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Ideas and Opinions |

Texting While Doctoring: A Patient Safety Hazard

Christine A. Sinsky, MD; and John W. Beasley, MD
[+] Article, Author, and Disclosure Information

From Medical Associates Clinic, Dubuque, Iowa, and University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-0931.

Request for Single Reprints: Christine A. Sinsky, MD, Medical Associates Clinic and Health Plans, Department of Internal Medicine, 1000 Langworthy Street, Dubuque, IA 52001; e-mail, csinsky1@mahealthcare.com.

Current Author Addresses: Dr. Sinsky: Medical Associates Clinic and Health Plans, Department of Internal Medicine, 1000 Langworthy Street, Dubuque, IA 52001.

Dr. Beasley: University of Wisconsin School of Medicine and Public Health, Departments of Family Medicine and Industrial and Systems Engineering, 1100 Delaplaine Court, Madison, WI 53715.

Author Contributions: Conception and design: C.A. Sinsky, J.W. Beasley.

Drafting of the article: C.A. Sinsky, J.W. Beasley.

Critical revision of the article for important intellectual content: C.A. Sinsky, J.W. Beasley.

Final approval of the article: C.A. Sinsky.

Ann Intern Med. 2013;159(11):782-783. doi:10.7326/0003-4819-159-11-201312030-00012
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Texting while driving is associated with a greatly increased risk for crashing and reduces the amount of brain activity devoted to driving. This commentary asks whether typing into electronic health records poses similar risks and discusses ways to reduce “texting while doctoring.”

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It's about time
Posted on December 3, 2013
LaPorta, Mark Antony, MD FACP
Conflict of Interest: None Declared

It's about time that someone "authoritative" reported these observations and assessments. Patient care is about CARE. The rest is Process.
I was on an appointed committee for our 17,000+ member state medical society in 2006 to gather and make recommendations to our membership on "how to buy a EHR" system. In the face of overwhelming committee support for the buying decision, my recommendation was no. DON"T allow a machine to dictate practice flow. DON'T trust the authorities whose agendas are NOT about patient, but rather, about something more nefarious, as yet not fully revealed. Then came the bribe and the extorsion -- and the marketing.

In 1968, my father, Michele Luigi LaPorta, MD, FACC, observed while directing an advanced intensive care unit and school of nurse anesthesia, that "Medicine is like the nuclear arms race; we have the technology but not the philosophy." This is ever more so true today, much to our loss -- of autonomy, reality, and even common sense.

My question to my "superiors" is this: Why didn't we know this and try our best to stop it?  I'll tell you part of it: we don't know our history, so we are doomed to repeat it.

So much for good care.
Let the process march on.
We did it to ourselves.
Posted on December 4, 2013
Brian Pollak, MD, FACP
WellSpan Health
Conflict of Interest: None Declared
We asked for electronic systems that would help generate notes that would standup in an audit, and that's what we got. We asked for electronic systems that would get us Meaningful Use dollars, and that's what we got.

We never asked for electronic systems that promote value based, patient-centered care. We never asked for electronic systems that are efficient to use.

Sure, we can share the blame with incentives. In a time when we are primed to leverage team-based care, incentives ask more from the provider as a lone caregiver. When we are sitting on mountains of data waiting to be mined for population and community health projects, incentives keep us focused on clicking the right button and using the right documentation template.

We bought electronic systems that help us pursue these incentives. That is the reason that we are in this situation. We need to take some responsibility and realize that we did it to ourselves.
Physician Multitasking
Posted on December 23, 2013
Michael E. Miller, MD
ACP member
Conflict of Interest: None Declared
As a long practicing physician of a certain age, I whole-heartedly agree with Sinsky and Beasley’s (Texting While Doctoring: A Patient Safety Hazard, Annals, Volume 159, Number 11, December 3, 2013) thoughtful caveat concerning physician multitasking-namely computer keyboarding and “mousing” during the patient visit. It’s distracting and impairs our observational skills, and it’s downright rude; clearly negatively affecting the quality of the encounter. I can also personally vouch that this behavior induces an unpleasantly fatiguing, hyper-vigilant state as the work day resembles a slowly accelerating treadmill. The last patient of the day departs, it’s dark outside, and I’m hungry, irritable, and tired. I want to go home, but now it’s time to contemplate the next two or three hours communing with the EMR to complete the always plentiful unfinished business of the day.

