Computers can do wonderful things. In many industries the people who analyze the data are a small, well payed elite and the people who enter the data are lineworkers.
Health care, a few decades ago, was something done by professionals, which is what we called physicians in those days.
Today, healthcare is a place where physicians are increasingly tasked with data entry and, as much as they may be analyzing the data for individual patients under their care, a much bigger purpose of the Electronic Record is the statistical analysis done by administrators, insurance companies, quality ranking institutions and others. Their needs supersede the needs of physicians caring for patients, but it is the physicians who are still tasked with entering the data that those other forces require.
Hippocrates had a word for all those people, long before he even knew who they would be in our era. He called them “the Externals”.
Today, the “externals” are running the show and we are pawns in their game. They don’t want us to even make clinical decisions – they have pre-programmed prompts in our #EMRs to order or initiate things that, generically speaking, might theoretically benefit our patients.
But people are complex and we do not have the technology to let computers decide what to do with individual patients. We still need well trained and experienced clinicians to make sense of all the data out there and apply it to our individual patients.
I think we, the physicians, need to reclaim the medical record. Its primary purpose absolutely must be to document what we do, how we think and what our patients tell us about their symptoms.
And I think the increasingly clever artificial intelligence systems could harvest what the bean counters need from the notes that we create for our purposes. We could even imagine a concept like metadata, background statistical stuff that clinical readers don’t need but nerds might need.
The other day a hospital outside my service area admitted one of my patients and needed our information. I faxed over my two most recent office notes that included important information about who this patient’s different specialists around the state were. But the hospital didn’t see that important nugget among the s***tload of mostly irrelevant data that printed out.
So let us put in the note what we need and make the computers harvest what the externals need – and make somebody else, besides the clinicians, responsible for entering that data.
A Country Doctor Writes: 
Once our office (which had become part of a health system to survive) started to use an EHR I was in trouble and started to hate going to work. That is something that had never happened to me in my previous 33 years of practice. I would begin to feel dread on Sunday evenings. I expressed my extreme unhappiness and stress from and due to the EHR to my “boss” (who by the way was a wonderful and caring woman- she was eventually fired for “caring too much about the doctor’s needs”). She arranged a 6-month trial with a scribe. I was blessed to have a very bright and highly self-assured young lady as my first scribe. What a revelation for me. My whole attitude and morale instantly improved. After 6 months I was told that I would now have to pay for the scribe myself if I wanted to continue to use them. That was $44,000.00 per year. I discussed this with my wife (who had been quite worried about me during the non-scribe EHR days) and without a moment’s hesitation she said “Yes.” A scribe would usually last 6 months or so and then they would move on to med school, nursing school, PA school, or NP school. It was always a stressful few weeks as I “broke in” a new scribe. Most were excellent and a distinct minority were not very good (poor work ethic, not interested in healthcare, and the like). This all helped me to decide to ultimately retire at age 65.5 years. I have not missed practice or looked back for one second. I am never bored. I am no longer consumed by EHR-induced stress.
My son is a family doctor who has known nothing but the EHR (and at that several different programs). He is able to type accurately quite rapidly and look at you while doing so. No scribe for him. He is not stressed but occasionally aggravated that the EHR doesn’t do what he needs it to do- work for him. He files a “ticket” and they slowly are modifying it to his needs.
I’m now starting my 5th retirement year and recently spent a month beach and poolside in St. Croix, USVI. I’m so glad I was a family doc. I’m so glad I’m retired and living a new life. I admire the doctor who writes this blog immensely. I knew I was done and had to move on.
I am a retired RN. 35 years experience in the ER and I just wish you were my doctor! For so many years I have followed and enjoyed your posts. Thank you.
Completely agree.
I had quit taking new patients but was still doing 2nd opinions/consults (I work in a major academic center and these are part of our mission).
However, I quit doing that a year ago because the notes from outside doctors were so immersed in worthless information that obscured the information I needed (like H&P, PMH, and especially Impression and Plan) so badly that I either just gave up and asked the patient OR felt like Sherlock Holmes as I tried to piece all the various data together into one meaningful story.
Pity. I enjoyed the actual patient contact and care, and I felt I was providing a useful service to our patients and my colleagues in the community who were seeking an expert opinion for difficult cases.
AS the recent article in the NYT noted, “We are not burned out, we are demoralized.”
Daniel F. Hayes MD, FASCO, FACP
Stuart B. Padnos Professor of Breast Cancer Research
University of Michigan Rogel Cancer Center
6312 CCC
1500 E. Medical Center Drive
Ann Arbor MI 48109-5942
hayesdf@med.umich.eduhayesdf@med.umich.edu
Academic Office: 734-615-6725
Academic Fax: 734-647-9271
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acountrydoctorwrites posted: ” Computers can do wonderful things.
Absolutely. Our office notes, generated by either Allscripts (no longer called that) or EPIC, were often more than 8 to 10 pages. Ninety percent of which was boilerplate reproduced stuff that had little to no importance to the patient’s visit with me. I would put all the important info at the very beginning and at the very end of the note so the middle 90% could be ignored. The EHR-generated office note was in general a nearly complete waste of time and resources, especially when printed out. I found it very unhelpful to care for my patients or those of my colleagues. My old dictated and typed SOAP notes told a medical story, my thinking, and rationale for diagnosis and treatment as well as follow-up that any healthcare professional could follow and at least usually find somewhat useful (as well as a reminder to me as to what was going on with the patient). All my immunization history, preventative medicine milestones (PAP smear, colonoscopy, mammogram, etc.), surgical and hospitalization history, med lists, problem lists, etc were kept on a heavy cardstock “green sheet” in the chart for a near-instant review. I was obsessive and meticulous at keeping that green sheet current. It was a concise and great system. It was a boon to patient care, not an obstacle.
Absolutely! And very timely – just yesterday JAMA published an article on the use of AI natural language processing to read and extract data from free-text in the EMR – and it seems to work quite well – see https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2801918?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamanetworkopen&utm_content=wklyforyou&utm_term=030323