Chris Notte, MD

In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.

Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:

"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.

"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.

"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."

Pierre B. Turchi, M.D.

Chambersburg, Pa.

"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.

"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."

Francine Palma Long, M.D.

Edward Hospital

Naperville, Ill.

"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."

Todd A. Stastny, M.D.

Blue Springs, Mo.

In reviewing many letters, of which these excerpts are only a few, we are struck by two main observations. The first is that we as physicians – busy though we are – feel strongly enough about the process by which we provide care that we take the time to write well-crafted, often detailed responses to the challenges of integrating technology into our practices. The second, less encouraging observation is that the bulk of the letters we have received point out primarily the problems with electronic records, and that we truly have "miles to go before we sleep."

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.

Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:

"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.

"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.

"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."

Pierre B. Turchi, M.D.

Chambersburg, Pa.

"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.

"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."

Francine Palma Long, M.D.

Edward Hospital

Naperville, Ill.

"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."

Todd A. Stastny, M.D.

Blue Springs, Mo.

In reviewing many letters, of which these excerpts are only a few, we are struck by two main observations. The first is that we as physicians – busy though we are – feel strongly enough about the process by which we provide care that we take the time to write well-crafted, often detailed responses to the challenges of integrating technology into our practices. The second, less encouraging observation is that the bulk of the letters we have received point out primarily the problems with electronic records, and that we truly have "miles to go before we sleep."

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

In Robert Frost’s poem "Stopping by Woods on a Snowy Evening," the speaker is tired and stops briefly to look at the beauty of the surrounding forest. He reflects on what he sees, then faces the reality of all he has to do and the need to move on. He states, "The woods are lovely, dark and deep. But I have promises to keep, and miles to go before I sleep." It strikes us that Frost is trying to teach the importance of balancing time for reflection with the necessity of getting done the work we need to do.

Each month we write on different aspects of electronic health records. We try to provide a balanced and reflective – albeit optimistic – perspective on the opportunities, promises, and challenges facing all of us as we integrate this new technology into our practice. We also try very hard to keep patient care, not technology, as the focus of our efforts. Regularly, we receive letters from readers – intelligent, hard-working doctors – who have taken time to reflect on their experience with EHRs. The comments are insightful and focus primarily on the difficulties and challenges that individual physicians have had with their electronic records. Since we all see things from different angles, we plan to periodically publish the thoughts and feeling of our colleagues who share their thoughts with us (with their permission, of course). Here are some of those thoughts:

"While I am not against the concept of EHR, I believe there are serious flaws in the current EHR systems. In our present system, the amount of information that we are required to put in makes it difficult for anyone to find promptly the most needed information due to the long, protracted details of everything being done, which ends up costing more time than anything else. In order to document accurately during office visits, the physician often concentrates on the computer and the template more than on making eye contact with the Patient, and that’s just wrong.

"Many Patients are complaining about that. I personally face each Patient and take notes on paper the old-fashioned way, using a paper template for a rough draft. Later, after hours, I dictate the notes into the system (I cannot type well). It takes me 1 to 2 hours, but I don’t mind doing it because it allows me to keep communication and direct eye contact with each Patient.

"The truth of the matter is that we have not been able to find yet a medically intuitive program. The more tasks that are included in a program, the less user-friendly and more confusing it becomes."

Pierre B. Turchi, M.D.

Chambersburg, Pa.

"I am writing in response to your column where you discuss EHRs, medicine, and humanism. You assert that since the computers will be doing all the work/thinking for us, our success will depend on our ability to connect with the patient-with ‘warmth, sensitivity, compassion, and empathy.’ Really? And how is the patient supposed to perceive that the doctor has these traits when he/she’s hunched over a computer with his/her back to the patient? How is the doctor supposed to look the patient in the eye, take her hand, see that tear welling in the corner of the patient’s eye? Just when we had arrived at some degree of choosing well-rounded young people [for admission] into our medical schools who could be taught the importance of developing good rapport with patients, the EHR and its odd placement in exam rooms will erase all the progress we have made.

"A doctor colleague relates his experience at a local teaching hospital where his aged mother was being admitted. As she lay in the hospital bed with the curtain closed around her, the intern took her history at a computer outside the curtain! ... I fear too many new doctors will take that route."

Francine Palma Long, M.D.

Edward Hospital

Naperville, Ill.

"I read your column with gritting teeth every time the ‘word’ EHR is printed. Embracing an EHR world, as you’ve suggested we do, that has NOT been validated by peer review and universal ‘physician’ endorsement, is like asking us to sail across the flat ocean and reassuring us that the world IS truly round and we won’t fall off. ... We are ‘sending the entire fleet’ ahead onto waters that are not known to be calm. Frankly, the commander and weathermen have not done their due diligence before committing us ALL to a voyage that is not even a 50/50 bet of success. And we (the ever so undervalued physicians, frequently now only referred to as ‘providers’) are mandated to shove off on our own dollar or be penalized for not complying. EHR costs physicians too much for any real benefit, and costs CMS/insurance payers too much for the ‘clicked up,’ fortified ‘document’ that is produced by the hand and mouse."