The as yet unacknowledged “big picture” of the state of primary care internal medicine today is the near total domination of the clinical encounter, sometimes for better, but in my opinion too often for worse, by the electronic medical record. Meaningful use becomes less meaningful every day, for patient care at least. Is this meaningful progress?

Unfortunately, the author’s solutions to the stated problems represent but an expensive compensatory approach, doing little to address the problem’s root cause: potentially helpful technology is forcing physicians to “serve the technology”, rather than utilizing the new technology to “assist” physicians in the service of improving the delivery of patient care.

The newer team based care models require the hiring of ever increasing members along with their associated costs. How many people does it now take to “feed” the constantly expanding clinical encounter information into the electronic record? For starters: nurses, physicians, medical assistants, “health coaches”, scribes, and probably more as these systems “mature”. It needs to be acknowledged that systems requiring such extensive human resource expenditures are by definition not well designed. Responses primarily designed to compensate for these poorly designed systems will ultimately fail, as the current environment, awaiting the impending health care system tsunami referred to by the authors, becomes unsustainably stressed.

Technologically, the “tail is wagging the dog”: as the capacity to acquire, record, and store information increases, the currently designed electronic systems will be reflexively generate more and more information to be stored. Care providers will never get ahead of the curve. Adding more employees and increasing practice overhead without any expectation or guarantee of increased reimbursement in a constrained financial environment (translation: “see more patients”) is not a responsible solution. The honorable intent of the EMR, its prime directive, was to facilitate the dispersion and availability of clinically useful patient information. That goal was coopted by the powerful, vested (non-physician) interests of the health care industry who instead reprogrammed the EMR, empowering it to be the primary managing director of the present all-consuming documentation frenzy that is the real “tsunami in the room”! I apologize to my patients as I begin the visit for not looking at them as I speak to the screen and type/mouse away.
I refer to our EMR as an all-powerful documenting, billing, and physician grading device masquerading as an electronic health record. I quote to my patients my practice manager’s simple and compelling charge to me when I complain: “if you wanna get paid”, he says as he points to the screen, “this is what you gotta do”.

I think we all, including the ACP, need to compensate less, open our eyes and minds, take and make a stand, and think bigger, a lot bigger, and better!
Author's Response
Posted on January 14, 2014
Christine A. Sinsky, MD, John W. Beasley, MD
Medical Associates Clinic
Conflict of Interest: None Declared

We thank both Drs. Pollak and Miller for their thoughtful comments regarding the impact EHRs have had on their practices.

Dr. Pollak points to the importance of efficiency. We agree. We believe that clinical excellence depends on operational efficiency. When a myriad of daily clerical tasks that previously took a few seconds, now take a few minutes each, the time adds up and something has to give. We are concerned that what gives is often the clinical care of the patient and the work-life balance of the physician.

Dr. Pollak observes that EHRs have not optimally supported team-based care. At a time when our rhetoric and our aspirations are moving toward teams, our technologies and our policies are paradoxically pushing more work to the physician and are conceptualized around the doctor alone in a room with the computer.

While we support teams helping with patient care and record keeping we believe much waste could be eliminated by decreasing requirements for work that does not uniquely add value for the patient, but which is consuming an ever greater portion of the collective clinical effort. Prime among this waste is documentation, especially of the visit note, often composed on a billing template. Most visit notes will be read once, if at all due to the lack of useful content, and then sink down into the sedimentary layers of the record.

Dr Miller observes “the near total domination of the clinical encounter” by the EHR and challenges us to think beyond survival strategies and work-arounds and get to the root of the “documentation frenzy” problem. Again we agree. Do we really need six page encounter notes composed primarily of boilerplate or billing-centric text? Does every clinical act and thought need to pass through the EHR? Do the hundreds of electronic signatures and sign-offs required of a physician each day add enough value to justify the costs?

Most readers will relate to being tired, hungry and just wanting to go home and yet facing several hours of clerical work before the day is done. And because, unlike other workers, doctors are off the clock, these costs are invisible to health care leaders. Invisible, at least, until students turn away from primary care specialties and doctors walk away from their profession, whispering I cannot do this any longer.

The cry of the heart manifest in high rates of physician burnout, particularly in primary care, we believe stems from the frequent mismatch of technology, policy and implementation to the mission of medicine. As physicians we know we are spending our days doing the wrong work. And we feel trapped at the sharp end of many well-intended technology and policy spears. Our collective challenge is to recognize the depths of the problem and bring our considerable energies and creativities to bear on its remedy.

Christine A. Sinsky, MD FACP
John W. Beasley, MD FAAFP
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