A Patient’s Story
Yet there is a far deeper and more pervasive problem with EHRs that was brought home to us recently by a patient we know. Mary is a frail woman in her 60s who was first diagnosed with a form of lymphoma about 20 years ago. She had been doing well until she developed abdominal pain, which was traced to diverticulitis. Surgery fixed the problem with her colon, but her recovery was quite difficult. Eventually, she was well enough to be sent home, but she was quite discouraged.At home, she developed a urinary tract infection and returned to the hospital. There she told the doctors treating her that she did not want any further treatment, and instead wanted to be referred to hospice. Plans were made to do so. Fortunately, her husband reached out to her long-time oncologist, who came and saw her. He persuaded her to accept a transfer to his hospital service, where she received a feeding tube, was placed on antidepressants, and about a week later, turned the corner.
The Patient-Doctor Relationship
Many experienced doctors can point to such stories. Too often, sophisticated new technology–in this case, the EHR–interposes itself between the patient and the doctor, drawing the doctor’s attention away from the patient. The EHR can also sometimes make the data in the medical record–physical examination findings, laboratory values, radiology scan results–seem more reliable and even more real than patients themselves.Over time, it becomes progressively more tempting for doctors and other health professionals to suppose that because they have thoroughly reviewed the EHR, they have a thorough grasp of the patient’s medical situation. Yet there is a profound difference between looking at the data and actually laying eyes on the patient; between reading physical exam findings reported by a colleague and performing your own; and between reading the patient’s story and actually hearing it yourself.
This difference was dramatized in a patient presentation by one of our third-year medical students. He reported that his patient was “status post BKA,” meaning that the patient had undergone a below-the-knee amputation. “Really?” said the faculty doctor, “Let’s go see the patient.” When the team walked in the room, the patient was seated on the side of the bed, two feet and 10 toes resting on the floor. Obviously, the patient had not had his leg amputated.
Putting Patients Before Systems
As this case also illustrates, patient data in an EHR should never be regarded as an adequate substitute for a doctor’s firsthand knowledge. The EHR has a role to play, but it is merely a tool, like a stethoscope or CT scanner, that must be wielded by a human being. When the EHR begins to be regarded as the most complete, reliable and illuminating source of medical knowledge, we think that doctors will have become the tools of their tools.Repairing the Damage
If over-reliance on the EHR is the diagnosis, what is the appropriate therapy? First, doctors need to insist that all such systems be designed and deployed for the principal purpose of enhancing their ability to care well for patients. Allowing coding and billing, compliance or risk management to supersede the interests of optimal patient care represents a violation of every health professional’s oath. The systems should serve patients and doctors, not the other way around.Second, patients need to take an active interest in their own care. Ensuring the best medical care is not primarily a technical challenge. It is a human challenge, which requires patients and doctors to be able to form deep and long-standing relationships. In most cases, the better your doctor knows you, the more likely she or he will be to ensure that you receive the best care. Changes in insurance contracts and the like should not supplant medical excellence.
Third, it is important to remember what medicine really is. It is not a means of sustaining hospitals, drug and device manufacturers, software developers, insurers or government health agencies. Medicine is an art dedicated to the care of patients, whose interests should always come first. In the right hands, an EHR can help patients get better care, but too often EHRs become ends in themselves, displacing patients as the center of medical attention. Patients and doctors will thrive only if we keep patients front and center.
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