Todd A. Stastny, M.D.

Blue Springs, Mo.

In reviewing many letters, of which these excerpts are only a few, we are struck by two main observations. The first is that we as physicians – busy though we are – feel strongly enough about the process by which we provide care that we take the time to write well-crafted, often detailed responses to the challenges of integrating technology into our practices. The second, less encouraging observation is that the bulk of the letters we have received point out primarily the problems with electronic records, and that we truly have "miles to go before we sleep."

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

We frequently receive comments on the column and podcasts that question our optimism about the benefits of electronic health records. The truth is that we continue to believe that electronic records will lead to better access to information, improved communication, and higher-quality patient care. We also agree with many of the e-mails that we have received from readers. There are many problems with current EHRs and the physicians who use them encounter many challenges. Some experiences with EHRs can be incredibly frustrating and create truly unforeseen challenges. Chris had one such experience recently that offered a heavy dose of reality and frustration. This occurred during the transition from one EHR to another, and we felt it would be worthwhile to share the story here.

The best of times...

In January 2012, Chris’s practice was acquired by a regional health system in southeastern Pennsylvania. This certainly presented an amazing opportunity for growth, as the hospital’s excellent reputation and expanding network would allow for better access and opportunities for both the practice’s patients and providers. One such opportunity was the chance to adopt the system’s enterprise-wide EHR. This was truly exciting to everyone in the practice, as the EHR software was the foundation of a successful health information exchange. Also, Neil, having been employed by the same system for years, was already using the EHR and felt that it was a system of quality and value. At first, Chris was really looking forward to the switch.

But there was a very large elephant in the room: the practice’s existing EHR. For several years prior to the acquisition, the practice had been very successfully using an excellent but different EHR. Also a high-quality and highly regarded product, this software had met the practice’s needs and everyone in the practice become comfortable – and "meaningful" – users of the system. No one really understood what it would be like to learn a completely new EHR. The practice as a whole was probably a bit overconfident in its ability to make an easy transition. The physicians, including Chris, thought that since they were already using an electronic record, it was unlikely that their workflow would need to change at all. Wasn’t this just like buying a new car? Sure, some of the knobs and buttons would look different, but we all know how to drive. This should be a snap, right?

Unfortunately, everyone in the practice quickly learned that EHRs and automobiles have very little in common.

The worst of times...

We have specifically chosen not to mention either EHR company by name because we feel both offer excellent products and meet the needs of their customers; to continue the automotive analogy, we would be happy to own either as our "set of wheels." But no two EHRs are ever alike, and physicians who make the switch are often shocked by some of the differences. For example, each EHR uses different terms to describe similar tasks. While the concepts might be easy to grasp, without a firm grip on this euphemistic language, it can be difficult to navigate the system. What one system might call a "task," another might call an "action." You could be searching for a "planned package" but should be searching for an "order set." And typically, none of the buttons or symbols look the same.

For physicians and staff in Chris’s practice, the change in "language" represented a steep learning curve, and learning curves translate to loss of productivity. The "muscle memory" that staff had developed over years of using the complex software was not easily reprogrammed. A friend likened it to switching to a Mac after years of using a Windows PC. Both devices essentially perform the same tasks – and do those tasks well – but all the icons and buttons seem to be in exactly opposite places.

In addition, there was the issue of data migration. How could we take years of structured demographic data, progress notes, scanned documents, medications, allergies, lab results, and other information and move them into the new system? While technically possible, this is a costly and time-consuming undertaking, and requires the full cooperation of both EHR providers to successfully accomplish it. We were lucky to have the financial backing and influence of a large health system to see this through to completion, but independent practices making the switch might not be as fortunate. Overall, the process went as planned, but it remains difficult to locate certain information when it’s needed because each EHR has its own areas in which data elements are held.

Great support is the key to success

Throughout the ordeal of changing our EHR, there was one factor that kept the process on-track: excellent support. Because of the resources provided by the health system, the practice did not need to rely on the expensive and sometimes less-than-responsive vendor to accomplish the transition. There was an entire team of individuals on- and off-site, dedicated to seeing us successfully transition from one EHR to the other. Even as the EHR "champion, Chris found his optimism tested, and now, almost a year after the transition, he is just starting to regain his prior efficiency.

