In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.
Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:
"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.
"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.
"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."
Pierre B. Turchi, M.D.
Chambersburg, Pa.
"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.
"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."
Francine Palma Long, M.D.
Edward Hospital
Naperville, Ill.
"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."