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The Real Reason Why Doctors Don’t Want To Adopt EMRs, And What To Do About It

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.


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11 Responses to “The Real Reason Why Doctors Don’t Want To Adopt EMRs, And What To Do About It”

  1. This is a great post, and I think you hit the nail right on the head. One of my big fears with respect to all this stimulus funding is that it'll go for technology that doctors will hate and ultimately not use.

    You (and your readers) might also find this National Academies report of interest, as it addresses a number of these issues: http://www.nap.edu/catalog.php?record_id=12572

  2. KG2V says:

    I can see your point on full EMRs, but it can also be the other extreme. An example is my children's MD. He's a wonderful OLD (and I say OLD with advise – hint, he was first licensed in the 1940s!) MD – loves his patients etc

    BUT, the guy is way way behind technology wise, to the point that EVERY time I go there, I have to fill out TWO NY State insurance forms (one for Mine insurance, one for my wife's), where even his coverage MD has that in a computer, they check the cards to see there is no change, and away we go – yes, his billing is still paper and pen

    I think MY primary has about the right mix – paper records, but has a wireless PDA to do things like enter the prescriptions, and print them out for his signature/send electronically to the store, and electronic billing. I don't spend 10 minutes filling out forms EVERY time I go

    There needs to be a balance – and I don't think EMR is it (and I'm an IT geek), but say billing? How many employees does the Government and Insurance companies have to have just to deal with paper insurance filings?

  3. Debbie K, NP says:

    My daughter's sports med MD has an EMR on some sort of mobile frame so that he can face us when he's looking at the EMR. The way the EMR at my clinic is set up, I have to turn my back to the patient so I usually document after the patient leaves. Unfortunately, sometimes I forget to ask a piece of info that the EMR requests, but I feel that turning my back to the patient is rude. I really hate it with a new patient. I must say though, that the EMR has greatly improved the detail of my documentation and I really love it.

  4. Ted Eytan says:

    Hi Val,

    For what it's worth, I was exposed to a different way of looking at this issue, when I visited Steelcase Nurture Headquarters as part of the Innovation Learning Network recently – I blogged about it and posted photos of their work:

    http://www.tedeytan.com/tag/iln09

    What I learned was that the design of the environment in which the technology is used can be as critical as the technology, so maybe work might be done on the part of EHR manufacturers, or maybe work might be done on the part of health care to think about the environments in which these tools are used.

    In Steelcase' case, they have done some interesting work with Mayo Clinic, including a randomized study to look at the impact of different design.

    I think most physicians and patients experienced in the use of electronic health records enjoy the potential for collaboration around the information contained in them, and to that end, I pondered whether there should be a percentage of funds spent on technology devoted to the design the environments of their use. See what you think,

    Ted

  5. rcantor says:

    I'm a 50 year old physician and I have no trouble with the technology, but I refuse to humiliate my patients by interacting with a computer while with them. This means typing my notes right after I see them. It doubles the time for each encounter. Some physicians in our multi-site group game the system by addressing monitored quality measures while not addressing the concerns of the patient. In one recent encounter like that I addressed the patients 8 concerns that were ignored by the other doctor for years. The patient encounter lasted 20 min, the EMR documentation took 40 min. A dictation would have taken 5 minutes.

    The other problem with EMRs is that they will eventually be used to enforce guidelines that save money but wont be in the best interest of all patients. Doctors will be punished for individualizing care rather than blindly following guidelines.

  6. David says:

    That is sooo not the reason why.. Most doctors only listen to their patients for about 65 seconds before they cut them off and all studies show that patients feel disrespected by their doc's. In a good EMR implementation the computer is a shared tool and there is very little time spent typing. Last time I checked most doc's make notes in the room on paper now and I don't think they do that without looking at the paper to write. Since you can type 3 times faster then you can write you have to assume it actually frees up face time not the reverse.

    The sole reason they haven't adopted is purely financial.If you told doc's for example that in Hawaii where they implemented EMR's and phone visits and email access that viists to family practice dropped by 25%. The first reaction would be oh no I would lose money doing that.. But since it is Kaiser and they are on salary what happened is that they now can treat people in the medical home model, see each patiert for longer visits, carry less on each panel and get home earlier. well then you might see adoption..

    Patients trust their providers but we aren't that naive to think it is becuase it might make them lose some relationship with us.

  7. Cindy Throop says:

    Undoubtedly, EMRs should encourage patient participation and should not detract from the medical encounter. Ted pointed out the great design options by Steelcase.

    This general design approach is already in use at Kaiser Permanente (KP). At my most recent medical appointment (last month), I looked at my EMR with my doctor. The room had a very large monitor that we could both view at the same time. He encouraged me to review information in the record with him. The conversation involved plenty of quality interaction and eye contact.

