Q&A Series 2 of 2: EMRs are disruptive, but simple solutions may present hope
laptop in hospital, female doctor - 207.35 Kb
On the whole, does the EMR do more harm than good in U.S. healthcare? If a case can be made to unambiguously answer in the affirmative, Elizabeth Toll, MD, does just that in “The Cost of Technology,” a compelling essay currently running in the opinion section of the Journal of the American Medical Association. Read the conclusion of this two-part Q&A series where Toll expounded on her points during a phone interview.

If you haven't read the first article in the series yet, please do. Toll, who practices pediatrics and internal medicine at a busy inner-city clinic of Rhode Island Hospital in Providence while teaching at the Alpert Medical School of Brown University, also located in Providence, R.I., expounds on some of the frustrations caused by EMRs in practice and expresses her hopes for the future.

Your exasperation sounds well-founded, but this ship cannot be turned around—EHRs are here to stay. There are reimbursement rewards for getting on board and penalties for failing to do so. I’m sure that aspect only adds another layer of pressure, but —
Well, it’s really easy to see everything you haven’t done. And they can always say, ‘You still have this many labs and you haven’t checked why the patient didn’t go to get them.’ And a phone call didn’t get returned for three hours because you were busy working with other patients, but nobody knows that. In the old days, somebody would come over and say, ‘This person really needs you to talk to them now.’ And there’s this sense that there’s stuff in there and you don’t even know it’s there, and you don’t have time to check because you’re doing this other thing.

I’m sure it’s the same thing everyone faces today—we have voicemail and email and cellphone and, now, electronic records. There’s just stuff coming in from too many directions.

Is the EMR harder to deal with for it being impersonal, driven by automated IT? It’s much different from getting a tug on your sleeve or a call in the night from a human voice.
Sure, and there are just infuriating things. It’s just all ongoing, and it’s like being nibbled to death by ducks. So this is my experience. About three months into this, my husband came home and said that somebody had given a pediatric resident this picture that this child had drawn of a doctor totally focused on a computer while the kid and her family were sitting there. This was about two years ago now. When I first saw the picture, I thought, if that’s the way people see that doctor—who is so wonderful, so deeply caring—how are they seeing the rest of us?

What kind of support have you gotten from your IT and informatics people?
One of the things that’s happening with big organizations is that they’re grappling with how much of their budget should be going into IT. After my JAMA editorial came out, I heard from someone who wrote from South Carolina to say, ‘My organization just spent $50 million and I am no longer a doctor.’

How many have contacted you with feedback on your essay so far?
Around 50 or 60, and from all over the country—San Francisco, Washington, Wisconsin, Tallahassee, North Carolina, South Carolina. Everyone is reeling with this, and people are saying, ‘We’re not technophobes; we love our technology. It just doesn’t work in our system.’ And ‘This technology is designed to make money so that people can bill at a certain level; it’s not designed for better care.’ That’s the thing that keeps coming through—and that people feel glued to a machine and unconnected from patients.

Have most of the messages consisted of expressions of solidarity from physicians?
Yes, and they’ve all been—‘The emperor has no clothes,’ ‘We’re like sheep,’ ‘It’s the people with the attaché cases that run this,’ ‘I wish this were the ’60s so that people would know how to organize,’ ‘I’ve been watching the erosion of the patient-doctor relationship for 25 years.’ Somebody said, ‘I have a sinking heart every time a specialist gets on the EMR because I realize I won’t have any new information about how to manage my patient; it will just be cut-and-paste.’

Did you hear from any EMR fans or at least defenders?
None. I did get a call from a pediatric otolaryngologist who has actually solved his problem by putting video cameras into his room and training his medical assistant to become a rapid transcriptionist. He dictates his notes during his patient visits, saying ‘Now we’re going to put you on this antibiotic, this number of tablets, you’ll take it three times a day’ and so on. This doctor didn’t write; he actually called me. He said, ‘I have the answer!’ He’s able to see 15, 24 patients in a morning using this system. It’s ear, nose and throat, so it’s not comprehensive visits like you would get with internal medicine, but it shows that no piece of the EMR is bad. It’s just that, when you put it all together, everything takes a lot longer and … the added time is not going to the patient.  

It’s distressing to hear that technology is the source of this much discouragement among physicians, especially given all we hear about the EMR’s potential to facilitate patient care that is not only more efficient and cost-effective but also of better quality.
From a primary care perspective, when people go to see their doc, something like 10 to 30 to 50 percent of what they talk about are symptoms of stress in their lives or worsened by stress in their lives. They just really need human contact. They need somebody to listen and they need somebody to connect with, and they’re better if that simple thing happens—without spending a dime and without writing a prescription. And the fact that that has been carved away from what happens—people still have that need. So they will start going to massage therapists and doing meditation and magnet therapy and aromatherapy—places where somebody just has enough time to be with them.

In the last sentence of your essay, you write: 'If we take time to connect with one another and draw strength from listening, learning, teaching and caring, we can join together to find ways to take on new challenges, including the electronic medical record.' What might those ways be?
The people who use the records have to be involved in their development, so that they are designed to think the way we [clinicians] think. Also, if we’re going to commit to technology, we have to get rid of paper. We can’t be doing everything twice. We have to have enough confidence in our systems that we aren’t duplicating them. People have to acknowledge that, if you want doctors to take care of all these things, they have to have time to do it. If the system is taking up most of the time, then the system has to be simpler. You just can’t keep asking people to do more things in less time forever because they’ll eventually just explode.

People will find simpler ways. And we’ll get better at letting systems talk to one another. Our interrelationships within the office have deteriorated because everybody is attached to a machine. We sit in a room with our backs to each other and that brings down morale among the staff. We have to find a way to give people connectivity with other human beings.

How hopeful are you that such a way will be found?
People will always idealize the healing aspect of being a physician, and I am hopeful that there will continue to be a way for that to remain a part of the profession. And I do see that trend in medical schools and residency training programs, where people are insisting on better human skills. As more and more people grow up with that insistence, I hope that they will say to the corporations, ‘We all have to work together to find the answers.’ I am hopeful that a dialogue is starting.