Have you ever been ignored by someone who was texting or otherwise engaged in a digital conversation? Did you feel that the person was being rude and unresponsive to you? If your answer to both of these questions is “yes” then you will understand the real reason why some doctors don’t want to adopt electronic medical records systems (EMRs).
As sappy as this may sound, most physicians were drawn to medicine because they wanted to help people, save lives, and improve the quality of life for those suffering from disease. Even after we’ve been beaten up by our training programs, and weighed down by debt and the mountains of paperwork required by a broken healthcare system, most of us still retain that do-gooder kernal inside us – we genuinely care about our patients.
And so because we care, we know instinctively that the human side of medicine – the attentive listening, the visual cues, the continued eye contact, and the careful history and physical exam – is critical to our profession. The problem we have with EMRs is that they often interrupt the sensitive and intuitive parts of what we do. EMRs and other digital “tools” designed to make our work more efficient, may do so at the expense of the human connectedness our patients deserve and need.
Most EMRs, as they exist today, are not designed to bring patients into the conversation. In order to maximize efficiency, the physician must type while the patient is talking – usually turning their gaze and even their whole bodies away from the individual or family. Those of us who feel that this behavior is socially inappropriate will take a verbal history from the patient and then type it up from memory later – this creates more work than if we’d simply taken notes during the conversation in a paper-record, and may introduce recollection bias if we do our typing at the end of a long day of seeing many patients.
There is certainly a generation gap in terms of EMR adoption (as my friend Dr. Geeta Nayyar has noted) – our new crop of doctors are very comfortable with EMRs and wireless tools of various kinds, while the “older” doctors are often highly resistant to adopting a digital system. But before we label senior physicians as “obstructing progress” – let’s look beyond the technology issues (yes, it takes time to learn how to do something a different way) and at some of the emotional reasons why physicians don’t like what EMRs do to their patient relationships.
Time and again I’ve heard my peers (who use EMRs in hospitals) say that they feel that they spend most of their time “talking to the computer” rather than the patient. They are wracked with guilt about this, and have actually lost a portion of their “job satisfaction” as a result. They know that the digitization of healthcare has robbed them of the luxury of full history and physical exams, conducted in an uninterrupted face-to-face encounter with their full attention on the patient. They feel like a robot – like a mere collection of algorithms used to process people in an “evidence based” framework. And the patients – they report that their doctors are hurried, uncaring, and potentially replaceable with a robot.
In my opinion, EMR manufacturers must understand the collateral damage that their products can do to the physician-patient relationship and create EMRs that engage patients in the physician encounter. I have seen at least one prototype product that is trying to do this (and there may be many more – it’s difficult to keep up with all the new innovations, so please leave a comment about other products that you know of), Microsoft’s Surface. Surface allows the physician and patient to sit together at a table with a screen embedded in its top. The physician can bring up lab results, radiology images, and medical records to discuss them with the patient so they can see it at the same time. I really like this concept, since it facilitates electronic record keeping while engaging the patient in the encounter.
When EMR vendors and civil servants bemoan the slow technology adoption rates of physicians, I urge them to recognize that there is more at play than just “resistance to change.” There is a resistance to dehumanizing doctor-patient interactions, to turning one’s back on a crying patient to type notes on a laptop, to spending more time “talking to a computer” than talking to a patient. That resistance is actually a good thing – it means we still care, we have hearts, we are human.
Now, to get physicians to adopt EMRs – don’t use a stick (“adopt our EMR or we’ll fine your practices”) use the younger generation of physicians (already comfortable with technology) to teach the older ones how to integrate digital record keeping into their workflow. During that interaction, I believe the senior physicians will be able to teach the junior ones a lot about the art of humanizing their patient interactions, while the younger ones train them about the technical process of incorporating EMRs into their own workflow.
In summary, EMR adoption is slow not just because of cost and technical skills barriers, but because of the potential dehumanizing effect they can have on medical practices. Senior physicians may understand this risk better than junior ones, and should be admired for their desire to maintain fewer barriers in their relationship with patients. EMRs created with the ability to include patients in the conversation can reduce the potential social damage they often introduce in patient encounters. Peer-to-peer training is valuable in improving adoption rates, teaching junior physicians the social etiquette important in a caring doctor-patient relationship (and to maintain the art of listening and observing), and helping senior physicians learn how to use technology to achieve the tasks they currently complete by other methods.