One morning recently, I found another physician standing morosely at one of the mobile computer terminals we refer to as “cows”—computers on wheels—that are everywhere now in our hospital. I asked what was the matter. “Oh nothing, really,” she said. “It’s just that I don’t feel I know the patients as well as I used to.”
I knew exactly what she meant. Things are different now that we have the EMR—the electronic medical record. After two months of use, we’ve learned, to our sorrow, that these records don’t tell us stories that make cognitive sense. Instead they offer data, but not information, in endless lists.
Before the written word, people told stories. In every culture, around hearths and on journeys, they remembered and retold tales of great deeds, romance and tragedy. When we were medical students, we learned to present each case on rounds by telling the patient’s story. The story had well-defined elements: the current complaint, the background of genetics or misfortune that led up to the present, the investigation that might clinch the diagnosis and the plan of action.
The best stories almost told themselves. The business executive fresh from a transatlantic flight presented with shortness of breath; VQ scan revealed a pulmonary embolism. The young woman with Marfan’s syndrome began exercising one morning and developed severe chest pain radiating to her back; the echo demonstrated aortic dissection.
Now, however, we have lists.
One list will give us the medical history. In no particular order of priority, it includes one-word problems such as osteoarthritis or hypertension that have nothing to do with the patient’s current admission for acute pancreatitis. The relevant history of alcohol abuse may be found elsewhere, in the list under “social history.” Our “social history” includes a field that will tell you whether or not the patient chews tobacco, which is so seldom helpful in southern California. The complaint of abdominal pain won’t be found anywhere near the list of laboratory values with the important amylase and lipase levels.
If you’re a consultant trying to make sense of the patient’s case, you can find yourself frustrated and stymied at the difficulty of getting the big picture. If you’re lucky, you can find a human who knows something about the patient, and get him or her to tell you the story. You can bet that this won’t be the resident, who has just come on the service, didn’t admit the patient, won’t be following the patient and will have to lie down for a nap soon. But with perseverance, you may find an attending physician who has no duty hour restrictions and actually knows what’s going on with the patient.
If finding a human fails, your second hope is to find a narrative note by a physician who is in the old-school habit of dictating an organized history and physical. This is the pot of gold in the EMR, but you may have to sift through pages of notes on the computer before you find one. Sometimes, just for fun, I print it out so I can refer back to it without logging on to anything.
The use of all the “smart fields” in the EMR looks appealing at first until you realize that they propagate themselves endlessly, like tribbles. The same “past medical history” will appear as an identical list in note after note, because it’s so easy to type “.pmh” instead of summarizing the patient’s problems as a narrative. If an error of any kind is made, it will continue until someone notices and takes the trouble to delete it. If “Lasix” instead of “latex” is entered as an allergy, it may be listed that way indefinitely. You’re much more likely to click on the wrong line of a list than you are to write down the wrong information in a handwritten note.
With the billions of dollars that are being spent on EMRs, and the Obama administration's keen interest in their implementation, no one wants to hear about the problems they cause. But the truth is that it's much harder for physicians and everyone else in the hospital to learn and remember what they need to know about their patients from reading electronic records. Human beings don’t learn best by memorizing disconnected lists. From fairy tales to patients’ histories, we’re hard-wired to remember stories.