Syndicom

Electronic Records and Responsible Interaction

“These narratives, or pathographies as they are sometimes called, demonstrate how critical is the telling of pain and suffering enabling patients to give voice to what they endure and to frame the illness so as to escape dominion by it.” -Dr. Rita Charon Narrative Medicine, P. 66

Recently, the editorial, The Computer Will See You Now was published in the NY Times and interestingly - as White Coat points out – there was another Op-Ed piece by the same title written in 2005 also in the NY Times by a different author. Both articles discuss electronic medical records in general and how the computer is depersonalizing medicine in particular. Interesting huh?

Dr. Rita Charon, whose quote opens this post, talks much about the narrative road to effective medicine. For her, health professionals and patients are at a crossroads. And together, “we have to discover means of sustaining the tremendous capabilities of our biomedical sciences while trying to ease the suffering and loss occasioned by serious illness” (p. 6). Furthermore, she states, “the price for a technologically sophisticated medicine seems to be impersonal, calculating treatment from revolving sets of specialists who, because they are consumed with the scientific elements in health care, seem divided from the ordinary human experiences that surround pain, suffering, and dying” (p. 6).

That being said, let me highlight some of the key points made in both of the NY Times pieces that spanned 4 years.

The 2005 article written by Dr. Barron H. Lerner begins by discussing the X-ray coming into wide use in the late 1800’s. Dr. Stanley Reiser described the use as, “those who possessed an X-ray picture could ponder and debate the medical problems of the patient without requiring his or her physical presence.” As discussed, the electronic record has several virtues such as being available when paper is not, reducing errors, helping coordinate providers and enhancing interaction, like adjusting the computer screen so it – and they – face the patient. The article, however, ends with a warning as one patient states, “I think that if I meet a new doctor and we don’t have that face to face contact, I would not feel comfortable telling him or her all my ills.”

4 years later Dr. Anne Armstrong-Coben opens her article by stating, “for 20 years, I practiced pediatric medicine with a ‘paper chart.’ I would sit with my young patients and their families, chart in my lap, making eye contact and listening to their stories. I could take patients’ histories in the order they wanted to tell them or as I wanted to ask.” Furthermore, she describes being able to draw pictures like rashes or birthmarks and she loved how patients would participate in their own care and own charts. Now, she describes how doctors in every specialty struggle to find a way to keep the computer from disrupting what should be going on in the exam room – “making that crucial connection between doctor and patient.” For example, she describes being forced to “bring up questions in the order they appear, to ask the parents of a laughing 2-year-old if she is ‘in pain,’” and to restrain her “potty mouth” when the computer malfunctions or locks up.

Thus, both articles allude to how the computer depersonalizes medicine. “It ignores nuances that we do not measure but clearly influence care.” And “it takes more effort and thought to write a prescription than to pull up a menu of medications and click a box.”

The recently passed stimulus package provides $17 billion worth of incentive payments to switch to electronic records so these conversations are paramount. And clearly, there are tensions revolving around following an order of questions in an ever complex and indeterminate encounter, among other things. But if humanistic medicine and personal relationships matter in the clinic, what role will electronic records play in coordinating a new interaction for clinical work and enabling patients to frame the pain and illness so as to escape it’s dominion?

Thanks to benben and Aphrodite for their images!

Carey Candrian