Thursday, September 18, 2008

The Electronic Medical Record-Changing the Way Healthcare is Delivered?

Monday was my second experience with the new Electronic Medical Record (EMR). Our first visit with the EMR was last year, when our pediatrician’s office converted. The nurse came in to take Dear Son’s history, walked in with her laptop, sat down and typed in my concerns. She took Dear Son’s vitals and then entered everything into the system. Very clinical, I thought. And extremely impersonal. I hated it. When the physician came into the room, he just jotted down the notes and elected to enter them into the EMR later. I was relieved.

My second experience with the EMR was on Monday. It was our first visit, Dear Son and I, with this GI physician, a motility expert. Dear Son is considered a complicated patient, by most physician’s assessment. At this stage of the game, he is out of the area of expertise for a lot of physicians, due to his diagnosis. Dear Son suffers from Cryptogenic Infantile Spasms, caused by the ARX mutation, has Progressive Motor Dysfunction and has a Progressive Neurological Disease caused by an abnormality of the dopamine receptors.

Our visit was scheduled for 3:40 p.m. We picked him up at school at 1:15 and arrived early for our appointment, allowing plenty of time for road closures. We had experienced heavy flooding in most areas, the worst in thirty years, so several highways were closed making travel difficult. We got into the examining room around 3:45 p.m. and the physician came into the room around 4:35 p.m.

Our visit started out fine. The hospital has forwarded extensive paperwork to be completed prior to the visit. This included pertinent medical history, all prior GI tests, medical history from birth to present, along with all hospitalizations, surgeries and growth records. The nurse took the medication sheet I had prepared and left the room to enter the information into the Electronic Medical Record. The physician, whom I had never met, came into the room and introduced himself, shook my hand and started the visit. He had read the history I prepared and asked a lot of questions. As we went through the visit, the physician repeatedly stopped to enter information into the EMR. When he did this, he would have to turn his back towards me, and then enter the data in the system. As he did this, he would take time to review it and edit it. Then he’d stop, turn around and continue on the visit, then stop again, turn his back and have to enter information into the system again. Our visit that started at 4:35 p.m. ended at 6:20 p.m. Over half of the time, was spent with the physician entering information into the EMR. It was distracting, it was annoying and excruciating to endure. I felt like I was having to do his job with him. The physician was personable and knowledgeable. He communicated well and when he asked me questions, he faced me and did everything right on an interpersonal level but there just wasn’t any getting around having to stop a visit and enter information into the EMR. I even asked him in the middle of all of this, how he liked the EMR. He explained that it was o.k. and that it took a lot of time, especially for complicated patients like Dear Son. He said it wasn’t as bad for the simpler cases however I would guess when you work at a Big City Pediatric Hospital, you probably don’t get many simple cases. He said that he would have to come back tomorrow and review the EMR and add more detail since he was just summarizing today. I thought of how excruciating it was to endure this. He wasn’t just jotting notes in here. It was more like the process of writing a letter; you know the kind when you sit down you think it’s only going to take five minutes and forty five minutes later, you are finished. In this case, the physician would type something, then go back and delete it, then write it again and edit it repeatedly. It was downright annoying. I wanted to take the keyboard away and just type it in myself. After all, I knew what my concerns were and I’d have been more than happy to summarize that for him.

In Dear Son’s case, his motility was affected by several issues: his gene mutation, the progressive motor dysfunction and the Scopolamine patch. The dopamine receptor problem (The progressive neurological disease is an abnormality of the dopamine receptors.) and lack of gaba (due to his gene mutation) may result in increased vomiting, GERD and gastric emptying delays (both dopamine and gaba are involved in reflux). In addition, when he is ill, his motility is worse, resulting in the bloating and vomiting issues we experienced earlier this year. The physician recommended a new gastric emptying study be completed and then after that, a possible g/j tube would be inserted. The g/j would allow us to bypass Dear Son’s stomach, where many of the motility issues are occurring. In addition, I’d have a consult with nutrition. I had many questions however it was a bit awkward trying to converse with him, with constant interruptions to enter the data.

