Commentary

The 3-Minute Goose Egg


 

I know that I’ve opined and whined about electronic health records several times in the last year and a half, but it’s an issue, a big issue that just isn’t going away. And it isn’t being realistically addressed in either the professional or the lay press.

Dr. William G. Wilkoff

Just to remind you, I am not a Luddite. We’ve had a computer in our home since Apple first started selling them. Our office has had its own homegrown electronic health record (EHR) system for a decade. It was embraced by all of us, but for a variety of reasons – some good and some bad – it was retired. We purchased an off-the-shelf model from one of the largest purveyors of EHRs.

About 4 months ago, I was still on the steep part of the learning curve, but was optimistic that I could adapt to its quirks and clumsiness. My biggest gripe then was that the new system didn’t allow me to enhance the record with my self-drawn illustrations. As I write today I’m resting somewhat uncomfortably on the plateau above the curve, curled up in a fetal position with my thumb in my mouth.

I have created a manageable number of shortcuts to create authentic text with just a few keystrokes. I can navigate the redundant screens with a minimum of mouse clicks. I haven’t seen anyone in the group who can chart electronically faster than I can. However, even at the top of my game, it takes me at least 3 minutes longer to complete an encounter with a patient than it did using our old system.

Where did this time go? To begin with, I quickly discovered that if I want to maintain eye contact with the patient, I will have to suspend my charting until they or I have left the exam room. When I was writing by hand, I could scribble a phrase or check a box or two and still be looking at the patient or parent 90% of the time. Even if the screen is well positioned, I still find that my eyes will be on it and not the patient. In situations in which I don’t know the patient well or his or her problems are very complex, I will try to review the record before I enter the exam room to minimize my screen time with the patient.

When the visit is over, there is some awkwardness. They were accustomed to my leaving the room first or walking with them to the front desk. Now I just want them to leave me alone with the computer so I can do my charting before I forget what I wanted to write. I have resorted to giving them a bogus piece of paper and asking them to give it to the receptionist on their way out. But the old system of last-in-first-out still prompts many families to linger uncomfortably. However, the trade-off is that I know that I am at least more visually attentive to patients.

So what about those 3 minutes? I suspect that to the program and system developers this doesn’t seem like a big deal. Most of them aren’t physicians, and the few who were have been so distracted by their algorithms that they haven’t seen a patient in years. But just do the math. If you only see 20 patients a day, an extra 3 minutes per patient is 60 minutes, known to most of us as 1 hour. And that’s what most of us in the office have found we’ve lost. We are spending nearly 1 hour more per day charting or, if our pocketbooks can absorb the associated loss, we are seeing fewer patients.

I am sure this ugly reality has been experienced by thousands of other physicians who have been electronified. The government is creating financial incentives to adopt EHRs, but if I were faced with the decision now, I would wait, wait, wait. If time is important to you, I don’t think there is a system out there yet that will save you any time, and most will lose you at least 3 minutes per patient of that precious stuff you can’t recoup once it’s lost.

Dr. Wilkoff writes the column, "Letters From Maine," which regularly appears in Pediatric News. He practices general pediatrics in a multispecialty group practice in Brunswick, Maine. E-mail him.

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