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

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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.
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