March 6, 2009
The Computer Will See You Now
By ANNE ARMSTRONG-COBEN
FOR 20 years, I practiced pediatric medicine with a “paper chart.” I would sit with my young patients and their families, chart in my lap, making eye contact and listening to their stories. I could take patients’ histories in the order they wanted to tell them or as I wanted to ask. I could draw pictures of birthmarks, rashes or injuries. I loved how patients could participate in their own charts — illustrating their cognitive development as they went from showing me how they could draw a line at age 2 and a circle at 3 to proudly writing their names at 5.
Now that I’ve been using a computer to keep patient records — a practice that I once looked forward to — my participation with patients too often consists of keeping them away from the keyboard while I’m working, for fear they’ll push a button that implodes all that I have just documented.
We have all heard about the wonderful ways in which electronic medical records are supposed to transform our broken health care system — by eradicating illegible handwriting and enabling doctors to share patients’ records with one another more easily. The recently passed federal stimulus package provides doctors and hospitals with $17 billion worth of incentive payments to switch to electronic records. The benefits may be real, but we should not sacrifice too much for them.
The problem is not just with pediatrics. Doctors in every specialty struggle daily to figure out a way to keep the computer from interfering with what should be going on in the exam room — making that crucial connection between doctor and patient. I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me. I am forced to bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is “in pain,” and to restrain my potty mouth when the computer malfunctions or the screen locks up. I advise teenagers to limit computer time as I sit before one myself for hours each day until my own eyes twitch and my neck starts to spasm.
In short, the computer depersonalizes medicine. It ignores nuances that we do not measure but clearly influence care. In the past, I could pick up a chart and flip through it easily. Looking at a note, I could picture the visit and recall the story. Now a chart is a generic outline, screens filled with clicked boxes. Room is provided for text, but in the computer’s font, important points often get lost. I have half-joked with residents that they could type “child has no head” in the middle of a computer record — and it might be missed.
A box clicked unintentionally is as detrimental as an order written illegibly — maybe worse because it looks official. It takes more effort and thought to write a prescription than to pull up a menu of medications and click a box. I have seen how choosing the wrong box can lead to the wrong drug being prescribed.
So before we embrace the inevitable, there should be more discussion and study of electronic records, or at a minimum acknowledgment of the downside. A hybrid may be the answer — perhaps electronic records should be kept only on tablet computers, allowing the provider to write or draw, and to face the patient.
The personal relationships we build in primary care must remain a priority, because they are integral to improved health outcomes. Let us not forget this as we put keyboards and screens within the intimate walls of our medical homes.
Anne Armstrong-Coben is an assistant clinical professor of pediatrics at Columbia.
What Dr. Armstrong-Coben is describing is what I term a "mission hostile user experience" (link to my series on this point), but she goes further, recognizing the paradigm change between paper and IT. She questions the wisdom of this still-exploratory change in medical practice.
Interestingly, renowned Merck scientist emeritus Dr. Maurice Hilleman, inventor of most of the vaccines we received as kids, also expressed similar concerns to me regarding biomedical research IT (link).
I've seen the following wisdom on the web as well by Scott Haig at Time.com. I think it sums up the controversy over this attempted paradigm change well:
Electronic Medical Records: Will They Really Cut Costs?Indeed.
... the doctors I know wince whenever electronic medical records are held up as some kind of silver bullet. Before we had them on every countertop, computers held such promise for us in medicine: doctors and patients live in a world of painful, pressing questions, the answers might be in there. Or so we thought. Twenty nine years from the night I first sat in a hospital in front of a computer screen the questions persist.
And I still don't see the profit-maximizing, cost-controlling physician with his nationwide computer treating patients any better than the great physicians I've known have. With pen and paper, personal commitment to each patient and judgment born of practical experience. None of which I have found in a machine..
I emphasize that I am an advocate for healthcare IT ... but only if that HIT is done well. That means not just technically, but operationally in real world settings, taking into account the clinical, social and organizational ramifications and realities of these technologies in clinical settings.
It's those two words "done well" that truly exemplify the old saying that the devil is in the details.
Addendum: the NY Times published letters from a varied audience in response to Dr. Armstrong-Coben's piece, largely agreeing with the issues above.