Tuesday, May 18, 2010

Bedside Manner in the Electronic Age

Electronic medical records are all the rage these days. I remember when we were first trying to get them installed in the first medical office I managed. It soon became evident that the younger doctors were eager to learn how to use the system, older doctors resisted it like the plague.

It's been nearly 15 years since we first started hearing about electronic medical records. It's been terrible for transcriptionists, especially in organizations where all the providers have to use the electronics -- like Kaiser. I wonder if Kaiser has any transcriptionists left any more? Now doctors and nurses fill out check-off forms and add brief notes. These are the kinds of notes which are better for HIPAA (Health Insurance Portability and Accountability Act) regulations and go a long way to protect patient confidentiality -- unless, of course, you have access to the computer. I don't know who can log into Kaiser's computers, but at least the janitor won't have access to the records, like they did in our office.

We preached confidentiality, gave workshops on it, but the records couldn't be locked up. The check-in desk was also set up so that anybody standing at the counter could see into the file of the clerk next to the one they were talking with and everybody in the office could overhear telephone conversations. At Dr. G's office, my computer terminal faced out so that it was easily visible to any patient sitting in the waiting room. I often had so much going at one time that it wasn't always possible to hide what was on the screen. To change to configuration would have involved exposing cords and neatnik Dr. G wouldn't have that.

I'm sure the first office has changed now and I know that Dr. G's office has changed, since it now has a new location, but I've always laughed at "patient confidentiality" in the days when I worked in medical offices. At one time or another, in my transcriptionist days, I think I worked in every medical office in Davis and none of them had true "confidentiality."

EMR (electronic medical records) is a good thing because your results are available to all of your providers instantly. I remember watching my mother have her ankle x-rayed and seeing the x-ray appearing on the computer outside the door instantly. The doctor doesn't have to wait for a report to be sent from the lab, it goes into the system and is available to any provider dealing with you right away.

So EMR has changed the confidentiality situation somewhat, but I realized today what else has changed now that your doctor has all of your information on a computer screen. They rarely make eye contact. They never talk to you -- really talk to you.

I don't think my ophthalmologist ever looked at me at all when I was going through all the before and after of cataract surgery. He was reading off a computer screen most of the time and seemed irritated if I said anything at all. Of course specialists don't really care much about patient interaction. They are there to do their specialty, not to be Mr/Ms. Personality with the patient. They are all "House" with a slightly more pleasant personality. You are the cataract in room 3 or the dislocated shoulder in room 5. They don't care if your mother just died or your child is failing in school, or you are in danger of losing your job. It's not pertinent to the specialty they are there to treat and they don't have--or want to--to know about you as a human being.

The optometrist was a bit better when I saw him recently. It was the day after the health plan bill passed and we actually talked about that.

I had a doctor's appointment this morning. The woman at the registrar's desk at Kaiser today never smiled or made eye contact, the nurse didn't make eye contact and the doctor almost never made eye contact.

You do expect your primary care physician to take the opportunity to know you a bit better, though. Dr. H. was my PCP for several years and his ex-wife is currently my gynecologist. He knew me from before, when I was managing the ob/gyn office next door to his suite of offices. So he knew me as a person before he knew me as a patient. I remember one appointment where we got through all the medical stuff in 5 minutes and then sat and chatted about things that might have a bearing on my physical health.

I had an appointment with his wife not too long ago, for what may have been my last Pap smear (how depressing is it when you find you are too old for Pap smears?). When she asked how I was doing, she said "I know abouat your...situation...so you don't have to explain that to me." She knew about my history, about Paul and David, and she asked questions about how I was handling the loss. It was a wonderful bonding moment. I cried, she understood, she spoke as both a doctor and a human being. I left feeling so much better.

Dr. H left Kaiser many years ago to start a private obesity clinic and he was replaced by Dr. A, a woman from Bangladesh who is very nice and whom I like, but who, I noticed today, doesn't make eye contact, except very briefly. She smiles. She speaks softly. She gives instructions, but all while she is looking at my lab results or her notes about me on the computer monitor.

She doesn't know a thing about me. She knows my blood pressure and my diabetes control, but she doesn't know me. Not really.

Today she was trying to explain why I needed to be more compliant with my medication regimen while I was trying to tell her I found it hard to care, which she kind of ignored. She didn't hear the flat tone in my voice. She had no way of knowing that it was the 14th anniversary of David's death. She didn't even know I had buried one, let alone two children. I finally decided to just tell her, after all these years, and mentioned that we had lost two children and what that does to your mental health.

She made eye contact then. She offered me antidepressants (been there, done that), she offered me counseling (been there, done that). I told her I wasn't in any deep depression, that I had been through a couple of years of counseling after the kids died and that I didn't really need to learn anything, and that all the counseling in the world wasn't going to bring either David or Paul back.

It seemed strange to be telling this to the woman who is supposed to know me intimately. But I am a set of lab results to her. It's not that she doesn't care--she doesn't have time to sit and chat and find out the peripheral things that might make a difference in understanding why I go hot and cold on medication compliance. I know from sitting on the other side of the desk that doctors' offices are all about productivity and getting patients in and out as quickly as possible.

I like her, but it's the Kaiser system. I've had a lot of doctors over my 40+ years with Kaiser and it is the rare physician who actually sees me as a person and not a chart that needs to be filled in as quickly as possible. I remember saying to one PCP that I was morbidly obese and was surprised he had to look in my chart to see if maybe that was true--when I was sitting there in front of him, love handles flopping on the exam table and double chins wobbling like a turkey's wattle. I switched to Dr. A right after that.

She sent me home with $85 worth of medication and paraphernalia, a list of things to do and medications to take, which matches the list that I've been ignoring for several months. She probably won't remember that I'm going to Russia. If I'm lucky, she'll remember that I have two dead children.

You don't expect Marcus Welby in these days when everything is computer driven.

But eye contact now and then would be nice.

Hi, David ohwell.gif  (381 bytes).

1 comment:

harrietv said...

I have my medical history on computer and print it out whenever I go to the doctor. (I originally compiled it in case one of my kids would need information if I were incapacited.) I had considered putting on a thumb drive for those doctors who use computers.

I loved the computer part of taking my husband, with his multiple issues, to the VA, where all the doctors put things into the computers. But what I like best of all is that my son is a database manager for a company that services hospitals. Note the plural.

In recent years, I have seen more confidentiality breaches with careless papers than I have with computers.