In reflecting on a recent hospital stay, Alan Spiro observes “For those of you worried about depersonalization of medical and nursing care I want to reassure you. The commitment to caring for the computer is front and center.” He goes on to say “The nurse and the doctor are diligent in paying attention to the computer, frequently touching the computer to show concern, and feeding it frequently.”
While Dr. Spiro employs gentle irony and humor to make his point, the problem is serious and vast. My colleague Alan Schwartz and I have spent over a decade listening to doctors talk to patients during the medical encounter. In one study we employed actors as unannounced standardized patients (USPs) to conduct 400 visits to physicians who thought, at the time of the encounter, that they were seeing a real patient. In another, over 600 real patients carried concealed recorders into their visits for our analysis. More recently we’ve invited Veterans to carry concealed audio recorders into their appointments, so that we can collect data on missed opportunities to provide optimal care, and then feed that information back to participating doctors. Our team has listened to over a thousand of those. Often it’s painful to hear how the demands of the computer consume a visit.
Nearly everyone — including clerks, nurses and pharmacists (and we collect audio recordings of all of them) — is meeting a data entry expectation. For physicians in the outpatient setting it’s typically E&M coding. How distracted and preoccupied are providers? One of the things we do when we send in USPs is we instruct them to drop little bombs during the visit that should get any conscious clinician’s attention. For instance, a patient with diabetes who comes in with repeated episodes of near fainting, says “you know doctor, sometimes I take 12 of the long acting insulin and 24 of the short acting one and sometimes I think I do it the other way around. It all probably evens out.” In the best case scenario, the physician looks up from the keyboard and says something like “That sounds like a problem. Can you tell me more about the challenges you are having taking your medications as directed?” Such a response is rare. More often, the physician’s focus is on what to put in the EHR when their patient can’t feed them the data they need. We’ll hear: “So, it’s probably 24 of the long acting and 12 of the short acting. Right? That’s the usual way it’s prescribed. That’s what I’ll put here…” The significance of the patient’s confusion as a problem that needs to be addressed directly gets lost.
Remarkably, quite a few physicians do an impressive job of multi-tasking. They attempt to simultaneously follow the patient’s lead, while interjecting questions to meet the documentation requirements for billing purposes. So, while trying to follow up on a comment by a patient that “boy, it’s been tough since I lost my job” they are running through a mindless checklist about possible headaches, constipation, itchiness etc… But even these doctors often make a Faustian bargain: while they take a rational approach to conducting a physical exam, they chart things they didn’t do. Most typically, they record a normal “review of systems” and head-to-toe physical exam without completing either. Interestingly, this phenomenon, which has been called “the ethical problem of false positives” (others just call it fraud), pre-dates widespread use of the EHR. What that 2002 USP study on false positives does not pre-date is Evaluation and Management Coding, established by Congress in 1995 as a pre-requisite to bill for reimbursement.
The admonition that “if you didn’t document it, you didn’t do it” profoundly changed healthcare over a 20 year period. Doctors and nurses, and other providers, are judged based on the thoroughness of their record keeping. So much is riding on it: First, there’s billing. If you didn’t document enough, you can’t bill at a particular expected level. Second, if you didn’t document it, you could get sued and lose in court. And third, documentation is regarded as a measure of quality during peer review. Health care providers are frequently nagged about documentation issues. It can define their worth.
It’s human nature that if you are judged on something (and your paycheck is riding on it) you are going to make that your focus. So the focus of health care is making the medical record look terrific or, at least, complete. It doesn’t look terrific a lot of the time because of all the copying and pasting, and a lot of what’s in it turns out to be fabricated….but it certainly looks like everyone’s keeping busy.
What if we assessed care delivery based on actually observing it now and then? Our work, and that of others who employ unannounced SPs, suggests it is readily feasible and is eye opening. It provides a window into the challenges providers face, the trade-offs they make, and consequences both for care delivery and documentation of care delivery. In fact, if we started observing care directly (think mystery shopper program, but with rigorous standardization) we could liberate health care professionals to just do the right thing (aware that some of their patients are collecting data on their performance), document what’s clinically important, and direct their attention to the patient before them.
One of the things I’ve been wanting to study is whether putting the electronic medical record on a huge screen hanging on the wall, instead of a little screen that only the physician can see, helps prevent some of the (non-contextual) errors we’ve seen in documentation. Could we make the EMR a shared tool of the patient and doctor – something that would not only help keep the record straight but also encourage greater, rather than less, conversation and engagement?
That’s a terrific idea. I wonder if anyone has tried it. It would give the patient real-time feedback on what the doctor is thinking. They would essentially be working together to decide what goes in the note. The patient could correct errors and also get clarity during the visit about what the plan is. It seems it would promote shared decision making. It would also partly avert the problem of the physician having to divide his/her time between the patient and the computer.
Communication between the provider and patient is extremely important: before, during, and after the visit! The suggestion (from Alan above) of placing a large television-like screen in the patient room is a great idea! The concept of patient involvement in the documentation/record keeping (suggested by Saul) is also a very good one that would both engage the patient, support shared documentation, and facilitate shared decision making. The combined suggestion suggests a way to engage patients and providers in meaningful open and trusting conversations that should be relatively free of fear of retribution and distrust (if everyone has the option to see everything there is nothing to hide). Some have suggested that patients should “sign off” on a note in the same way a provider signs off on a note; others suggest this might be going too far. The trend has already begun toward sharing more, finding effective ways to utilize that information (for both providers and patients) is going to be very important.
Thanks, Jennifer. It’s interesting how these transformations seem to require changes in both attitudes and technology. Alan’s suggestion that the note be viewable on a large flat screen during the visit represents a relatively recent advance in technology…but not that recent. However, we are now seeing greater acceptance of sharing of the medical record with patients…a social change. I hope someone is trying this out to see how patients and doctors like it.
Just came from an office visit with a doctor, nurse and medical student involved. The nurse and student seemed to pre-populate the EMR so that when the doctor came in he could actually lay hands on the patient. That seemed like a good approach.
On a visit two weeks ago, a different doctor I saw was reaching behind herself typing without looking, all the while looking directly at me and asking questions. I was impressed.
What do we know from research on doctors and their preferences about using EMRs during a visit? Is there a way to make it better for both doctor and patient?
You described some great examples of doctors adapting to the challenge of managing the EMR while giving the patient their full attention. It’s hard for me to picture that doctor reaching behind herself to type while talking to you. It sounds remarkable!
I am not that well versed in the literature on physician experience with the EMR so I’d welcome input from others. But part of the problem I think is that the EMR isn’t really evolving based on what physicians find works best, but based on what a wide range of regulator and payers want. That said, I don’t think physicians should be the only deciders. Physicians may not be fully aware of how EMR design can impact patient safety for better or worse.
I do think your question is an important one: I think there are opportunities for innovative work on how to improve the use of the EMR for both patients and providers. As an example, Alan’s suggestion above about putting it on a big screen that patients can see is a good example.