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The Unfortunate Therapeutic Myopia of the EMR

January 19, 2012

There’s a lot you can say about an electronic medical record (EMR).  Some of it is good: it’s more legible than a written chart, it facilitates billing, and it’s (usually) readily accessible.  On the other hand, EMRs are often cumbersome and confusing, they encourage “checklist”-style medicine, and they contain a lot of useless or duplicate information.  But a recent experience in my child/adolescent clinic opened my eyes to where an EMR might really mislead us.

David, a 9 year-old elementary school student, has been coming to the clinic every month for the last three years.  He carries a diagnosis of “bipolar disorder,” manifested primarily as extreme shifts in mood, easy irritability, insomnia, and trouble controlling his temper, both in the classroom and at home.  Previous doctors had diagnosed “oppositional defiant disorder,” then ADHD, then bipolar.  He had had a trial of psychostimulants with no effect, as well as some brief behavioral therapy.  Somewhere along the way, a combination of clonidine and Risperdal was started, and those have been David’s meds for the last year.

The information in the above paragraph came from my single interaction with David and his mom.  It was the first time I had seen David; he was added to my schedule at the last minute because the doctor he had been seeing for the last four months—a locum tenens doc—was unavailable.

Shortly before the visit, I had opened David’s EMR record to review his case, but it was not very informative.  Our EMR only allows one note to be open at a time, and I saw the same thing—”bipolar, stable, continue current meds”—and some other text, apparently cut & pasted, in each of his last 3-4 notes.  This was no big surprise; EMRs are full of cut & pasted material, plus lots of other boilerplate stuff that is necessary for legal & billing purposes but can easily be ignored.  The take-home message, at the time, was that David had been fairly stable for at least the last few months and probably just needed a refill.

During the appointment, I took note that David was a very pleasant child, agreeable and polite.  Mom said he had been “doing well.”  But I also noticed that, throughout the interview, David’s mom was behaving strangely—her head bobbed rhythmically side to side, and her arms moved in a writhing motion.  She spoke tangentially and demonstrated some acute (and extreme) shifts in emotion, at one point even crying suddenly, with no obvious trigger.

I asked questions about their home environment, David’s access to drugs and alcohol, etc., and I learned that mom used Vicodin, Soma, and Xanax.  She admitted that they weren’t prescribed to her—she bought them from friends.  Moreover, she reported that she “had just taken a few Xanax to get out the door this morning” which, she said, “might explain why I’m acting like this.”  She also shared with me that she had been sent to jail four years ago on an accusation of child abuse (she had allegedly struck her teenage daughter during an argument), at which time David and his brothers were sent to an emergency children’s shelter for four nights.

Even though I’m not David’s regular doctor, I felt that these details were relevant to his case.  It was entirely possible, in my opinion, that David’s home environment—a mother using prescription drugs inappropriately, a possible history of trauma—had contributed to his mood lability and “temper dysregulation,” something that a “bipolar” label might mask.

But I’m not writing this to argue that David isn’t “bipolar.”  Instead, I wish to point out that I obtained these details simply by observing the interaction between David and his mom over the course of ~30 minutes, and asking a few questions, and not by reading his EMR record.  In fact, after the appointment I reviewed the last 12 months of his EMR record, which showed dozens of psychiatrists’ notes, therapists’ notes, case manager’s notes, demographic updates, and “treatment plans,” and all of it was generally the same:  diagnosis, brief status updates, LOTS of boilerplate mumbo-jumbo, pages and pages of checkboxes, a few mentions of symptoms.  Nothing about David’s home situation or mom’s past.  In fact, nothing about mom at all.  I could not have been the first clinician to have had concerns about David’s home environment, but if such information was to be found in his EMR record, I had no idea where.

Medical charts—particularly in psychiatry—are living documents.  To any physician who has practiced for more than a decade or so, simply opening an actual, physical, paper chart can be like unfolding a treasure map:  you don’t know what you’ll find, but you know that there may be riches to be revealed.   Sometimes, while thumbing through the chart, a note jumps out because it’s clearly detailed or something relevant is highlighted or “flagged” (in the past, I learned how to spot the handwriting of the more perceptive and thorough clinicians).  Devices like Post-It notes or folded pages provide easy—albeit low-tech—access to relevant information.  Also, a thick paper chart means a long (or complicated) history in treatment, necessitating a more thorough review.  Sometimes the absence of notes over a period of time indicates a period of decompensation, a move, or, possibly a period of remission.  All of this is available, literally, at one’s fingertips.

EMRs are far more restrictive.  In David’s case, the EMR was my only source of information—apart from David himself.  And for David, it seemed sterile, bland, just a series of “check-ins” of a bipolar kid on Risperdal.  There was probably more info somewhere in there, but it was too difficult and non-intuitive to access.  Hence, the practice (adopted by most clinicians) of just opening up the patient’s most recent note—and that’s it.

