by Danielle Ofri
New York Times
Despite being considered by some as a hospital of last resort, the sprawling city hospital where I’ve spent 20 years is at the forefront of electronic trends. Although some hospitals are computerized, most do not have fully functional electronic medical records, as promoted by the health care reform law of 2010. And more than half of all outpatient practices still use paper charts, making health care the only major industry that is not fully computerized.
But in this inner-city hospital, sleek flat screens sit in every one of the nearly 500 outpatient clinic rooms and nurses’ offices. The inpatient wards are veritable hubs of hardware and wireless technology. Every M.R.I. scan, X-ray, CT scan and EKG can be viewed by any doctor anywhere in the hospital. Prescriptions can be renewed in seconds. Medication interactions are automatically flagged. Lab results are queued to the individual doctor. Immunizations can be tracked. One click brings up a patient’s blood pressure readings for the past decade. Doctors can be reminded to ask about smoking, depression, domestic violence and asthma.
In this heroic pursuit of the “paperless chart,” the hospital often seems a bit like the 21st century equivalent of the 1950s secretarial pool: doctor after doctor hunched over the desk, dutifully pounding away at their keyboards. Nurses, respiratory technicians, nutritionists and pharmacists are glued to their computers. Mobile computer carts fill the hallways for doctors to review X-rays or order stat medications while on rounds.
Rampant carpal tunnel syndrome notwithstanding, this new system clearly has advantages: no more chicken scrawl on the charts, or hieroglyphics on prescriptions. No more hunting down lost charts in the bowels of Medical Records. No more EKGs crumpled away in some intern’s back pocket. No more X-rays lost in surgery clinic.
But the presence of computers in the exam room has had another consequence. Both physically and psychologically it has placed a wedge in the doctor-patient relationship.
In the old days, when a patient arrived in my office, I laid the paper chart on the desk between us. I looked directly at the patient. As we spoke, I would briefly drop my eyes to jot a note on the page, and then look right up to continue our conversation. My gaze and my body language remained oriented toward the patient nearly all the time. In the current computerized medical world this is impossible. I have to be tuned toward the computer screen to check labs, review X-rays, read prior notes, document the patient’s current concerns.
Like most internists, I know that the interview is the most important part of a patient visit. It always yields far more information than the physical exam, which, in many ways, is an afterthought.
But now that the computer is impeding the intimacy normally achieved during the talking part of the visit, I find that I rely on the physical exam more. Once the patient and I have broken free from confines of the desk, with its dictatorial PC, we have a more comfortable realm, that of touch. As soon as there is skin-to-skin connection, conversation flows more easily. In the absence of a machine lodged between us, the traditional doctor-patient relationship is restored.
Still, after the physical exam, when we return to the desk to wrap up the visit, we are stuck back with the computer screen between us as I print out prescriptions, order labs and document all the elements of our visit in order to comply with the vast and ever-expanding charting requirements. The clicking of the keyboard interrupts our conversation, and there are uncomfortable periods of silence as the patient waits for me to scroll through the seemingly endless number of screens in order to close the visit.
I’m sure it’s not a pretty sight: the profile of the doctor squinting at the screen, hands endlessly back and forth between mouse and keyboard, invariably muttering mild expletives as accidental strokes cause data to disappear and printers to jam. However, there is no practical way to keep up with the flow of work and the backlog of other patients waiting.
Don’t get me wrong. The computer has much to offer, but I mourn the loss of intimacy that it has engendered. For the longest time, the ophthalmologists in our hospital resisted the electronic medical record. Perhaps they were too used to drawing diagrams in their notes, or maybe they were just lazy Luddites. But whenever I clicked on their notes to see what happened to my patient during their recent visit to the eye doctor, I would invariably see this neatly typed, succinct summary: “See paper chart.”
But in the era of the paperless chart, no such actual chart would ever show up, so that computerized note may as well have said: “Please read my mind.”
And then I would need to ask the patient what happened when they went to the eye doctor. Luckily, this would give us a chance to talk again.