Electronic Medical Records and the Dehumanization of Medicine
Claire Zilber, M.D., is a psychiatrist in private practice in Denver, a faculty member of the PROBE (Professional Problem Based Ethics) Program, and chair of the Ethics Committee of the Colorado Psychiatric Society. She is the co-author of Living in Limbo: Creating Structure and Peace When Someone You Love Is Ill, the winner of a 2017 Silver Nautilus Book Award.
The popular narrative about the electronic medical record (EMR) is that it makes a patient’s health care information more accessible across providers; allows medical history, diagnoses, problem lists, and medications to be tracked and reconciled to increase accuracy; and results in improved quality of care.
The reality is that the Affordable Care Act mandated the EMR for all of the above reasons and to serve as a billing platform. All of the EMR’s purported benefits, including accurate and efficient billing, are laudable; however, it has had unintended and devastating consequences. These include reduced face-to-face time between clinicians and their patients, a note cluttered with meaningless information because of excessive reliance on checkboxes, reduced clarity of communication because the cluttered notes make it hard to find the most important pieces of information, and diminished job satisfaction for health care professionals. In addition, there are some potential ethical concerns regarding the EMR, including a loss of the virtues inherent in professionalism.
A Google Scholar search for “electronic medical record and burnout” limited to articles published since 2017 results in 5,160 published articles. The findings include that primary care physicians spend more than half of their 11 hours of daily clinical work interacting with the EMR. One review article Current Opinion in Anaesthesiology concludes, “In multiple recent studies, electronic health records have been shown to decrease professional satisfaction, increase burnout, and the likelihood that a physician will reduce or leave clinical practice.” Many articles concern improving work-life balance through physician self-care, and others describe assigning a clerical scribe to each health care professional to reduce time spent directly interacting with the EMR. Those suggestions are good, but they are not good enough.
What the data fail to capture is the dehumanization of health care professionals in an increasingly corporate, market-driven world. In the effort to track meaningful quality improvement data, the EMR has shifted the focus from the patient to metrics. Physicians feel like cogs in the wheel of the billing-and-reimbursement machine, our service reduced to billable units.
This is not what motivated any of us to attend medical school. Virtues such as altruistic service, compassion, diligence, and communication with patients are not supported by typing and clicking on a computer for six hours a day. The requirement to have notes entered in a timely fashion elevates other virtues, such as efficiency, but perhaps not the ones patients and their families care most about. When the values that motivate us to work hard in service of our patients are subverted by administrative mandates, we may feel diminished and demoralized. Our demeanor at work may shift, and our professionalism may suffer.
APA’s The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry (2013) exhorts the physician to respect the law and “recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient” (Section 3). If psychiatrists find that the EMR in its current incarnation is compromising the best interests of the patient, it is our ethical duty to seek changes. Furthermore, Section 4, Article 1, acknowledges, “Growing concern regarding the civil rights of patients and the possible adverse effects of computerization, duplication equipment, and data banks makes the dissemination of confidential information an increasing hazard.”
To preserve the healing nature of the doctor-patient relationship we must protect our ability to spend time talking face to face with our patients, and we must practice in a way that feels true to the values that brought us into this healing profession. Individual psychiatrists cannot achieve this kind of systemic change on our own. We need the organizational capacity of APA, AMA, and other professional advocacy groups to work with the federal government, health care systems, and insurers to promote deep shifts in health care business practice. Unless we find a way to rehumanize the profession, we will be reduced to mere technicians in the medical industrial complex. ■