Lessons learned

There were three important lessons learned from this experience that are relevant to practices planning to switch EHR systems. First, make sure that you are picking the right EHR to which to transition, as changing will be a daunting task and added to the cost of the new software will be a cost in lost productivity. Second, make sure all members of the practice have as complete an understanding as possible about what to anticipate and expect the significant changes in the way things are recorded, stored, and processed. And third, since "no practice is an island," carefully plan and clarify who will be your main sources of support when the inevitable frustrations – which you could not anticipate – develop.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

We frequently receive comments on the column and podcasts that question our optimism about the benefits of electronic health records. The truth is that we continue to believe that electronic records will lead to better access to information, improved communication, and higher-quality patient care. We also agree with many of the e-mails that we have received from readers. There are many problems with current EHRs and the physicians who use them encounter many challenges. Some experiences with EHRs can be incredibly frustrating and create truly unforeseen challenges. Chris had one such experience recently that offered a heavy dose of reality and frustration. This occurred during the transition from one EHR to another, and we felt it would be worthwhile to share the story here.

The best of times...

In January 2012, Chris’s practice was acquired by a regional health system in southeastern Pennsylvania. This certainly presented an amazing opportunity for growth, as the hospital’s excellent reputation and expanding network would allow for better access and opportunities for both the practice’s patients and providers. One such opportunity was the chance to adopt the system’s enterprise-wide EHR. This was truly exciting to everyone in the practice, as the EHR software was the foundation of a successful health information exchange. Also, Neil, having been employed by the same system for years, was already using the EHR and felt that it was a system of quality and value. At first, Chris was really looking forward to the switch.

But there was a very large elephant in the room: the practice’s existing EHR. For several years prior to the acquisition, the practice had been very successfully using an excellent but different EHR. Also a high-quality and highly regarded product, this software had met the practice’s needs and everyone in the practice become comfortable – and "meaningful" – users of the system. No one really understood what it would be like to learn a completely new EHR. The practice as a whole was probably a bit overconfident in its ability to make an easy transition. The physicians, including Chris, thought that since they were already using an electronic record, it was unlikely that their workflow would need to change at all. Wasn’t this just like buying a new car? Sure, some of the knobs and buttons would look different, but we all know how to drive. This should be a snap, right?

Unfortunately, everyone in the practice quickly learned that EHRs and automobiles have very little in common.

The worst of times...

We have specifically chosen not to mention either EHR company by name because we feel both offer excellent products and meet the needs of their customers; to continue the automotive analogy, we would be happy to own either as our "set of wheels." But no two EHRs are ever alike, and physicians who make the switch are often shocked by some of the differences. For example, each EHR uses different terms to describe similar tasks. While the concepts might be easy to grasp, without a firm grip on this euphemistic language, it can be difficult to navigate the system. What one system might call a "task," another might call an "action." You could be searching for a "planned package" but should be searching for an "order set." And typically, none of the buttons or symbols look the same.

For physicians and staff in Chris’s practice, the change in "language" represented a steep learning curve, and learning curves translate to loss of productivity. The "muscle memory" that staff had developed over years of using the complex software was not easily reprogrammed. A friend likened it to switching to a Mac after years of using a Windows PC. Both devices essentially perform the same tasks – and do those tasks well – but all the icons and buttons seem to be in exactly opposite places.

In addition, there was the issue of data migration. How could we take years of structured demographic data, progress notes, scanned documents, medications, allergies, lab results, and other information and move them into the new system? While technically possible, this is a costly and time-consuming undertaking, and requires the full cooperation of both EHR providers to successfully accomplish it. We were lucky to have the financial backing and influence of a large health system to see this through to completion, but independent practices making the switch might not be as fortunate. Overall, the process went as planned, but it remains difficult to locate certain information when it’s needed because each EHR has its own areas in which data elements are held.

Great support is the key to success

Throughout the ordeal of changing our EHR, there was one factor that kept the process on-track: excellent support. Because of the resources provided by the health system, the practice did not need to rely on the expensive and sometimes less-than-responsive vendor to accomplish the transition. There was an entire team of individuals on- and off-site, dedicated to seeing us successfully transition from one EHR to the other. Even as the EHR "champion, Chris found his optimism tested, and now, almost a year after the transition, he is just starting to regain his prior efficiency.

Lessons learned

There were three important lessons learned from this experience that are relevant to practices planning to switch EHR systems. First, make sure that you are picking the right EHR to which to transition, as changing will be a daunting task and added to the cost of the new software will be a cost in lost productivity. Second, make sure all members of the practice have as complete an understanding as possible about what to anticipate and expect the significant changes in the way things are recorded, stored, and processed. And third, since "no practice is an island," carefully plan and clarify who will be your main sources of support when the inevitable frustrations – which you could not anticipate – develop.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

We frequently receive comments on the column and podcasts that question our optimism about the benefits of electronic health records. The truth is that we continue to believe that electronic records will lead to better access to information, improved communication, and higher-quality patient care. We also agree with many of the e-mails that we have received from readers. There are many problems with current EHRs and the physicians who use them encounter many challenges. Some experiences with EHRs can be incredibly frustrating and create truly unforeseen challenges. Chris had one such experience recently that offered a heavy dose of reality and frustration. This occurred during the transition from one EHR to another, and we felt it would be worthwhile to share the story here.