    I decided *with* my doctor a plan of action, which he proceeded to record in the EHR while I observed. The visit was empowering because I was a partner in the process. The overall physical setup and real-life use (or shall I say, interpretation?) of the EMR facilitated that partnership. The collaboration continued after the visit. I received my test results (at the same time as my doctor) through my PHR, with the information displayed next to the range of normal values and links to explanations of the point of each test (in “normal people” language).
    I've ended up in different “exam rooms” over time at KP, but each one has had a monitor in full view to me, the patient. The exact placement and size of the monitors varies from room to room. Surely I will be a tad bit disappointed if we end up in a room with a smaller monitor next time around, but I appreciate the real-life implementation of patient-centered design, even if it is a little messy (at least compared to the sleek Steelcase setup).

    BTW, I saw a video demo of Microsoft’s Surface. I will probably drool on it when I finally see it in real life…too cool!

  8. Cindy Throop says:

    Undoubtedly, EMRs should encourage patient participation and should not detract from the medical encounter. Ted pointed out the great design options by Steelcase.

    This general design approach is already in use at Kaiser Permanente (KP). At my most recent medical appointment (last month), I looked at my EMR with my doctor. The room had a very large monitor that we could both view at the same time. He encouraged me to review information in the record with him. The conversation involved plenty of quality interaction and eye contact.

    I decided *with* my doctor a plan of action, which he proceeded to record in the EHR while I observed. The visit was empowering because I was a partner in the process. The overall physical setup and real-life use (or shall I say, interpretation?) of the EMR facilitated that partnership. The collaboration continued after the visit. I received my test results (at the same time as my doctor) through my PHR, with the information displayed next to the range of normal values and links to explanations of the point of each test (in “normal people” language).
    I've ended up in different “exam rooms” over time at KP, but each one has had a monitor in full view to me, the patient. The exact placement and size of the monitors varies from room to room. Surely I will be a tad bit disappointed if we end up in a room with a smaller monitor next time around, but I appreciate the real-life implementation of patient-centered design, even if it is a little messy (at least compared to the sleek Steelcase setup).

    BTW, I saw a video demo of Microsoft’s Surface. I will probably drool on it when I finally see it in real life…too cool!

  9. We use a questionnaire tool by Primetime Medical that i think it would be worth you learning more about… visit http://www.medicalhistory.com for more.

    As the other David (previous comment) states: “In a good EMR implementation the computer is a shared tool and there is very little time spent typing”. I completely agree with this and think that a good EMR implementation involves the patient before and after the consultation too. The benefit of engaging patients is considerable but is so different to today's status quo (where patients are the most underutilised individual in the healthcare industry).

    In our use of the preconsultation Medical History Questionnaire (on patients mobile phones) we find patients benefit greatly because they can take as much time as they like, can reveal their full history and they get to think more about the concerns they have that they'd like to use the consultation time talking with their Doctor about.

  10. We use a questionnaire tool by Primetime Medical that i think it would be worth you learning more about… visit http://www.medicalhistory.com for more.

    As the other David (previous comment) states: “In a good EMR implementation the computer is a shared tool and there is very little time spent typing”. I completely agree with this and think that a good EMR implementation involves the patient before and after the consultation too. The benefit of engaging patients is considerable but is so different to today's status quo (where patients are the most underutilised individual in the healthcare industry).

    In our use of the preconsultation Medical History Questionnaire (on patients mobile phones) we find patients benefit greatly because they can take as much time as they like, can reveal their full history and they get to think more about the concerns they have that they'd like to use the consultation time talking with their Doctor about.

  11. Ex Transcription Gal says:

    From a from a medical transcriptionist’s point of view, I think the EMR is great—as long as a trained medical transcriptionist is doing the typing, not the doctor! I find it interesting that no mention is made at how EMR has impacted the careers of thousands of us. As a medical transcriptionist for 30 years who trained one year at school before entering the field, it has been disheartening to see the occupation I love being taken over by professionals who, as this article so eloquently states, are SUPPOSED TO BE TAKING CARE OF PATIENTS! I have always admired physicians and their dedication, but, sorry, as transcriptionists, you suck! At 51, I’m still working in the medical field (though had to find a different job with the advent of EMR) and regularly review records as part of my current work. I am amazed at the atrocious quality I see. No offense. After all, you didn’t go to school eight or more years so you could sit and type medical reports, did you? I’ve seen so-called “templates” being used inappropriately, (i.e. normal template used with abnormal findings), clipped, short reports with many missing details, or worse, complete lack of any documentation at all—in some cases these records that are going to court. As transcriptionists, whether or not we had jobs depended on the quality and accuracy of our work, and quality is now seemingly irrelevant.

    And, yes, I’ve been on the patient end of things too and have become irritated at seeing my primary care doc typing and “mousing” away with his back to me as I sit on the exam table.

    I have about 12-15 years until retirement but have hopes that some of the “older” physicians mentioned in the article will somehow rediscover the marvels of actually having someone else transcribe the records while they spend the time they should be with the patient. You take care of the patient; we do the typing and clerical work—gee, what a concept!

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