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.
“We must pick and click according to the EMR's pathways, rather than by following the patterns of learning and thinking we have internalized over years of training and practice,” writes Toll, who practices pediatrics and internal medicine at a busy inner-city clinic of Rhode Island Hospital (RIH) in Providence while teaching at the Alpert Medical School of Brown University, also located in Providence, R.I. “You survive in this new system by giving the computer complete attention, the kind of attention we used to reserve for a patient. By default, the patient moves down to second place. As sad and horrifying as this sounds and feels, it is becoming the new reality.”
Toll expounded on her points during a phone interview.
You led off by describing and showing a child’s drawing sent to a colleague. What struck you about the picture?
TOLL: There’s a famous painting from the late 1800s by an artist named Luke Fildes called “ The Doctor.” It shows a doctor in a home, sitting next to a child who’s extremely ill. Her parents are in the background. It shows the very intense focus of this physician connected with this child and her parents. That picture was used by the American Medical Association during, I believe, the Franklin Roosevelt administration, when physicians felt the government was getting too involved in their business. They had a campaign essentially saying, ‘Don’t let the government into your office.’ This picture appeared all over the U.S. at that time.
In 2009, we switched over to EMRs—and it has been a completely different job ever since. We had been doing e-prescribing up to then and everyone saw the value of that, where you could easily see the last time something was filled. You could easily figure out who did it and when, and you could do it from a distance and so on. So we knew that this could be a valuable change. But the system is so over-engineered, and there are so many design flaws, that this has just become a really different job.
We have a lot of young residents. They’re really good on computers. All of us have worked really hard to learn the EMR. But it’s made our days 10 percent to 30 percent longer. Everybody charts late at night and we constantly see everything we haven’t done. We never feel finished. Stuff comes in 24 hours a day, our little jelly beans are blinking to let us know ‘more labs, more prescriptions.’
And there are some really serious safety issues that come up, mostly involving prescribing. When you order medicines, you can’t see the full prescription in the window. You just pick the medicine and pick the dose, pick how many refills and so forth, but you can’t see the whole thing. You can open it in another version to see the whole thing at once, but we have patients who have 12 to 15 medications and there simply aren’t enough hours in the day to do things completely and correctly using this system.
Going in and out of all these windows, doing all these different things, I personally felt like I was training myself to have Attention Deficit Disorder. The way that I had learned to think, and the organized way I kept things going, became completely irrelevant. I had to re-learn everything, and the amount of time involved—we have 20 minutes and can’t fit all these things into that.
People have found different ways of getting through it. We will often pre-round on our patients, which means that we’ll go through and look at what immunizations a child will need or what labs a patient will need, and we’ll pre-fill the record with that, so we’re not doing that work during the patient visit. Each of us has different ways. Some people type while with the patient, but I don’t. I print out the last note and write on it so that the only thing I do in the exam room is sit with the patient. Then I excuse myself at the end of the visit, send any medicines that need to be sent, get any labs ready and then I come back in. I just can’t stand to have patients watching me use the computer, because you literally have to shut the patient out in order not to make mistakes.
My husband is a pediatrician on the same EHR system. We’re always on the computer at home, all the time. We’re on