Reflections on the EHR: Gains, Losses, Opportunities

Sonia Nagy Chimienti, MD FIDSA

A few months ago, I completed training on the electronic health record (EHR) at my new place of employment. Given that I have used electronic health records for more than 15 years and had familiarity with this particular system, the EHR training should have been easy. Here’s the thing: it wasn’t easy. As I participated in the training, I had to pay close attention in order to remember where to click to complete certain tasks. My brain needed to be attuned to the task, not the clinical decision I was making. This contrasts starkly to my early days as an attending physician, when I could easily write notes by hand while actively thinking about the patient and their medical issue. The neurons in my brain would fire and jump from one issue to the next, as I was thinking about what I was missing, wondering about the esoteric as well as the commonplace, making sure that I had it all down in my typical lengthy infectious diseases consult note, without needing to think about how my reasoning was being communicated on the page. Similarly, writing the orders was easy; I just had to remember to make sure that the dial on the chart was on the right color, so that the desk clerk could see that there was a new order to convey. When rounding on the consult service, I used to be able to manage a list of 25 consult patients without a problem; but with use of the EHR, despite my familiarity with the system, it was difficult to manage the work for 10-15 patients in a timely manner.

My primary role these days is in education and administration. My inpatient rounding days are over, and I typically precept students and fellows in clinic. It occurred to me recently that I have not once heard our trainees express concern or dismay regarding the function of the EHR system, other than being locked out because of password issues. This got me thinking: Is there a generational issue at play here impacting my love-hate relationship with EHRs?

To try to understand differing perspectives on the EHR, I asked trainees at all levels, together with early-, mid- and later-career physicians, how the EHR impacted their work with patients, if at all. Here’s what I found.

For the most part, all providers I spoke with valued the EHR because of improved coordination of care and ease of communication across teams, specialties and institutions. Many were able to access information from outside of their own department or organization with a click of a button, enabling timely review of laboratory results and notes without frustrating delays waiting for faxed and mailed medical information. A seasoned physician noted that “in the past, communicating with specialists was time consuming, inconsistent, and at times aggravating. Now for the most part it is fantastic.”

In this sense, all of my colleagues felt that EHRs had the potential to improve patient care. One senior physician noted, however, that actual improvement in care depends on how the provider uses the EHR system. Even though communication is easier, and data are readily available, this does not necessarily mean that a patient will receive better care; the provider still needs to be present, acting on the data, listening to the patient, discerning the correct clinical information and applying all of that knowledge to sound clinical decision-making. He astutely noted that, “The EHR hasn’t made things more complicated or complicated things, it has made it clearer that care is complicated by having it all documented better...it has neither improved nor worsened care. The EHR is a tool, used by practitioners who deliver the care, so use of this is only so good as the caregivers. It creates the possibility of safer, better care but doesn’t guarantee it.”

Almost all of the physicians with whom I spoke felt that the EHR changed how they interacted with patients, and not always for the better. For instance, a Chief Resident enjoys “pulling up notes and results via the EHR and reviewing them live with the patient, which they often appreciate.” Yet the EHR adds a dimension, regardless of training or stage of professional practice, that can lead to a disconnect from the patient. Paying attention, being present and connecting with patients requires extra effort when the computer is in the room. One resident noted that “The EHR can impede interactions with patients... it can be difficult to break away from the habit of trying to type a note at the same time as I gather a history. I prefer to face my patient and give them my full and complete attention rather than attempting to review a patient’s chart while also listening to their needs.” A new intern wrote, “When I am in a patient room and have a computer in front of me, while I am being more efficient, I sense the disconnect, even as a ‘millennial’ who grew up with the Internet. I try to be very mindful of this and intentionally make eye contact and avoid fixating on the computer screen... There was once a time when I asked a patient how they were doing, and they expressed that times were difficult because they had recently lost a loved one. It took a few moments for their words to hit me; I was still typing away their response to the previous question and let out a reflexive ‘I’m so sorry to hear that’ without really just taking it in and being present with them at that moment. Once I caught myself, I closed my laptop and turned my attention to them.”