Sometimes, I’d lose my train of thought because he’d ask to stop and enter in the data before he forgot. In the meantime, I am trying to think through the ramifications of this new g/j tube on our lifestyle. For example, the g/j tube would mean that he could only receive feedings via the feeding pump and never via a syringe since via the syringe would cause severe diarrhea. This would mean that I would have to give meds at midnight and then get up by 3:30 a.m. to start his feeding so it would be completed in time for school. This would be difficult to administer since I need to get some sleep and the sound of the pump running all night is loud and annoying, assuming I could actually get up at this hour every day, in addition to having my own business, working, and caring for Dear Son 24/7 without any nursing help. Of particular concern, was that if the g/j tube would become dislodged, I’d have to take Dear Son to the nearest ER where he would have IV feedings, until the g/j tube could be placed in him again. Without a wheelchair van, I’d have to call an ambulance for transport and this would be very expensive. It would also mean that on a day when I’d have a doctor’s appointment, it would be extremely tough-how would I administer a three hour feeding when I am transporting him to a doctor visit? While a g/j tube might be a simple solution bypassing the stomach motility issues, from a more practical standpoint, as far as I am concerned, it requires more thought as a long term solution for Dear Son.

The visit was compounded by the physician’s heavy accent, making it hard to understand him at times. I had to ask him several times to repeat things, which only added to my frustration and probably his as well. Entering all of this data in the system, along with sixteen year medical history, was time consuming for the physician.

There were signs in the examining room about how they were converting to the EMR. I thought about how expensive it must be for a facility to do this. If every visit takes 50 % longer, then a physician will see less patients in the course of a day, just to enter in the data. In addition, if I personally were seeing a new physician, and he was stopping to enter data into the EMR, I can’t imagine I would ever feel comfortable asking him about a personal concern relating to a medical issue. Entering data into the system, is about as impersonal as it gets.

I remember a few years ago, when I went to an orthopedic spine surgeon about my back issues. He had asked if it would be o.k. if he dictated during my visit. I agreed. The visit started and he introduced himself and asked about my concerns. He stopped and dictated my name and concern. Then he reviewed the x-ray, explained it to me and then stopped and dictated the x-ray results. This went on through the entire visit. I never saw this physician after that because I refused to pay for an office visit and then have to sit there while he did his work, dictating. I chose another neurosurgeon instead, one where I didn’t have to endure his dictating. It was the same experience with the EMR. I felt like I had to sit while the physician did his paperwork, even though there isn’t any paper involved anymore.

The problems with the EMR in a patient visit are as follows:

  • It’s time consuming. It took 50% more time to get through our office visit when he had to enter the data.
  • It’s annoying. I don’t want to sit through the data entry piece.
  • It’s impersonal and critical information could be missed. If I am not comfortable talking to a physician in the office visit, then perhaps I might not share information that may be critical to a diagnosis. If that occurs, then the diagnosis could be wrong and the treatment may not be effective.
  • It’s disrespectful. I don’t want to sit through a physician doing his paperwork any more than I think he wants to sit with me while I do my paperwork. If they are asking me to complete medical history paperwork prior to the office visit, then I would expect that they could enter the data after I leave the room.

From a healthcare executive perspective, the problems would be:

  • It’s time consuming. If office visits take 50% more time, the physicians are seeing less patients. Less patients equal less revenue.
  • It’s expensive. Not only are the docs seeing less patients, but I’ve just replaced a lower cost worker, the medical transcriptionist, with my highest paid employee. Instead of the transcriptionist turning dictations into medical records of sorts, I have the highest paid worker, the physician, performing data entry.
  • It’s less personal and critical information could be missed. If the patients are comfortable and can’t bring up their personal concerns to the physicians, then the physicians make the wrong diagnosis therefore increasing medical errors.
  • Some patients don’t like it. If a patient finds it annoying, they may elect to go elsewhere, therefore decreasing revenue.

As a patient, I hope I don’t encounter any more physician’s with the EMR however I know that is only wishful thinking on my part. As more and more convert to electronic medical records, I hope they give some thought on the front end to how this will impact patient care. I am certain that even if they don’t give it any thought, about the time they realize the money they are losing by having their physicians spend precious time doing data entry when they could be making money, will change everything. After all, if I were employing physicians, I’d want them performing the tasks that no other person in my organization was qualified to do. In essence, I’d want them doing the job they were paid to do. I could pay another work much less to perform data entry. And isn’t that precisely what we are doing when they dictate? We are paying for a lower cost worker, a medical transcriptionist to turn that dictation into office visit write ups. Why make a huge investment mistake and have our highest paid workers, the physicians, do a data entry task? It’s a huge waste of their time and their money. In addition, it’s doesn’t attract any patient loyalty to the organization. What patient wants to sit through this?

