The Patients vs. Paperwork Problem for Doctors

The Patients vs. Paperwork Problem for Doctors


Part of the issue is that there are simply more patients, most of whom are living longer with many more chronic illnesses, so each patient has many more health concerns that need to be taken care of in a given visit.

But the main reason that I can’t keep up is the E.M.R. Like some virulent bacteria doubling on the agar plate, the E.M.R. grows more gargantuan with each passing month, requiring ever more (and ever more arduous) documentation to feed the beast.

I try to spend as much time as I can directly focused on each patient, listening to what she is saying, thinking hard about her clinical situation. This is the essence of good medicine. But it’s not the essence of what makes the clinical enterprise proceed forward. In today’s medical world, nothing exists until the E.M.R. requirements are tended to.

The painful truth is that every minute I spend talking with my patient or doing the physical exam — that is, any time not spent on the E.M.R. — simply grinds down the progress of the day.

To be sure, keeping electronic records has benefits: legibility, electronic prescriptions, centralized location of information. But the E.M.R. has become the convenient vehicle to channel every quandary in health care. New state regulation? Add a required field in the E.M.R. New insurance requirement? Add two fields. New quality-control initiative? Add six.

Medicine has devolved into a busywork-laden field that is slowly ceasing to function. Many of my colleagues believe that we’ve reached the inflection point at which we can no longer adequately care for our patients. The E.M.R. isn’t the only culprit, but it’s certainly the heavy-hitter.

Medicine traditionally puts the patient first. Now, however, it feels like documentation comes first. What actually transpires with the patient seems like a quaint trifle, something to squeeze in among the primary tasks of getting everything typed into the E.M.R.

More and more doctors are concluding that the overbearing E.M.R. actually jeopardizes patient safety, by pushing patients to the margin of the medical encounter.

It’s time, then, to take action, as we do in other areas that harm patients. Currently, hospitals can be fined for hospital-acquired infections, bedsores, medical errors, privacy violations, and patients who are readmitted within 30 days. The same logic should now be applied to electronic busywork.

Health systems should be required to periodically measure the E.M.R. burden, and should be fined when it detracts too much from face-time with patients. Hospitals might then think twice before tossing in 10 more required fields that cover their own needs but end up leaving patients with even less attention from their doctors and nurses. Things might actually change if money were on the table.

Similarly, E.M.R.s themselves need to be held to a higher standard. Given how much they affect patients’ medical care, they should be treated like any other medical device and subjected to thorough scrutiny before being allowed onto the market. E.M.R. vendors ought to be held responsible when their medical documentation product harms patient care.

If patient safety — and patient satisfaction — truly are goals of 21st century medicine, then we need to rethink how we view the E.M.R. and the related electronic burden on clinicians.

“Soap and water and common sense are the best disinfectants,” wrote the esteemed physician Sir William Osler. However, it took medicine more than a century to incorporate hand-washing as one of the best investments in our patients’ health. Let’s hope it takes less time when it comes to common sense and the E.M.R.



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