Is Patient Story Lost in Electronic Clinical Documentation?

Jan. 21, 2014
An article in the most recent New York Review of Books by Arnold Relman, M.D., highlights how clinical documentation tends to disengage clinicians from patients. "Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient," he writes.

During last fall’s AMIA symposium in Washington, D.C., one panel discussed the future of electronic clinical documentation. Panelists said providers identify many benefits from the shift to electronic clinical notes, including being able to access the notes from anywhere, but many problems persist. Physicians often identify the loss of the patient story from the encounter and the increase in time they spend in front of the computer instead of with patients.

Thomas Payne, M.D., an associate professor in the Department of Medicine at the University of Washington and medical director of Information Technology Services for UW Medicine, began his discussion by showing a photo of his offices -- and pointed out that all of the clinicians were staring at computer screens.

He said that a recent study found medical interns spend 40 percent of their time in front of computer screens and more time reviewing patient charts than directly engaging patients. “I don’t know what the correct percent is, but it seems to me that 40 percent is a little high,” he said.

I was reminded of that conversation and its implications when reading an article in the most recent New York Review of Books by Arnold Relman, M.D., called “On Breaking One’s Neck.” 

I highly recommend this article. Dr. Relman, a former editor of the New England Journal of Medicine and professor emeritus of medicine and social medicine at Harvard Medical School, describes in great detail his experiences, both good and bad, in two hospital settings after falling down stairs in his home and breaking his neck. I enjoyed reading all of his observations about being a physician suddenly thrust into the role of intensive care unit and rehab patient. But the ones that really caught my attention dealt with this issue of clinical documentation and how it tends to disengage clinicians from patients. Here is the relevant paragraph:

What I hadn’t appreciated was the extent to which, when there is no emergency, new technologies and electronic record-keeping affect how doctors do their work. Attention to the masses of data generated by laboratory and imaging studies has shifted their focus away from the patient. Doctors now spend more time with their computers than at the bedside….Reading the physicians’ notes in the Massachusetts General Hospital and Spaulding Rehabilitation Hospital records, I found only a few brief descriptions of how I felt or looked, but there were copious reports of the data from tests and monitoring devices. Conversations with my physicians were infrequent, brief, and hardly ever reported.

As Dr. Payne noted at the AMIA meeting, this “is an important issue for us to quantify and improve upon. What we learn the most from is human interaction.” Because UW has been using electronic notes for only seven years, he said, it is not surprising their use is far from perfected yet.

At AMIA, Peter Embi, M.D., Vice-Chair of the Department of Biomedical Informatics and chief research information officer of the Ohio State University Medical Center, described a recent study he led at five Department of Veterans Affairs facilities. What their focus groups found was that the current clinical documentation systems, while better than paper overall, often do not meet the needs of users, partly because they are based on an outdated “paper-chart” paradigm.  “There is a feeling that the electronic notes don’t impart a story, a flow,” Embi said. “They make it tough to piece together the patient’s story.” That seems to be exactly what Dr. Relman experienced. In the future providers will have to find the right balance between doing the documentation and keeping the focus on the patient interaction and the patient story.

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