The best of times...

In January 2012, Chris’s practice was acquired by a regional health system in southeastern Pennsylvania. This certainly presented an amazing opportunity for growth, as the hospital’s excellent reputation and expanding network would allow for better access and opportunities for both the practice’s patients and providers. One such opportunity was the chance to adopt the system’s enterprise-wide EHR. This was truly exciting to everyone in the practice, as the EHR software was the foundation of a successful health information exchange. Also, Neil, having been employed by the same system for years, was already using the EHR and felt that it was a system of quality and value. At first, Chris was really looking forward to the switch.

But there was a very large elephant in the room: the practice’s existing EHR. For several years prior to the acquisition, the practice had been very successfully using an excellent but different EHR. Also a high-quality and highly regarded product, this software had met the practice’s needs and everyone in the practice become comfortable – and "meaningful" – users of the system. No one really understood what it would be like to learn a completely new EHR. The practice as a whole was probably a bit overconfident in its ability to make an easy transition. The physicians, including Chris, thought that since they were already using an electronic record, it was unlikely that their workflow would need to change at all. Wasn’t this just like buying a new car? Sure, some of the knobs and buttons would look different, but we all know how to drive. This should be a snap, right?

Unfortunately, everyone in the practice quickly learned that EHRs and automobiles have very little in common.

The worst of times...

We have specifically chosen not to mention either EHR company by name because we feel both offer excellent products and meet the needs of their customers; to continue the automotive analogy, we would be happy to own either as our "set of wheels." But no two EHRs are ever alike, and physicians who make the switch are often shocked by some of the differences. For example, each EHR uses different terms to describe similar tasks. While the concepts might be easy to grasp, without a firm grip on this euphemistic language, it can be difficult to navigate the system. What one system might call a "task," another might call an "action." You could be searching for a "planned package" but should be searching for an "order set." And typically, none of the buttons or symbols look the same.

For physicians and staff in Chris’s practice, the change in "language" represented a steep learning curve, and learning curves translate to loss of productivity. The "muscle memory" that staff had developed over years of using the complex software was not easily reprogrammed. A friend likened it to switching to a Mac after years of using a Windows PC. Both devices essentially perform the same tasks – and do those tasks well – but all the icons and buttons seem to be in exactly opposite places.

In addition, there was the issue of data migration. How could we take years of structured demographic data, progress notes, scanned documents, medications, allergies, lab results, and other information and move them into the new system? While technically possible, this is a costly and time-consuming undertaking, and requires the full cooperation of both EHR providers to successfully accomplish it. We were lucky to have the financial backing and influence of a large health system to see this through to completion, but independent practices making the switch might not be as fortunate. Overall, the process went as planned, but it remains difficult to locate certain information when it’s needed because each EHR has its own areas in which data elements are held.

Great support is the key to success

Throughout the ordeal of changing our EHR, there was one factor that kept the process on-track: excellent support. Because of the resources provided by the health system, the practice did not need to rely on the expensive and sometimes less-than-responsive vendor to accomplish the transition. There was an entire team of individuals on- and off-site, dedicated to seeing us successfully transition from one EHR to the other. Even as the EHR "champion, Chris found his optimism tested, and now, almost a year after the transition, he is just starting to regain his prior efficiency.

Lessons learned

There were three important lessons learned from this experience that are relevant to practices planning to switch EHR systems. First, make sure that you are picking the right EHR to which to transition, as changing will be a daunting task and added to the cost of the new software will be a cost in lost productivity. Second, make sure all members of the practice have as complete an understanding as possible about what to anticipate and expect the significant changes in the way things are recorded, stored, and processed. And third, since "no practice is an island," carefully plan and clarify who will be your main sources of support when the inevitable frustrations – which you could not anticipate – develop.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics at Abington Memorial. They are partners in EHR Practice Consultants. Contact them at info@ehrpc.com.

"We cannot get to where we need to go by remaining where we are."
–Adopted from Max de Pree
Leadership Is an Art

In our last column, we discussed an article published in JAMA that showed a crayon drawing that was given a doctor by the 7-year-old girl who had drawn the picture (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family. The message of the drawing was clear, that the way we are viewed by our patients is changing. What is equally remarkable though, when you view the picture from the girl’s perspective, is that there was nothing sad about the drawing. The colors where vivid and all the figures in the room were smiling. Why would there be anything sad about this encounter? This is the world that the 7-year-old knows, it’s her reality, a world in which attention is regularly divided, and electronic devices are how information is stored and through which communication occurs. This fact is difficult to integrate and understand for those of us who are a bit older but is simply an ordinary part of life, like milk in a jar or plastic lids for those young enough to know no other world. Nonetheless, the concern remains that we need to be careful that the patient’s needs do not become buried underneath the clicks and hums of the machine.

