I have a deeply ambivalent relationship with electronic medical records systems, or EMRs. Initially, like many young people, I was completely on board with the transition to paperless and the efficiencies that come with it. However, my stance has changed during the course of my work at the free clinics in Worcester.
A lot of the clerical volunteers are older folk—people who are quite skeptical of technology. The physicians, too, are hesitant to embrace EMRs in the free clinics because of their constant struggles with the systems in their day jobs. In his well thought out and in-depth article, Dr. Atul Gawande describes the dangers and pitfalls of EMRs. Specifically, he mentions how EMRs are in fact a big contributor to physician burnout as a result of excessive record keeping and administrative burden that falls on the shoulders of physicians.
The physicians at the free clinics explain that the biggest reason why they enjoy volunteering is that they can practice true medicine without being encumbered by the unnecessary complexity of EMRs. Instead of staring at their screen trying to document patient encounters writhing the 15-20 minute time slot allotted, physicians can be more present with the patient, carefully listening to their story. This personal touch is why many doctors decided to pursue medicine in the first place, and EMRs should not take that away.
This is one big benefit of the free clinics, that doctors can devote their full time to listening to patients, answering their questions, and understanding their situation. They have a piece of paper in front of them rather than a screen and keyboard. They enjoy the freedom of being unshackled from their computers and electronic medical records systems.
Yet, all of these physicians also recognize the immense benefits that EMRs provide. Being able to quickly look up past patient records, even from different providers is incredibly useful. Automatic prompts that remind physicians to ask questions if a patient is at-risk can catch some maladies that might easily go overlooked without such systems in place.
Communication in medicine is critical to patient care. In fact, one of my past projects was to design a mobile application, quite akin to a pared-down EMR, for the labor and delivery ward to make patient handoff between providers easier and less prone to user error. A big challenge that we faced was ensure in that the system does not get in the way of patient care. We knew that often, software causes more problems than it solves, even if well-intentioned. So we put a lot of effort in observing the workflow of physicians and nurses to see where we can make a difference and where we need to make adjustments once our software was put in place.
There are times when there is utility for EMRs, even at the free clinics. For example, EMRs can be used to collaborate between clinics where patients may not be able to return to the same location or time due to transportation issues or scheduling issues, allowing them to easily come in where is most convenient. This alone would be immensely beneficial to patients, especially when the patient population is prone to not following up. Even just pulling charts from the filing cabinets, because sometimes they get lost, or are filed in the wrong area, or a patient used a different name. Having an EMR would probably alleviate 99% of all of those problems and save countless hours of work. However, careful, diligent testing and making sure that the EMR actually is is solving the problem rather than creating more problems is absolutely necessary.
And so there’s this dichotomy of whether we should actually use any EMR system or not. I really don’t know what the right answer is. I think both have their pros and cons and I think there should be more debate. I love the fact that Epworth is doing a pilot study to figure out the best way to implement an EMR system.
My mother, a primary care physician, comes home every day with a multitude of notes left over to finish. She wants to spend more time with her patients, and I talked to her about this because user experience design and software development is an area that I’m interested in (particularly after my time working in the labor and delivery ward) and so I knew a bit about what goes into an EMR system. She told me how she doesn’t even bring her computer in, instead choosing to just bring a clipboard and some paper so that she can be fully present with the patient. There’s a computer in the room, but she only uses it if she needs to look up something that she didn’t jot down before entering.
And when I talk to the doctors and volunteers at the free clinics, where they still use paper, they consistently tell me how refreshing it is to go back to the original practice of medicine where EMRs aren’t getting in the way. I worked as a chart puller when I started volunteering, and still do when when the clinic is packed, and that’s when I think to myself, “maybe an EMR wouldn’t be so bad—I wouldn’t have to do all of this running around to find a specific chart.” But every time, I quickly realize that it would just cause even more problems with burnout and the volunteers likely wouldn’t want to come in. Patients would lose out on the personal connection with the physicians that the free clinics are able to provide.
This is ultimately why I think that EMRs, and specifically human computer interaction, is becoming a big problem in medicine. It’s contributing to physician burnout, worse patient outcomes. Importantly, though, it’s also a problem that we can reasonable work towards a solution and eventually solve. There are so many benefits to EMRs, but we should make them work for doctors, not the other way around.
“Why Doctors Hate Their Computers,” by Atul Gawande, November 5, 2018. https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers