Last year Alok Khorana published a really excellent short piece on the impact of electronic medical records (EMRs, those things that are supposed to save medicine) on the way doctors interact with patients and communicate with one another. “I look forward to EMR implementation for the ease of writing chemotherapy orders and for not having to hunt down a paper chart whenever I need a patient’s height or weight,” he says, but “[w]hen I practice note writing on our new EMR, I am struck by how poorly it actually documents my encounter with a patient.” The digital versions of these notes have become bloated yet depersonalized– lots of copy-and-paste content gets dropped in, in an effort to meet the requirements of insurance companies to “fully” document their work– thus making them less useful as a means of communicating between specialists. But they’re also changing the relationship between doctor, patient, and medical record:

[T]here are two major narratives associated with the physician-patient encounter. The first is the narrative told by the patient to the physician. The starting point of this narrative is relatively uniform: the complaint that brought the patient in. From here onward, however, the narrative can be remarkably free-flowing and often tangential. To make sense of this free-flowing story, we as providers resort to a second narrative. The physician’s narrative repackages the patient’s tale, but in a format that serves the scientific goal of the note, which is to reach a diagnosis and treatment plan. Of necessity, it requires the act of listening closely and mindfully to the patient first.

The provider note portion of the EMR manages to disrupt both of these narratives. My patients report a sense of disengagement from having a provider look at the computer screen rather than at them. Eye contact, reading nonverbal cues, noticing interactions between family members, and providing nonverbal cues that respond empathetically to the patient’s story are tools as vital for a physician as the stethoscope. Indeed, patients perceive (perhaps accurately) that the EMR is being accorded greater emphasis in the building of the narrative rather than what is clearly the primary source of information, the patient. As for the physician’s narrative, nowhere is it clearer than in the EMR note that reality is under-represented. The cut-and-paste and point-and-click portions of the software program allow us to quickly generate notes, but they also force us to reduce our patients to the boxes that have been provided by the software designer.

Worse, current EMR software is highly likely to serve as a template for future programs. The process of software lock-in can cause software design choices made at an early stage of development to become entrenched for future iterations of such programs. Indeed, little appears to have changed in the 2 years since an initial critique of EMR capabilities. Although physicians in practice currently have been exposed to both paper and EMR-type notes, a generation of providers is currently being trained with exposure only to the latter. A tradition dating back several hundred years is being lost in less than a decade.

I find this a really smart little piece. It illustrates how documents aren’t just passive or accidental carriers of information, but have physical affordances and are created out of (and in their own turn influence) social interactions. The traditional paper chart with hand-written notes was challenging from an IT point of view, but it didn’t raise as many obstacles to physicians interacting with patients as today’s systems do. Forgetting this makes designing new systems that raise their own issues more likely: even at the Palo Alto Medical Foundation, which is one of the more high-tech clinics around, I’m slightly disquieted when my doctor talks to me from the PC in the examining room, rather than looking at me.

But the piece also suggests that we could design systems that didn’t accidentally short-circuit the social exchanges and interior thinking– the processing that the doctor does when crafting that second narrative. I suspect there will be HIPPA or cost obstacles, and problems of having to over-document your work in order to meet insurance billing requirements or paying more attention to the chart in your hand rather the patient before you are ones that can’t be solved just through better design or more mobile technology, but it strikes me that iPads or other tablets could be used more unobtrusively when interacting with patients.