There are many physicians who are sad about the demise of the paper chart. We hear from those people daily. If we acknowledge the complexity of our needs, then we see that the old paper-based chart system, while easier to use than an electronic chart, simply does not allow us to record information in a form that is retrievable for the evolved purposes for which we are now keeping records. Population management in not just a buzz word, it is the area toward which our care of patients is evolving if we are to truly make an impact on improving their health. So EHRs are a necessary component of this evolution. Our challenge, as physicians who are now beginning to care for populations as well as individual patients, is how to balance and integrate the immediate needs that occur in the exam room – the need to provide the proper diagnosis and treatment, to record data, and to truly listen to the patient. To make sure that the patient feels heard. A colleague of ours who has thought a lot about electronic records, Dr. Keith Sweigard, feels that the EHR will eventually be a tool that will facilitate medical humanism. To use his words:

"Technology will paradoxically foster humanism in medicine. As we implement [EHRs] with standardized templates, care pathways, and order sets, patients will more likely receive the same work-up and evidence based interventions from any care provider. In that scenario, what will become the distinguishing factor that a patient selects one physician over another? Access will certainly be a factor, but ongoing relationships will depend on connecting with the patient on a humanistic level – warmth, sensitivity, compassion, and empathy. In other words, the dictum of patients choosing their physician based on access, affability and then ability – in that order – will be more important than ever!"

The literature supports that how well a doctor communicates influences patients’ satisfaction, sense of well-being, overall health, malpractice suits, and may even influence health care costs. When we are ill, we yearn for two things – to be well, and for someone to understand our suffering. Science and technology improves our chances of being well, but it does not address our need to be understood. The doctor is in a unique position to provide for both aspects of what the ill person needs: to help alleviate their suffering and to understand their unique human position in the world, as all suffering is unique. In order to fulfill this role, there has to be ongoing reinforcement of the “centrality of relationships” in medical care (Ann. Intern. Med. 2008;149:720-4).

We agree with Dr. Sweigard’s assessment that, as the protocols and decision support become easier to use and as the quality tools that EHRs will provide become more sophisticated, what will distinguish us from one another and what payers will increasingly support, is our attention to the patient and his or her needs as a person. That attention to the person will be measured through patient satisfaction, and that quality measure will be reimbursed. It will not be difficult to figure out what medication to use next for this person’s hypertension or elevated glucose. The decision support will be there, integrated and easy to use, and our smile and perhaps our attentiveness to the small tear welling in the corner of a patient’s eye, will again distinguish us and allow us to connect as human beings. In a future column on electronic health records and humanism, we will discuss strategies to help us to use the electronic record to accomplish these goals.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at info@ehrpc.com.

"We cannot get to where we need to go by remaining where we are."
–Adopted from Max de Pree
Leadership Is an Art

In our last column, we discussed an article published in JAMA that showed a crayon drawing that was given a doctor by the 7-year-old girl who had drawn the picture (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family. The message of the drawing was clear, that the way we are viewed by our patients is changing. What is equally remarkable though, when you view the picture from the girl’s perspective, is that there was nothing sad about the drawing. The colors where vivid and all the figures in the room were smiling. Why would there be anything sad about this encounter? This is the world that the 7-year-old knows, it’s her reality, a world in which attention is regularly divided, and electronic devices are how information is stored and through which communication occurs. This fact is difficult to integrate and understand for those of us who are a bit older but is simply an ordinary part of life, like milk in a jar or plastic lids for those young enough to know no other world. Nonetheless, the concern remains that we need to be careful that the patient’s needs do not become buried underneath the clicks and hums of the machine.

There are many physicians who are sad about the demise of the paper chart. We hear from those people daily. If we acknowledge the complexity of our needs, then we see that the old paper-based chart system, while easier to use than an electronic chart, simply does not allow us to record information in a form that is retrievable for the evolved purposes for which we are now keeping records. Population management in not just a buzz word, it is the area toward which our care of patients is evolving if we are to truly make an impact on improving their health. So EHRs are a necessary component of this evolution. Our challenge, as physicians who are now beginning to care for populations as well as individual patients, is how to balance and integrate the immediate needs that occur in the exam room – the need to provide the proper diagnosis and treatment, to record data, and to truly listen to the patient. To make sure that the patient feels heard. A colleague of ours who has thought a lot about electronic records, Dr. Keith Sweigard, feels that the EHR will eventually be a tool that will facilitate medical humanism. To use his words:

"Technology will paradoxically foster humanism in medicine. As we implement [EHRs] with standardized templates, care pathways, and order sets, patients will more likely receive the same work-up and evidence based interventions from any care provider. In that scenario, what will become the distinguishing factor that a patient selects one physician over another? Access will certainly be a factor, but ongoing relationships will depend on connecting with the patient on a humanistic level – warmth, sensitivity, compassion, and empathy. In other words, the dictum of patients choosing their physician based on access, affability and then ability – in that order – will be more important than ever!"

