A recent article in the Journal of the AMA (June 20,2012) has rekindled the debate about whether the use of electronic medical records (EMR) interferes with the doctor-patient relationship. In the editorial, the author recalls the story of a colleague whose 7-year-old daughter draws of picture of him in an examination room with his family. Everyone is smiling, but the physician is typing away on his computer with his back to the others. The implication, of course, is that the doctor is not interacting with his patients in a meaningful fashion – and that this is evident even to his young child.
[frame align=”right”][/frame]Many prominent physicians have expressed their decision not to implement EMR for various reasons including: no evidence of a return on their investment, difficult-to-achieve criteria for federal incentives, fear of disruption of clinic workflow, fear of disruption of the doctor-patient relationship, age of physician close to retirement.
It is unlikely that most practices would realize a significant short-term return of their investment on EMR if one includes the cost of hardware (which has a limited lifespan), the purchase and on-going support costs of the software, employee training costs including overtime, and expense of upgrading physical infrastructure. But, like computerized practice management systems, EMR is here to stay. So why not try to offset some of your investment with the federal incentives (while they still exist)?
For doctors nearing retirement, investing in EMR may seem akin to an empty-nester building a huge house just before retiring to a south Florida condo. But increasingly, new physicians coming out of training are looking for progressive practices to join or buy, and a practice using EMR has a marketing advantage. Still, these doctors can be forgiven for not ponying up part of their retirement savings for a project they may not see to fruition.
As far as the effect of EMR use on clinic workflow, those fears are often unfounded if the implementation is properly planned and executed. Often practices overestimate the impact that EMR will have on productivity and make the mistake of trying to do too much at once, cutting clinic volume in half in order to launch a 100% rollout on all patients. This, then, is a self-fulfilling prophecy. Our practice, on the other hand, performed a gradual EMR rollout with no reduction in patient volume and no decrease in productivity. But it took planning to accomplish this.
So what do patients think? In a study presented at ARVO in May, 2012, Patel et al studied patients’ perceptions of service quality in an ophthalmology clinic using electronic medical records. The mean age of patients was 63 and the sex distribution was essentially equal. 95% of the patients were aware that EMR had been implemented in the clinic.
Patient satisfaction scores were unchanged after implementation of EMR compared with before implementation. 76% of the patients reported efficiency of the clinic improved with EMR. Of the patients who were aware of a patient portal function, 58% felt it was a useful feature. And 48% of patients agreed that the ePrescribing function made obtaining their medications easier.
In another study in BMC Psychiatry (2010), Stewart et al found that “numerous studies have shown little change to overall patient satisfaction when physicians use computers.”
Still, physicians have an amazing ability to shoot themselves in the foot, so awareness of the potential downsides of using a computer instead of a paper chart is important. We have found the use of scribes, the ability to ‘clone’ previous information on established patients, and continued doctor input to a customizable EMR system resulting in easier, more efficient processes to mitigate this problem for us. Additionally, some thought should go into the physical layout of the exam room to avoid turning one’s back to the patient.
Still, we must make the extra effort to bond with the patient. As one of my partners, Mark Jank, MD, puts it, “Eye contact, active listening, medical speak a patient can understand, a reassuring touch when appropriate, a shared laugh, or a personal remembrance are all important aspects of quality care and could never be replaced by a computer.”