The Doctor vs The Computer

computerby Danielle Ofri
New York Times

Electronic medical records promise efficiency, safety and productivity in the switch from paper to computer. But there are glitches, as a patient of mine recently brought to light.

My patient needs prostate surgery. It is my job, as his internist, to estimate the risks this surgery poses, decide whether he can proceed with the surgery and make recommendations for his medical management before and after the operation.

He is an extremely complicated patient. His hypertension requires three concurrent medications. He’s taking pills for diabetes, but he really should be giving himself insulin injections. His kidneys are wending their way toward dialysis. A few years ago he had a reaction to a diabetes medication that caused congestive heart failure. His aortic valve is narrowed — not severely, but enough to keep me on edge.

Estimating my patient’s surgical risk and planning for his operative care is not a straightforward process. After our physical exam, I sit down to write a detailed evaluation, because I want the surgeons and anesthesiologists to fully understand the complexity of his situation.

As I type away, I feel like I’m doing the right thing, explicating my clinical reasoning rather than just plugging numbers into a formula. I’m midway into a sentence about kidney function when the computer abruptly halts.

I panic for a moment, fearful that the computer has frozen and that I’ve lost all my work — something that happens all too frequently. But I soon realize that this is not the case. Instead, I’ve come up against a word limit.

It turns out that in our electronic medical record system there is a 1,000-character maximum in the “assessment” field. While I’ve been typing, the character number has been counting backward from 1,000, and now I’ve hit zero. The computer will not permit me to say anything more about my patient.

I go back and remove excess articles: the, a, an. Then I try to gain a few characters by using abbreviations: DM for diabetes mellitus, CRF for chronic renal failure. Still, I am over the limit.

A new trick dawns on me. Maybe if I cut back on my descriptions of the clinical problems I’ve already assessed, then I can gain enough characters for his cardiac status and operative assessment.

I nip and tuck my descriptions of his diabetes, his hypertension, his aortic valve stenosis, trying to placate the demands of our nit-picky computer system. Nevertheless, I am still unable to fit a complete assessment into the box.

In desperation, I call the help desk and voice my concerns. “Well, we can’t have the doctors rambling on forever,” the tech replies.

I want to retort with something snarky, like I hope that his next critical illness clocks in at less than 1,000 characters, but I hold my tongue. Instead I focus on eliminating verbs and prepositions, wondering just how skeletal my text can become.

As I do this, I think about the current push for all doctors to convert to electronic medical records. I don’t deny that it is much easier finding information online than running around the hospital hunting for a chart stuck in the dermatology clinic.

But there are huge trade-offs. Nobody, for example, leafs through a chart anymore, strolling back in time to see what has happened to the patient over many years. In the computer, all visits look the same from the outside, so it is impossible to tell which were thorough visits with extensive evaluation and which were only brief visits for medication refills. In practice, most doctors end up opening only the last two or three visits; everything before that is effectively consigned to the electronic dust heap.

Most importantly, the electronic medical record affects how we think. The system encourages fragmented documentation, with different aspects of a patient’s condition secreted in unconnected fields, so it’s much harder to keep a global synthesis of the patient in mind.

Now I’ve learned that file-size restrictions will limit the extent and depth of analysis. What will happen to the tradition of thorough clinical reasoning?

I’ve finally condensed my patient’s complicated medical conditions to exactly 1,000 characters. I quickly hit “save” before I lose everything. I wish him good luck on his operation, wondering if his surgeons will have to condense the entire operative report to 1,000 characters as well. What happens if there are complications?

For my next medical evaluation, I think I will use haiku.  (From the New York Times)