Do Electronic Health Records Make You a Better (or Worse) Clinician?

December 6, 2015

Paul E. Sax, M.D.

Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.

Earlier this week, JAMA Internal Medicine published a study entitled, "Level of Computer Use in Clinical Encounters Associated with Patient Satisfaction".

A more descriptive title would have been "More Computer Use in Clinical Encounters Associated with Reduced Patient Satisfaction", as here's the take home point:

High computer use by clinicians in safety-net clinics was associated with lower patient satisfaction and observable communication differences. ... Concurrent computer use may inhibit authentic engagement, and multitasking clinicians may miss openings for deeper connection with their patients.

As I've mentioned before (probably more times than you'd like), the computer's power to grab our eyes away from our patients is one of the things I like least about EHRs. Of course people are less satisfied with their care when their doctor spends tons of time typing away at the keyboard and looking at the glowing screen.

(Brief aside: Some clinicians mention triangulating the encounter by having both patient and doctor review information from the EHR together. Yes you can do this sometimes, but this tactic really doesn't work when taking a detailed history. Plus, it's a capitulation -- the computer is now the center of attention, not the patient. Finally, it's all but impossible to pull this off in many exam rooms, especially those originally designed with no computer in mind. You'd practically have to ask your patient sit on a step-stool or hang from a trapeze over your shoulder to make this work. Not such a brief aside after all, I guess.)

I'm bringing this difficult situation up again not solely because of the published study -- similar findings have been reported before. This feeling of being trapped by EHRs is not just an issue for patient satisfaction, but clinician happiness as well. One of my colleagues received a letter from her PCP, informing her that she (an experienced internist) planned to retire. It included this paragraph, which I'm sharing with that doctor's permission:

resignation letter

So it's not just the patients who don't like it -- we clinicians aren't too thrilled either. This internist is hardly the first to complain about becoming a click-slave, though she's the first I know to use this venue (a letter to patients) to express her opinion.

But the EHR must be good for some things, right?

Of course -- a short but not all-inclusive list of the benefits could include trending of lab results, bringing up previous medication histories, displaying radiology images, reviewing other clinicians' notes, issuing reminders about health maintenance tasks, and receiving warnings about dosing errors, allergies, and drug-drug interactions. Access to records remotely is a huge bonus.

Note I'm deliberately excluding the billing and medicolegal features, as frankly they are usually irrelevant to quality patient care. They are part of EHRs for other reasons. See here for what I think of that "functionality" (a word which always makes me cringe).

All of which makes me wonder -- do EHRs make us better at what we do? Or worse?

Help please.

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This article was provided by NEJM Journal Watch. NEJM Journal Watch is a publication of the Massachusetts Medical Society.
See Also
Electronic Health Record and Drug Prescribing Warnings: The Good, the Bad, the Ugly
The Pain -- and Potential Power -- of Electronic Health Records in One Little Anecdote

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