The literature supports that how well a doctor communicates influences patients’ satisfaction, sense of well-being, overall health, malpractice suits, and may even influence health care costs. When we are ill, we yearn for two things – to be well, and for someone to understand our suffering. Science and technology improves our chances of being well, but it does not address our need to be understood. The doctor is in a unique position to provide for both aspects of what the ill person needs: to help alleviate their suffering and to understand their unique human position in the world, as all suffering is unique. In order to fulfill this role, there has to be ongoing reinforcement of the “centrality of relationships” in medical care (Ann. Intern. Med. 2008;149:720-4).

We agree with Dr. Sweigard’s assessment that, as the protocols and decision support become easier to use and as the quality tools that EHRs will provide become more sophisticated, what will distinguish us from one another and what payers will increasingly support, is our attention to the patient and his or her needs as a person. That attention to the person will be measured through patient satisfaction, and that quality measure will be reimbursed. It will not be difficult to figure out what medication to use next for this person’s hypertension or elevated glucose. The decision support will be there, integrated and easy to use, and our smile and perhaps our attentiveness to the small tear welling in the corner of a patient’s eye, will again distinguish us and allow us to connect as human beings. In a future column on electronic health records and humanism, we will discuss strategies to help us to use the electronic record to accomplish these goals.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at info@ehrpc.com.

"We cannot get to where we need to go by remaining where we are."
–Adopted from Max de Pree
Leadership Is an Art

In our last column, we discussed an article published in JAMA that showed a crayon drawing that was given a doctor by the 7-year-old girl who had drawn the picture (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family. The message of the drawing was clear, that the way we are viewed by our patients is changing. What is equally remarkable though, when you view the picture from the girl’s perspective, is that there was nothing sad about the drawing. The colors where vivid and all the figures in the room were smiling. Why would there be anything sad about this encounter? This is the world that the 7-year-old knows, it’s her reality, a world in which attention is regularly divided, and electronic devices are how information is stored and through which communication occurs. This fact is difficult to integrate and understand for those of us who are a bit older but is simply an ordinary part of life, like milk in a jar or plastic lids for those young enough to know no other world. Nonetheless, the concern remains that we need to be careful that the patient’s needs do not become buried underneath the clicks and hums of the machine.

There are many physicians who are sad about the demise of the paper chart. We hear from those people daily. If we acknowledge the complexity of our needs, then we see that the old paper-based chart system, while easier to use than an electronic chart, simply does not allow us to record information in a form that is retrievable for the evolved purposes for which we are now keeping records. Population management in not just a buzz word, it is the area toward which our care of patients is evolving if we are to truly make an impact on improving their health. So EHRs are a necessary component of this evolution. Our challenge, as physicians who are now beginning to care for populations as well as individual patients, is how to balance and integrate the immediate needs that occur in the exam room – the need to provide the proper diagnosis and treatment, to record data, and to truly listen to the patient. To make sure that the patient feels heard. A colleague of ours who has thought a lot about electronic records, Dr. Keith Sweigard, feels that the EHR will eventually be a tool that will facilitate medical humanism. To use his words:

"Technology will paradoxically foster humanism in medicine. As we implement [EHRs] with standardized templates, care pathways, and order sets, patients will more likely receive the same work-up and evidence based interventions from any care provider. In that scenario, what will become the distinguishing factor that a patient selects one physician over another? Access will certainly be a factor, but ongoing relationships will depend on connecting with the patient on a humanistic level – warmth, sensitivity, compassion, and empathy. In other words, the dictum of patients choosing their physician based on access, affability and then ability – in that order – will be more important than ever!"

The literature supports that how well a doctor communicates influences patients’ satisfaction, sense of well-being, overall health, malpractice suits, and may even influence health care costs. When we are ill, we yearn for two things – to be well, and for someone to understand our suffering. Science and technology improves our chances of being well, but it does not address our need to be understood. The doctor is in a unique position to provide for both aspects of what the ill person needs: to help alleviate their suffering and to understand their unique human position in the world, as all suffering is unique. In order to fulfill this role, there has to be ongoing reinforcement of the “centrality of relationships” in medical care (Ann. Intern. Med. 2008;149:720-4).

