By: Alisha Maity, SKMC Class of 2020
I sat on a stool in the corner of a small office, silently grimacing. In another corner, an anxious, middle-aged woman sat as she stared down her doctor who had been occupied for the last 30 seconds searching the woman’s electronic medical record (EMR) for her latest CT scan. When the doctor finally looked up from the screen, he delivered the news about the presence of new nodules that would require biopsy, words that overwhelmed the woman. Throughout my afternoon of shadowing, I witnessed every complaint that I had heard doctors and nurses mention about the EMR, in action. The doctor had to click on box after box to establish diagnoses in the EMR, tests had to be reordered multiple times because the system kept crashing, and patient after patient waited with bated breath while their doctor struggled to cut through the “note bloat” of the EMR to unearth critical information.
As someone who cherishes the organization and capabilities of Google Calendar and makes detailed to-do lists, the EMR seems exciting and essential. But as the daughter of two health care professionals, I’ve heard the full gamut of complaints ranging from the costly implementation of EMR into private practices to the idea of doctors getting “dinged” for not filling out electronic forms properly. While EMRs have been around for a while, a mandate to adopt the EMR was put in place in 2014 through the American Recovery and Reinvestment Act (ARRA). In an effort to improve healthcare, engage patients, improve care coordination, and maintain patient privacy, hospitals that demonstrated “meaningful use” of the EMR were eligible for various financial incentives and, as of 2015, hospitals that failed to comply faced penalties. (1)
However, studies on EMR effects on doctors and patients have demonstrated mixed results. For example, numerous studies detail low physician satisfaction and increased physician burnout associated with the EMR. (2, 3, 4) Furthermore, one recent study found that a sample of Family Medicine doctors spent 6 of their 11-hour work days and 1.5 hours after clinic working on the EMR, with nearly half of this time spent on electronic clerical and administrative tasks. (5) Yet, numerous other studies have demonstrated an improvement in patient care with the advent of the EMR; in fact, according to the National Physician Survey, over 75% of physicians use EMR and, of these, 65% believe patient care has improved. (6, 7) From the information in these studies, it appears that EMR has improved healthcare at a cost. While EMRs are capable of improving patient care through the consolidation of information, doctors forced to undertake time-sucking administrative tasks and their patients can be affected negatively because of this technology.
One possible solution to this problem is the use of scribes. Pooja Selvan (MS2 at SKMC), a former scribe with ScribeAmerica, describes a scribe’s role as “removing the clerical aspects of a patient’s care from a doctor’s workflow.” Although provided with several training sessions on medical terminology, SOAP notes, and some basic instruction on the EMR, much of scribes’ training occurs on the job. In the doctor’s office, a good scribe should “be invisible” and record all aspects of a patient’s visit, allowing the doctor to maximize patient contact. While scribes can be beneficial, some argue that they serve as a quick-and-dirty fix that obfuscates larger problems that need to be solved like better workflow designs. (8) If scribes are not the final solution, what is the future of doctors’ interactions with the EMR?
Dr. Kent Berg is an Associate Professor in the Department of Anesthesiology at TJU. He also holds the title of Vice Chair of Information Systems & Technology and has been working on adapting Epic in an Anesthesia-specific setting and remains positive about the benefits of EMR. “[Although] it was a very steep learning curve, I am confident that most of our Anesthesia colleagues now would find the EMR very hard to live without.” Dr. Berg has recently been working on improving Status Boards, large-screen monitors in pre-op and post-op areas. These boards serve as communication tools amongst staff and reduce the need for constantly checking in on computer terminals. Because the EMR can often be filled with so much extraneous information, changes that are specific to a department or specific workflow seem to be the best kind of mechanism of improving EMR use.
Dr. Berg’s advice to physicians struggling with balancing patient interactions and utilizing the EMR is to “practice the workflows in the training environment and reach out to a ‘SuperUser’ (someone who has been identified as someone who excels using the system), as mentor-mentee relationships can be extremely valuable, especially for improving your EMR skills.” At a place like Jefferson, where the EMR has been in place for over a year and has specific workflows in place, this advice is exactly what experts suggest in the implementation of EMR.
The advent of EMR has scared some physicians and won over others. Future physicians, such as ourselves, have the advantage of letting technology work out its kinks before engaging with it fully. And by the time we do engage with it, EMR will be the norm. From the diverse range of opinions expressed in research over EMRs, it is clear that the best way to approach EMR is to embrace it as a tool that can enhance patient interactions and outcomes. Over-reliance and under-reliance on such a tool both pose their own problems. Disregarding the EMR as an instrument for collaboration of care, a way to reduce medical errors, and a solution to physicians’ terrible handwriting is impractical. On the other hand, relying on an electronic device without also maintaining a strong doctor-patient relationship interferes with the tenets of good clinical practice.
In researching the EMR, I found one message from a breast cancer patient who found her experience with her oncologist negatively impacted by the introduction of the EMR, particularly memorable: “It’s very hard to…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.” (9) As future physicians, the EMR is a tool that will continue to evolve and improve but throughout this process we must remember that it is the patient and not their medical record that represents the true consolidation of medicine.