EHR frustration has created a bit of nostalgia about the “good old days” of medical practice — the days before data entry dominated the patient visit.
Judy Mandell wrote an article in the Observer that addressed this frustration, felt by both patients and providers. The loss of eye contact, decreased focus on the patient and the amount of time (often a third of the visit or more) devoted to documentation has removed much of the relational element from the care equation.
While more than one physician would be happy to do away with the EHR forever, we know that’s simply not possible. Given the needs of our patient panels (including a large aging population), developments in medicine and the necessity of increased coordination between providers, the EHR is critical to competent and successful care.
The data entry clerk will see you now
But the breakdown occurred with an exam room delivery model that made the physician responsible for the EHR. When my system put me on the EHR back in 1998, it didn’t take long to realize I now had two patients in the exam room — and the most difficult patient was the EHR. It demanded the most time and was the most difficult, uncooperative and argumentative. And the real patient — the one who I was there to serve in the first place and who gave me the real pleasure of practicing medicine — no longer received my total focus because I was busy entering data into the computer.
Physicians are required to focus on the EHR because it must accurately reflect the patient visit — the circumstances, the details of that particular patient and why the physician made certain decisions. It’s impossible to remember all the information and make correct judgments without it. Not to mention the risk of massive fines or even prison time physicians can face if an audit of records finds inconsistent or fraudulent information.
Scribing: only a partial solution
Mandell’s article presents scribing as the answer to our exam room dilemma. While I agree that someone other than the physician should be responsible for documentation of the patient visit, I don’t believe a scribe is the ideal solution. Scribing can free up the physician from the EHR, which is a real benefit. But the scribe isn’t helping with any other clinical responsibilities, and the limitations of this role don’t provide enough assistance to fix the situation in which we find ourselves.
The best way to address this need is to have the scribing function performed by a clinical team member (a specially-trained nurse or MA) who can help the doctor accomplish the objectives of the visit. It’s not simply a matter of recording information, but assisting with the data collection, patient education and implementation of the treatment plan.
The intersection of meaningful use and meaningful care
Many doctors talk about a return to the traditional care delivery of the past, and that’s where we see new models emerging like concierge medicine and direct primary care. It’s understandable why this is attractive to physicians because it allows for smaller patient panels and enough time to focus on each patient and do the necessary EHR work. But we wouldn’t have enough physicians to provide the kind of primary care our society needs if they all migrated to a concierge model. Affordable, accessible primary care shouldn’t be a luxury.
Some might argue that it doesn’t matter whether or not patients see a doctor who knows them. But people respond differently when they’re treated in a personal way. While personalized service from a barista who remembers your name and coffee order or a car mechanic you trust provides a sense of familiarity and comfort, the advantages of a good doctor-patient relationship extend far beyond meeting an innate interpersonal need. The improved health outcomes make this relationship essential to comprehensive, quality care.
As much as we need enhanced technology and all the benefits of the EHR for better clinical delivery, the doctor-patient relationship remains a foundational element of meaningful care. That’s why we must turn the doctor’s attention away from the computer screen and back to the patient. Our industry’s move toward meaningful use depends on a delivery model that maximizes the value of a familiar physician and coordinated, team-based care. Because meaningful use — and any other efforts to improve quality, safety, efficiency and population health — will be most effective in the context of meaningful relationships.