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On Being a Doctor |

Brave New EMR

Stuart Lewis, MD
[+] Article and Author Information

From New York University School of Medicine, New York, NY 10012.


Corresponding Author: Stuart Lewis, MD, New York University School of Medicine, 594 Broadway, Suite 310, New York, NY 10012; e-mail, stuart.lewis@med.nyu.edu.


Ann Intern Med. 2011;154(5):368-369. doi:10.7326/0003-4819-154-5-201103010-00012
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Last year, I took the great leap forward to a totally electronic medical record. My project manager at the software company guided me through thickets of timetable confirmations, equipment inventories, data migration assessments, benchmark checklists, and conference calls. She also sent me regular e-mails that included an invitation to the national users' conference in Las Vegas. I didn't make it to Vegas, but I did survive my first year.

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My doctor doesn't look at me
Posted on March 4, 2011
Gregory B Patrick
Heritage Valley Sewickley Medical Specialists
Conflict of Interest: None Declared

I have noted an unexpected side effect of the office EMR. Recently several of my patients (and their families) have complained that their physician spent the office visit interacting with the computer screen rather than interacting with them. "He spent all his time reading questions from the computer." "She barely looked at us at all." "I didn't think that he was giving me his full attention since I never saw his eyes." This seems to be a particular issue with computers that are mounted on the wall.

Some physicians may readily multitask between computer screen and patient. But as a parent who has attempted conversation with children who SWEAR that listening to me while they are texting on their cellphones, I appreciate my patients' concern that their doctors are not fully engaged with them and their complaints because their eyes remain focused on documenting the encounter.

Building relationships between people requires time and attention. Relationships between doctors and patients are no different.

Conflict of Interest:

None declared

Follow the money
Posted on March 9, 2011
Ronald A. Arakelian
No Affiliation
Conflict of Interest: None Declared

Your article echoes much of what I've heard from my colleagues. When a highly educated and technically sophisticated group such as physicians needs money to convince them to buy a computer system, something just doesn't smell right. The brutally honest among us say, "they won't save you time but you can bill a 99214, get away with it, and make a little extra money".This whole EMR concept has torn the fabric a medicine asunder. There is nothing more beautiful than three or four sentences describing a medical history. How are we letting 3rd parties shred our language and prose for no demonstrably and scientifically proven benefit? But who cares when there is 44,000 at the other end. Ronald Arakelian MD

Conflict of Interest:

None declared

The patient's view should be a main thread in the EMR's skein
Posted on March 17, 2011
Zackary D Berger
Johns Hopkins School of Medicine
Conflict of Interest: None Declared

Dr. Lewis's thoughts on the EMR as an imperfect representation of the whole patient are engaging and necessary. One point deserves particular comment. He suggests that "a capacity to switch threads, akin to watching a movie from one character's perspective and then switching to the point of view of another character, would be enormously useful." He then proposes that different threads might identify, for example, diabetes or vasculopathy as independent strands in a single patient's chart.

But if we're talking about "the point of view of another character," there's someone in the room with the doctor whose perspective goes almost wholly unmentioned even in the newest EMRs: the patient. If this record could include the patient's thoughts on his or her own symptoms, disease course, treatment, compliance, and relationship with the physician, I think - rather than expecting the patient to "speak template" - we might get the template to speak patient, to everyone's benefit.

Conflict of Interest:

None

Obstacles to EMR
Posted on March 23, 2011
Claus Petermann
No Affiliation
Conflict of Interest: None Declared

I read with great interest the excellent article in the On Being a Doctor Section of Annals of Internal Medicine on the description of "Brave New EMR," written by Stuart Lewis, M.D. It describes vividly the obstacles of a solo practitioner facing the brave cruel world of implementing electronic records in his office. How did he find the time to become a full time computer specialist, requiring additional training including one -on-one training, while still looking after his patients full time? While continuing to study medicine daily in order to be up to date for his patients?

How did he pay for the system, being an internist with one of the lowest reimbursements among all those other specialties? We are a group of five internists and converting our present computer system to have it interface with EMR and the hospital computers and various labs and xray facilities will cost us about $600,000-$700,000. This amount of money we just don't have and there is some talk that our practice may cease to exist, increasing the shortage of primary care physicians. Dr. Lewis also describes that the new system is more time consuming and the notes being generated by the system read like fast food. The moments he shares with his patients are often too short since new silent messages pop up on the computer screen, turning his head to the desktop monitor.

In conclusion, Dr. Lewis states very clearly that our primary task in internal medicine is: "To try to accurately and comprehensively understand my patients, not merely document them." One easy solution to some of the problem might be to have computer printouts in our records, including our hospital records. This would enable the physician again to have all the important information at his or her fingertips and in front of him/her while talking and examining his/her patient. No need to turn your head to the desktop monitor or walk down the hallway to the next computer station.

I wrote to Senator Stabenow about that easy solution, to have computer printouts in our medical records, and she replied that she is willing to legislate computer printouts for the medical records, should the topic come up with her senator-colleagues.This way doctors again would be able to spend more time at the bedside talking and examining patients instead of wasting time logging in to many different computer screens.

Conflict of Interest:

None declared

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