Unfortunately, this leads to a therapeutic myopia that may change how we practice medicine.  EMRs, when used this way, are here-and-now.  They have become the medical equivalent of Facebook.  When I log on to the EMR, I see my patient’s most recent note—a “status update,” so to speak—but not much else.  It takes time and effort to search through a patient’s profile for more relevant historical info—and that’s if you know where to look.  After working with seven different EMRs in the last six years, I can say that they’re all pretty similar in this regard.  And if an electronic chart is only going to be used for its most recent note, there’s no incentive to be thorough.

Access to information is great.  But the “usability” of EMRs is so poor that we have easy access only to what the last clinician thought was important.  Or better yet, what he or she decided to document.  The rest—like David’s home life, the potential impact of his mother’s behavior on his symptoms, and environmental factors that require our ongoing attention, all of which may be far more meaningful than David’s last Risperdal dose—must be obtained “from scratch.”  If it is obtained at all.

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EMRs and Zombie Psychiatry

April 5, 2011

I consider myself to be a fairly tech-savvy guy.  I grew up in the 80s and computers have been a part of my leisure time, my academic life, and my work environment for as long as I can remember.  But using an electronic medical record (EMR) is testing my patience.

More importantly, it’s yet another example of an external influence which is changing the practice of psychiatry.  And not for the better.

I learned how to practice medicine from teachers who valued the essence of the interpersonal relationship between patient and doctor.  What attracted me to psychiatry in particular was the fact that in this field, these unspoken and unquantifiable aspects of the doctor-patient dyad are paramount, much more so than in any other medical specialty.  The patient’s subjective feelings about the therapeutic relationship—the patient’s unconscious transference of experience from past relationships into the present, for example—are as much a part of the therapeutic process as his or her verbal reports or directly measurable behavioral symptoms.  The “soul” of psychiatry lies in this nonverbal interaction.

Moreover, this relationship transcends time.  For as much as we like to bemoan the “15-minute med check” appointment, the truth is that fifteen minutes is plenty of time for an expert clinician to get an overall feeling for a patient—the “Gestalt” impression that informs the treatment process.  By the same token, a one-hour session by a poorly trained clinician is nothing more than data gathering.

EMRs are changing how we document information.  One could argue, correctly, that documentation has always been an important part of clinical care, and not directly related to the doctor-patient relationship.  However, a well-written note (not to mention the exquisitely detailed psychodynamic case formulations from years past) can convey a rich trove of information about a patient’s history, symptoms, underlying pathology, and future goals.

The type of information we document in an EMR, however, is different.  I’ve commented elsewhere that the ideal EMR for a psychiatrist would be a word processor and an encrypted hard drive.  Nothing more.  Just let me enter all the information that I think is relevant in a given session and save it for next time.

But EMRs weren’t designed for the psychiatrist or the patient.  They were designed for administrators, billing experts, lawyers, insurance companies, and others who care more about the quantifiable aspects of the interaction (the diagnosis, the medication prescribed, the presence/absence of discrete symptoms) than about the patterns of symptoms, the clinician’s subjective assessment, and the hypotheses underlying the patient’s behavior which are being actively tested in the therapeutic relationship.

The amount of time it takes me to document everything that is required for “correct billing” of my appointments (and to double-check everything, lest I get a call from my administrator the next day to “fix the chart”) takes up virtually the entire scheduled appointment time.

But my concern here is not about the time it takes, or even about the nuisance of having to click on a few dozen boxes during each patient encounter, or open six different documents—in different formats, in non-overlapping windows—to see what’s happened since a patient’s last visit.  (I like to think that I’m a quick enough learner to do all of that.)  My concern instead is with how I’m now starting to think of patients not as human beings with interesting and complicated histories which inform my care, but rather as collections of symptoms which change from visit to visit.

EMRs demand measurement and assessment of patients on scales that are, for the most part, arbitrary, and which may be completely “off the mark” vis-à-vis what’s really happening in a person’s life.  They ask us to quantify things that cannot be quantified, and distract our attention from what might be truly significant in the patient’s life at the time of the encounter.

Hey, maybe that’s okay.  After all, it’s the monthly visits by patient 2010-00224, dx code 296.34, that pay the bills.  And as long as I’ve checked the boxes next to “depressed mood” or “insomnia” or “feelings of guilt” (not to mention the other two-dozen boxes I need to check for his mental status exam and review of systems), and updated his problem list, and made sure I checked the box indicating he isn’t suicidal (never mind whether I actually asked him or not), that counts as “good” care.

But by this time, I’m not a psychiatrist.  Heck, I’m not even a human, I’m entranced, soulless, and following someone else’s commands.  A zombie.  And patient 2010-00224 deserves more than that.


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