We agree with Dr. Sweigard’s assessment that, as the protocols and decision support become easier to use and as the quality tools that EHRs will provide become more sophisticated, what will distinguish us from one another and what payers will increasingly support, is our attention to the patient and his or her needs as a person. That attention to the person will be measured through patient satisfaction, and that quality measure will be reimbursed. It will not be difficult to figure out what medication to use next for this person’s hypertension or elevated glucose. The decision support will be there, integrated and easy to use, and our smile and perhaps our attentiveness to the small tear welling in the corner of a patient’s eye, will again distinguish us and allow us to connect as human beings. In a future column on electronic health records and humanism, we will discuss strategies to help us to use the electronic record to accomplish these goals.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at info@ehrpc.com.

"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

Sometimes, simple things can make a big difference. Attention to ergonomics of the exam room is important to minimize the negative impact that using an EMR can have on physician-patient interaction.

This may seem obvious, but a large multispecialty practice that we have visited has had significant problems, as well as physician and patient dissatisfaction, simply because they chose to use desktop computers located on small tables or desks in each exam room.

This initially seems like a clear and easy decision. The costly equipment was secure, and physicians did not have to carry laptops with them from room to room.

Unfortunately, because the desks are located against the wall in the exam room, the physician has to have his or her back to the patient in order to fill in a note during the visit. Alternatively, the physician can face the computer screen and keep turning her neck to look over her shoulder to maintain eye contact with the patient, then turn back to look at the computer to record the encounter. This behavior is awkward interpersonally and leads to physical discomfort for the physician.

Another helpful hint can be drawn directly from observations of physicians who use electronic health records.

Many physicians, particularly older physicians, never learned how to type well. They peck away at the keyboard, staring at the computer screen – or, even worse, the keyboard itself – while slowly entering a patient’s history. However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.

Even though it requires an investment of time, physicians who do not have sufficient typing skills might consider acquiring this new skill so they can be more productive in their office.

Plenty of effort is given to improving workflow in the office – but if a physician cannot get information easily into the chart, the biggest funnel for office workflow is occurring right at the beginning of the patient encounter. And that interferes with everything downstream, including the quality of the note, the time taken for the encounter, and ultimately the physician’s relationship with their patient.

If learning how to type does not seem like a reasonable use of time, or if it seems too daunting a task to learn, then we would encourage these physicians to explore the use of voice recognition software. The software is now sophisticated enough to be useful and accurate, and allows us to look at the patient while dictating a note in front of them in a timely fashion.

Recognizing the challenges inherent in electronic documentation, and keeping in mind the importance of our goal of maintaining empathic relationships, allows us to critically look at our encounters. This critical, analytical eye allows us to creatively pursue the elusive ideal so persuasively described by Mr. Ciardi more than 40 years ago: "Where science touches man, it turns to art."

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at info@ehrpc.com.

"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

Sometimes, simple things can make a big difference. Attention to ergonomics of the exam room is important to minimize the negative impact that using an EMR can have on physician-patient interaction.

This may seem obvious, but a large multispecialty practice that we have visited has had significant problems, as well as physician and patient dissatisfaction, simply because they chose to use desktop computers located on small tables or desks in each exam room.

This initially seems like a clear and easy decision. The costly equipment was secure, and physicians did not have to carry laptops with them from room to room.

Unfortunately, because the desks are located against the wall in the exam room, the physician has to have his or her back to the patient in order to fill in a note during the visit. Alternatively, the physician can face the computer screen and keep turning her neck to look over her shoulder to maintain eye contact with the patient, then turn back to look at the computer to record the encounter. This behavior is awkward interpersonally and leads to physical discomfort for the physician.

Another helpful hint can be drawn directly from observations of physicians who use electronic health records.

Many physicians, particularly older physicians, never learned how to type well. They peck away at the keyboard, staring at the computer screen – or, even worse, the keyboard itself – while slowly entering a patient’s history. However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.

Even though it requires an investment of time, physicians who do not have sufficient typing skills might consider acquiring this new skill so they can be more productive in their office.

Plenty of effort is given to improving workflow in the office – but if a physician cannot get information easily into the chart, the biggest funnel for office workflow is occurring right at the beginning of the patient encounter. And that interferes with everything downstream, including the quality of the note, the time taken for the encounter, and ultimately the physician’s relationship with their patient.

If learning how to type does not seem like a reasonable use of time, or if it seems too daunting a task to learn, then we would encourage these physicians to explore the use of voice recognition software. The software is now sophisticated enough to be useful and accurate, and allows us to look at the patient while dictating a note in front of them in a timely fashion.

Recognizing the challenges inherent in electronic documentation, and keeping in mind the importance of our goal of maintaining empathic relationships, allows us to critically look at our encounters. This critical, analytical eye allows us to creatively pursue the elusive ideal so persuasively described by Mr. Ciardi more than 40 years ago: "Where science touches man, it turns to art."

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at info@ehrpc.com.

"I won’t insist that the patient is a soul,

But he’s a something, possibly laughable,

Or possibly sublime, but not quite graphable.