Not surprisingly, some physicians commented on the “fluff” that is carried forward, in notes and problem lists, that can make it difficult to figure out what truly is important. A resident wrote, “I have found I miss the simplicity of notes in a pre-EHR practice. Now it is very easy to pull information into documentation in a way that makes notes feel lengthy and unhelpful. Oftentimes I wish for a succinct assessment and plan statement rather than… templated notes that lack any nuance or true ability to communicate a patient’s current experience.” Similarly, multiple senior-level physicians noted that the ease of copying forward prior notes exacerbates this problem and that “Once something is in, it is seemingly in forever.” They did also note, however, that “wading through too much information is better than not having it.”

In terms of training, all the providers I connected with expressed satisfaction with their EHR training. There were a few best practices that I found interesting and potentially valuable. One of the residents indicated that their program has a Housestaff Information Technology Enhancement Council that provides monthly email updates regarding new features in the EHR system and new workflows. Similar monthly updates do occur at some hospitals, distributed by “super user” teams from clinical informatics. Some systems also include “skills practice” in a “sandbox,” together with the online training modules.

Finally, a surprising theme that was shared was the unintended negative impact of the EHR on the close and collegial relationships that are the hallmark of clinical care. This concern was noted by providers at all levels of practice, from a new intern to a seasoned physician. When we interact primarily with the EHR rather than each other, the nuanced reasoning that leads to our specific recommendations may be lost, and the critical relationships that we build across specialties and providers can be eroded. One resident lamented, “We have built this system in such a way that doesn’t require us to engage with the people we ask many things from throughout the day. Everything is assumed to be as easy as a click of a button. If you don’t spend time speaking to nursing staff, you can’t appreciate how frustrating it is to draw labs at 6 a.m., then 7 a.m., then 8:30 a.m. for a patient when they could have all just been drawn at 7 a.m. This lack of a relationship and understanding of the nuances in everyone’s experience contribute to burnout and overall dissatisfaction in the workplace.” A department Chair concurred, noting that EHRs “seem to have had a negative impact on teams really getting to know each other. Colleagues can work together for years and never get to know each other in shoulder-to-shoulder, elbow-to-elbow ways. Without this, the personal humanity of sharing stories about kids, family, life experiences is missing. It is a barrier to cohesion and teamsmanship.”

When I embarked on this exploration, I thought that I might find some generational or specialty-specific opinions on the impact of EHRs on clinical care, but this was not the case. My colleagues universally felt that the EHR system helps to streamline communication and can decrease medical errors in ordering and prescribing. There was general agreement that notes seem a bit too long, and that it is hard to weed through carried-forward information to find what really matters. Notably, the EHR may have a very real impact on our interactions with each other, and potentially contributes to the burnout that is prevalent in healthcare today. I recognize that this is a complex issue, but the connections that we forge across disciplines and specialties as we care for patients can have a profound and positive impact on our sense of satisfaction in healthcare, as was shared by my colleagues. It is possible that the time we spend connecting with EHRs has negatively impacted our opportunities to connect with each other in real time, in person, learning from each other, understanding recommendations from consultants, and appreciating the nuanced reasoning that leads to clinical care decisions. +

Sonia Nagy Chimienti, MD FIDSA is Senior Associate Dean for Medical Education at Dartmouth’s Geisel School of Medicine

The author would like to thank, with deep gratitude, those physicians quoted in this piece. These connections were forged through in-person conversations, although technology did facilitate data gathering for this particular piece. Quotes above were shared, with permission, from the following treasured colleagues:

Falen Demsas, MD, Intern in Vascular Surgery, Massachusetts General Hospital, Harvard Medical School

Laura Desrochers, MD, Chief Resident, Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School

Shernaz Dossabhoy, MD, Resident in Vascular Surgery, Stanford University Hospitals/Stanford Medical School

Phillip Fournier, MD, Professor of Family Medicine and Community Health, Medical Director of Student Health Services, UMass Chan School of Medicine/ UMass Memorial Health

David Hatem, MD, Professor of Medicine, Co-Director of the Learning Communities, UMass Chan Medical School/UMass Memorial Health

Tiffany A. Moore Simas, MD, MPH, MEd, FACOG, Donna M. and Robert J. Manning Chair in Obstetrics and Gynecology, Professor, Obstetrics and Gynecology, Pediatrics, Psychiatry and Population and Quantitative Health Sciences, UMass Chan Medical School/UMass Memorial Health