but I have reservations that EMRs are a principal culprit. More on this another day. So, over the past year, as I’ve conversed with several of my docs and nurses regarding EMRs, I’d comment that many of the issues raised were almost identical to complaints about charts, charting and messaging that my colleagues and I experienced dating back over 40 years.
To be honest, I didn’t comprehend the vitriol that I unearthed. Especially surprising were the references to how much better it used to be “before.”
Really? I ascertained that “before” was a nebulous term with diverse implications. The more contemporary group had no clue of the abuses that we (especially women) were subjected to 40-50 years ago. Many of my contemporaries and older appeared to have a jaded view of what the “good ole days” were really like. Being the data-driven person that I am, I wanted to review the “issues” through a historical perspective. To supplement my memory, I reviewed the history of EMRs and/or EPIC at a few specific institutions that I had frequented. An article in the New Yorker by Atul Gawande, MD, provides an excellent history of EMRs and reviews current provider objections.2 I’d like to address some of the salient grievances.
I vaguely remember a time when we didn’t even document our phone queries. Granted, advice was simpler. The admonition was likely to go to the ER, L&D or come directly to the office. “Same day” appointments were the norm! We used “call slips” once “documentation” became the “new norm.” I had to carry these pieces of paper with me everywhere. We rarely had charts readily available even with in-hospital call. It was always a treat to pair call slips with charts. Invariably, charts were misplaced, and patient’s histories could not be accessed. History and medication lists, lab and X-ray results were nowhere to be found. I don’t doubt that the volume and acuity of messages are overwhelming at times. It always has been like that. Except that the inbox took the form of stacks and stacks of paper charts that could only be accessed in person at the office or in medical records at the hospital. I vividly recall routinely returning early from vacation to spend an afternoon at my office to “clear” my desk from the proliferation of accumulated charts and messages.
Are computer clicks really that difficult? I barely notice from my vantage point as a patient. I shudder to think of how many miles I logged running around searching for paper charts, paper lab reports, trips to radiology to look at hard copy films, or trips to look at “histo” slides with the pathologist.
I don’t doubt that developers “sold” administrators on the value of EMRs to maximize billing and revenue. But is the never-ending conflict between bean counters and trench docs really a new phenomenon? As an intern, we were provided with a manual to dutifully carry in our white coat pocket that listed the universe of procedures, CPT codes and charges for our specialty. As an HMO doc more than 35 years ago, we were similarly burdened with tasks to document diagnoses or justify the amount of time spent with patients. Ah, but what about the annoying CPT codes that give you an error message? As a patient, I’ve been on the receiving end of incorrect codes resulting in obnoxious bills requiring hours to resolve or alternatively delays at the lab before my blood could be drawn. I’d bet that a few extra minutes spent during a visit likely translates into a much larger time savings when the patient calls in a panic.
Lack of eye contact with patients
I think we all agree that the practice of typing into a computer with your back to your patient is annoying at best, detestable at least. Fortunately, most of my current docs aren’t guilty of this transgression. They either jot notes on a pre-scripted page, talk and type, or have a scribe (admittedly not my favorite), and yes, they look and interact with me. But I’ve certainly had more than one doc from those idyllic good ole days, who never looked up from the chart notes they scribbled. Worse, it was clear from their questions at subsequent visits that they acted more like a court stenographer than a caring professional as they could neither recall our previous discussion nor read their scribbled, handwritten notes. Similarly, those narratives were worthless for most any purpose. My conclusion is that docs come in all varieties. Some were never (and still aren’t) adept with patient interactions.
Cut and paste
Some of my progress notes have reached in excess of 20 typed pages for a single 30-minute visit! Usually, subsequent consultants refuse to read them and simply ask me for a summary distillation. I’m complicated but not that complicated. Is it really necessary to include my last three to 12 months of labs, imaging and procedures in the body of a progress note? I recall some version of this (especially in hospital charts) during the good ole days where each successive consultant reviewed all the notes and associated data of the previous specialist. I’m not certain how this practice originated, but it definitely antedated EMRs and still makes no sense to me.
Quality of notes
I’ve been on both sides of this one. I always seemed to omit or misconstrue a key factoid, no matter how much attention I paid contemporaneously. What makes sense at the moment doesn’t always make sense in the future, regardless of whether the notes are hand-written, typed, or dictated. That said, legible typing is a great improvement rather than struggling to decipher sloppy handwriting (including prescriptions and critical orders).
Unable to delete inaccurate data
Agreed. I have been the victim of this indignity and spent many hours remedying these inaccuracies dating back to the days of paper charts. Modern-day bureaucracy may be more robust. But is it really the EMRs that are to blame?
Remember, there’s a perspective for everything: I do miss the good ole days … I’d trade it all for good health. I’d gladly “spend” my “free” evenings and weekends driving to and sitting in my office responding to my patient’s issues in my “inbox.”