The EMR is just another trend towards the depersonalization of healthcare. First we had the hospitalists and now the EMR. What I wish healthcare executives would understand is that the physician is the most powerful person in your organization. The physician is why I come to your facility. I don’t come because you have nice rooms, I don’t come because you are on the best hospital list (o.k. maybe a little on that one), I don’t come because you have nice landscaping. I come to your facility because I like your physician. Your physician is who I want to see when my Dear Son has an issue. It’s who I want to see walk through the door of the hospital room when my precious Dear Son is sick and it’s who I want to follow Dear Son through his medical issues. That is why I come to your facility and that is why I come back. I don’t come to see “any” of your physicians, I come to see “our” physician. As Dear Son deteriorates, the role of his physician’s become more important. Not only in terms of Dear Son’s care but in terms of what I need as Dear Son’s mother. I don’t want a hospitalist to come into a room when Dear Son’s dying, I want Dear Son’s doctor in the room. I want him to tell me that we did everything we could. And that is the power of your physician. That’s what makes me come back.


Anonymous said...

I wonder if your experience was the result of the newness of the technology and/or the way it is being implemented at your hospital? Our academic medical center has used EMR for a while and other than an extra minute or two for the nurse to enter the vitals, I have not had an experience anywhere near what yours was. My daughter's surgeon sees her just as briefly as he always has :-)

Anonymous said...

does your hospital have medical scribes? lots of hospitals do this because of the concerns you have mentioned....annoying to the patient and the MD, impersonal, time consuming. scribes are trained in how to use the EMR system and type WHILE the physician does his job.

Dream Mom said...

Anon-This was the first time I used this physician at this Big City Pediatric Hospital; I also haven't used this hospital in years. The EMR was new and I don't know if they have scribes.

I am glad you commented. It's good to know other people have the same concerns.

The Microblogologist said...

I actually benefit from the EMR I think. Of course my case is very very different from you and Dear Son. When my clinic converted they put all my history into the system, my nurse/doc didn't have to spend a visit entering it all (which would have been annoying), they just update what they need to which takes very little time, it would have to be done anyway. My Doc LOVES the new system, he is such a nerd about it it is funny.

My nurse enters my vitals and any "new" history and why I am there and Doc will sometimes add something to it but generally just talks to/examines me. He uses it to go over my treatment options, which we then discuss and he often lets me have input in. Since the pharmacy is a part of the clinic he sends over my script(s) and that somewhat cuts down on my wait time over there.

To me it enhances the visit though, especially since he can pull up the different meds and the statistics of different side effects so we can find one we agree on. If anything I wish they would expand the system. There are times it would be nice if I could have access to it and enter in new symptoms or side effects of a new medication and what not, it would help me keep track of my own health at the same time as aiding him in determining if I am on the right dose or if I should make an appointment with him. I get busy and forget to call in and I hate playing phone tag when I do call them so often I will sit on a problem until it gets too bad to ignore. If I could interact through the system when I have time to do so he would likely be better able to treat me without it getting so bad.

I am sure the entire thing is way more complicated for you with Dear Son, especially if they are still getting the system in place. They should work out a system that works for you. The point of these systems is to make these visits easier, and hopefully if they ever get it right it would reduce your workload because any of his team of doctors should have access to his electronic chart so you wouldn't have to deal with all the history with each one.

Sorry for the long rambling comment. I wish you and Dear Son the best =)!


Anonymous said...

Hi Dream Mom;

I'm a long time reader...really enjoy the blog.

I work in a program that supports many people with feeding tubes at home. Most G-J or J tubes can be fed by gravity or slow syringe feed without triggering diarrhea. There often is a period of adaptation, but we find with these tubes diarrhea is not a major concern.

One ongoing program with G-Js is migration of the J-extension, which seems to be dependent on tube type. (Seems more common with endoscopic tubes vs. radiologic or surgical).

Something to think about...I just wanted to allay some of your concerns about diarrhea.

Anonymous said...

We have also begun to "experience" the (alleged) benefits of EMR.

At a recent specialist vist, Twinks doctor spent most of the visit "tweaking" (as she put it) Twinks medical records. She was distracted, I was annoyed, and Twinks was frustrated. It is difficult at best; painful at it's worst.

I realize that this is the coming way - that some day this will be the norm. But, until we are all "in the system" and until all of the providers are used to it (and so many doctors seem to be technophobes, oddly enough) is is going to be "unfun" as Twinks so succinctly put it.

Anne said...

We have Kaiser for insurance and they changed to EMR some time ago, maybe 2005. At the beginning it was a pain. The first few visits seemed to take longer because the nurse and Dr. had to enter all sorts of history and spent a lot of the visit looking at the computer screen. Now, it makes visits a lot easier. There are a number of drop down menus with various phrases and medical conditions on them. Because everything is there time is saved looking from looking through a chart for test results or the last time a lab was run. It has really sped up the pharmacy as well. Usually the prescription is ready by the time we walk over to the pharmacy.

I don't think it's an more expensive in a Dr.'s time, you as the patient just see the time that the Dr. spends charting instead of having it done at the end of the day.

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