The Journal of the Arkansas Medical Society Med Journal March 2020 Final 2 | Page 6

You take care of Arkansas WE TAKE CARE OF YOU Security / HIPAA Compliance Medicare & Medicaid Audits Transactions Medical Medi Malpractice Employee Matters Fraud & Abuse Physician Contracts & C ompensation Operations & Management Private Wealth Services Taking care of all the legal needs of medical providers 198 • The Journal of the Arkansas Medical Society Commentary by Tobias Vancil, MD, FACP Our Patients are Talking. Are We Listening? I ’ve wanted to write some kind of commentary about the effects of the EMR on provider-patient relationships for some time. Within the last two weeks, a couple of things happened that have given me some inspiration. The first occurred while working with a student one afternoon in my clinic. The student had been reading in the EMR about the patient they were about to go see; they were actually looking ahead because of an apparent “no-show.” As I was off to see a patient with another student, the late patient arrived. Knowing that not seeing them now meant an over-book later, we triaged the pa- tient. I casually told the student to change gears and go see the late patient. They looked at me oddly and said, “I haven’t had a chance to look over the chart, what should I ask them about?” Now, this very bright individual will no doubt go on to have a successful career as a physician, but through no fault of their own, they had asked a trivial question. My answer was simply, “just go ask them why they are here.” The second thing that happened was the time- ly publishing of an article in the Annals of Internal Medicine regarding the time spent by physicians using an EMR/EHR in an outpatient setting. This was looking at PCPs and ambulatory medical sub- specialists, but I think any provider who works reg- ularly with an EMR can use this article as a way to be reflective about its effect on their practice. In sum- mary, the study included data from approximately 100 million patient encounters with about 155,000 physicians from 417 health systems. It found that physicians spent an average of 16 minutes and 14 seconds per encounter using EHRs, with chart re- view (33%), documentation (24%), and ordering (17%) functions accounting for most of the time. This certainly is not the first article of its kind, but it disturbs me that the most time spent was on chart review. Certainly, there are ways the EMR can help with more accurate order/medication entry and the adaptive documentation options are vast, but why are we spending so much time in chart review? My fear is that we enter a patient’s room with a pre-con- ceived bias about the purpose for that day’s visit. Based on prior issues/co-morbid conditions noted in the chart, we may not be ready to listen to the ac- tual chief complaint of the day. There is abundant data that shows either missed or delayed diagno- ses due to diagnostic suspicion/provider bias based on a too-narrow differential diagnosis framed by pre-conceived notions. A basic example would be assuming all patients who present with pain with a sickle-cell disease history are having a pain crisis. It is not that I feel chart review is not helpful, but we need to ask ourselves what’s more important: the information in the EMR or the patient sitting right in front of us? The challenges with using an EMR while still maintaining tactful provider-patient communica- tion divides clinicians into two groups. The first in- cludes those of us who trained mostly without an EMR or at least using a hybrid system with comput- ers for order entry or data retrieval. The problem is that most of our training and prior practice involved sitting face-to-face with the patient and/or family, looking them eye-to-eye, and maybe intermittent- ly jotting down notes while absorbing the story of their current worry. In clinical practice, we must transition to a model that now involves splitting time between a computer screen and our patient, with some compromise of our clinical assessment skills. These skills, for most of us, have significant reliance on the non-verbal communication from our patients. The second group encompasses the newer challenge of teaching interpersonal communica- tion skills to new trainees who have never lived without computers and are more dependent on digital communication than their analog elders. Medical education has been diligently focusing on strategies to teach more enhanced provider-pa- tient communication skills to our trainees. Over at least the last decade, this has become a more thought-provoking endeavor due to more depen- dence on the EMR. These students’ first patient ex- perience very likely is now a provider-patient-com- puter encounter. This can be a change for even the most seasoned veteran of clinical practice. I am not “against” the EMR and I do see the promise of a clinical workflow that is more efficient by a well-designed computerized system, but let us not lose sight of the importance of the human role in health care delivery. The information contained within these databanks can assist patient care delivery, but we always need to keep in mind that clicking a mouse is not the same as listening.