Patient-Doctor Interaction Suffers with EMRs in Outpatient Clinics

The intended goals of requiring electronic medical record (EMR) systems in all hospitals and clinics were rational and, for the most part, patient-centered. EMRs have prevented large numbers of potentially serious medication errors, served as a secure means of making laboratory and imaging data readily available to surgeons, and have provided an efficient mode of communication among members of health care teams.

Unfortunately, the design of most, if not all, EMR systems is focused on coding and billing, not on the doctor-patient interaction during the all-important face-to-face clinic visit. This has had the unintended consequence of requiring dense, protracted documentation of care interactions that seems to de-emphasize the most important part of the EMR entry: the physician’s thought process and treatment plan.

In the September 19, 2018 edition of The Journal, Scott et al. provide us with a unique cost-and-productivity view into the impact that implementing an EMR had within an outpatient orthopaedic clinic.  During the first 6 months after a new EMR was launched, total labor costs increased, driven by attending surgeons and medical assistants spending increased time documenting visits. Although the total per-encounter cost returned to baseline levels after 6 months, more time was spent documenting encounters and less time was spent interacting with patients than before EMR implementation. So, even after a return to normal clinic “productivity” after the 6-month learning period, the price paid for increased time spent documenting on the new EMR was decreased provider-patient “face time.”

In my opinion, it is essential that we work to remedy this deficiency. Personally, I do not use EMR-provided templates for documenting physical exam findings, imaging study results, and treatment plans. Instead, I engage with the patient during the visit and make detailed notes in the EMR after the patient leaves. This probably results in “under-billing” for my services, but I am willing to pay that price to increase the value of the visit for the patient—and for my colleagues who may review my notes.

The study by Scott et al. is a necessary first step in understanding EMR ramifications in orthopaedics, but our community needs more broad-based research to further delve into the full impact of EMRs on patient care, patient satisfaction, and cost. Toward that end, the Orthopaedic Research and Education Foundation (OREF) recently extended until September 28, 2018 the deadline for grant proposals to investigate the impact of EMR regulations on the patient-physician relationship. We must continue to address this apparent problem to improve patient care, which was the goal of EMRs in the first place.

Marc Swiontkowski, MD
JBJS Editor-in-Chief