Electronic health records, touted as tool for efficiency and better care, are coming between doctors and patients, surgeon writes

Illustration by Ben Wiseman for The New Yorker

Electronic health records were supposed to "make medical care easier and more efficient," says The New Yorker. "But are screens coming between doctors and patients?" Yes, surgeon Atul Gawande writes in the magazine's latest issue, starting with a description of his 2015 training session on the Epic Systems Corp. system, which now has information on more than half of Americans.

"The new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear. We’d be greener, faster, better. But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one," Gawande writes.

"A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population. Something’s gone terribly wrong. . . . We’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers."

Gawande offers many examples to show why. Here's one, gathered by talking to physician Susan Sadoughi: "Piecing together what’s important about the patient’s history is at times actually harder than when she had to leaf through a sheaf of paper records. Doctors’ handwritten notes were brief and to the point. With computers, however, the shortcut is to paste in whole blocks of information—an entire two-page imaging report, say—rather than selecting the relevant details. The next doctor must hunt through several pages to find what really matters. Multiply that by 20-some patients a day, and you can see Sadoughi’s problem."

Patience, counsels Gregg Meyer, chief clinical officer at Partners HealthCare, who supervised the software upgrade at Gawande's hospital. “We think of this as a system for us and it’s not,” he told Gawande. “It is for the patients.”

Gawande writes, "In Meyer’s view, we’re only just beginning to experience what patient benefits are possible. A recent study bolsters his case. Researchers looked at Medicare patients admitted to hospitals for fifteen common conditions, and analyzed how their 30-day death rates changed as their hospitals computerized. The results shifted over time. In the first year of the study, deaths actually increased 0.11 per cent for every new function added—an apparent cost of the digital learning curve. But after that deaths dropped 0.21 per cent a year for every function added."

“I’m playing the long game,” Meyer told Gawande. “I have full faith that all that stuff is just going to get better with time.”

Gawande concludes his long story with an episode involving a patient on whom he had turned his back to do a computer task during a pre-surgery visit. As they headed to surgery, he started to do that again, and thought better of it. He writes: "I angled the screen toward the couple. Side by side, we confirmed that his medical history was up to date, that the correct surgical site was marked on his body, that I’d reviewed his medication allergies. His shoulders began to relax. His wife’s did, too. 'Are you ready? I asked. 'I am,' he said."