Not quite containable on a bed chart.

Where science touches man it turns to art."

–John Ciardi

The Saturday Review, Nov. 18, 1967

"Not quite graphable" is how John Ciardi described patients in a wonderful poem titled "Lines From the Beating End of the Stethoscope." In that poem, which he read at the inaugural for the new president of New York Medical College, he describes medicine, as the title suggests, from the patient’s point of view.

The poem was meant to be a reminder of the subtle needs that patients have during their encounters with doctors around some of the most important decisions and events in their life, their health, and their physical and mental well-being. It was a reminder to doctors that patients’ needs are varied, complex, difficult to discern, and not able to be fully explained or understood through math and science.

How Mr. Ciardi had such insight 45 years ago into the issues that we are all facing today is remarkable. It is a rare day in which I do not hear from one of my colleagues about how the computer screen is getting between them and their patient.

We talk in conferences about how we have become so focused on the needs of the computer that the needs of the patient get left behind. How we are so busy making sure that the "checklist" of tasks for meaningful use have been completed, that the meaningful encounter – that feeling that the patient keeps with them after they leave the doctor’s office that they have encountered someone who cares about them – recedes into the background, while the foreground is filled with clicks and navigated pages.

A recent commentary in JAMA displayed a crayon drawing by a 7-year-old girl, which was given to her doctor (JAMA 2012;307:2497-8). The drawing showed the girl sitting on the exam table, with her sister and mother in nearby chairs, while the doctor was sitting hunched over a computer with his back to the patient and her family.

The message implicit in the publication of this drawing is clear – that patients are now beginning to see us in ways that are different than how we have traditionally seen ourselves. Ways that are frankly embarrassing. I don’t think that any of us go to the office desiring to be the kind of doctor that a child or an aging adult perceives as hunched over a computer screen distractedly listening to their concerns while typing away with our back toward them.

Integrating the electronic record into the exam room brings with it certain inherent tensions that potentially interfere with the interaction of patients and their physicians. These tensions are consistent with the tensions imposed by the necessity of documenting the patient encounter, and this tension exists whether the physician is using paper or electronic media.

Once this fact is understood, and the importance of maintaining an empathic interpersonal encounter with the patient is accepted as something that cannot be compromised, we can begin to thoughtfully and honestly develop methods that allow us to keep the encounter personal while integrating the electronic medical record into our office.

Sometimes, simple things can make a big difference. Attention to ergonomics of the exam room is important to minimize the negative impact that using an EMR can have on physician-patient interaction.

This may seem obvious, but a large multispecialty practice that we have visited has had significant problems, as well as physician and patient dissatisfaction, simply because they chose to use desktop computers located on small tables or desks in each exam room.

This initially seems like a clear and easy decision. The costly equipment was secure, and physicians did not have to carry laptops with them from room to room.

Unfortunately, because the desks are located against the wall in the exam room, the physician has to have his or her back to the patient in order to fill in a note during the visit. Alternatively, the physician can face the computer screen and keep turning her neck to look over her shoulder to maintain eye contact with the patient, then turn back to look at the computer to record the encounter. This behavior is awkward interpersonally and leads to physical discomfort for the physician.

Another helpful hint can be drawn directly from observations of physicians who use electronic health records.

Many physicians, particularly older physicians, never learned how to type well. They peck away at the keyboard, staring at the computer screen – or, even worse, the keyboard itself – while slowly entering a patient’s history. However, we have also noticed that some physicians are able to type their history of present illness while maintaining eye contact with their patient, only occasionally looking down at the screen.

Even though it requires an investment of time, physicians who do not have sufficient typing skills might consider acquiring this new skill so they can be more productive in their office.

Plenty of effort is given to improving workflow in the office – but if a physician cannot get information easily into the chart, the biggest funnel for office workflow is occurring right at the beginning of the patient encounter. And that interferes with everything downstream, including the quality of the note, the time taken for the encounter, and ultimately the physician’s relationship with their patient.

If learning how to type does not seem like a reasonable use of time, or if it seems too daunting a task to learn, then we would encourage these physicians to explore the use of voice recognition software. The software is now sophisticated enough to be useful and accurate, and allows us to look at the patient while dictating a note in front of them in a timely fashion.

Recognizing the challenges inherent in electronic documentation, and keeping in mind the importance of our goal of maintaining empathic relationships, allows us to critically look at our encounters. This critical, analytical eye allows us to creatively pursue the elusive ideal so persuasively described by Mr. Ciardi more than 40 years ago: "Where science touches man, it turns to art."

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. He is also editor in chief of Redi-Reference, a software company that creates medical handheld references. Dr. Notte practices family medicine and health care informatics for Abington Memorial Hospital. They are partners in EHR Practice Consultants, helping practices move to EHR systems. Contact them at info@ehrpc.com.