EHRs, Medicine, and Humanism, Part 1

"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.