Dr. Larry Cohan, a pediatrician who has always kept voluminous files on his patients from birth through college, is used to examining his young charges, questioning and quipping, while scribbling notes in the medical record. But a few years ago a third party came between him and his patients: a computer screen.
Prodded by the federal government, doctors are replacing their paper files with electronic records. There have been growing pains. As efficient as the technnology is, neither physicians nor patients want a computer screen separating them.
“I was faced with a choice,” says Cohan, who has practices in Braintree and Boston. “When writing my exam notes in the computer, do I turn my back on my patients sometimes? Or do I try to maintain eye contact and write my notes later, when frankly there isn’t time later?” Cohan has hit upon a third way, which seems to work: He invites his young charges to sit in a chair near his desk, so he can explain things to them as he’s typing notes.
But e-records are only part of e-medicine. Patients are increasingly turning to medical websites and message boards to become “experts” on their own health care. Many expect to keep in e-mail touch with their physicians. And some patients are even involved in home e-monitoring for chronic conditions.
Together, these changes — all of them fueled by our increasing reliance on digital devices — are fundamentally altering the doctor-patient relationship, nudging health care from medical settings into people’s day-to-day lives.
The most obvious change is in the doctor’s office. The doctor-patient bond has always relied on interaction, and both sides worry about that bond weakening as electronic medical records slowly but surely replace the voluminous paper files that doctors have always kept. In 2009, Congress approved the Health Information Technology for Economic and Clinical Health Act, with the government offering financial incentives through Medicare and Medicaid for physicians who go electronic, and reimbursement penalties for those who fail to do so by 2015.
Lawmakers believe that electronic records will cut down on redundant tests, reduce errors — doctors’ illegible scrawls are legendary — and enable physicians to share patient information easily. According to the federal Centers for Disease Control, 57 percent of office-based physicians used electronic records last year, up from 18 percent in 2001.
‘With the older kids, I turn the screen so they can see what I’m writing. If teens can see what I’m writing about them, they won’t think I’m writing secret thoughts into a computer.’
“In the coming years, we’ll see more patient empowerment, more instances where consumers can make their own health care decisions without a physician, and more opportunity to streamline care delivery, making it simpler and more patient-friendly,” says Dr. Joseph Kvedar, director of the Center for Connected Health, a division of Partners HealthCare that develops high-tech strategies to make the health-care system more user-friendly.
Working with teens
Cohan’s examining rooms are compact, but he keeps a patient chair by his desk, so the two can chat. If his patients remained on the examining table while he typed his notes, he would have his back to them.
“With the older kids, I turn the screen so they can see what I’m writing,” Cohan says. “If teens can see what I’m writing about them, it makes them a little more engaged. They won’t think I’m writing secret thoughts into a computer.”
Isaac Brown, 9, was in recently for his annual checkup. Cohan — genial and bearded with a comfortable, casual manner — invited Isaac to sit and talk. He went through a litany of questions: What’s your favorite subject? (Math and reading.) What have you read lately? (“Harry Potter.”) Did you think Snape was a good guy or bad guy? (Good guy.)
“Let’s see how you’re growing,” said Cohan, scrolling to the boy’s chart. He pointed to a spike in height while Isaac leaned in and looked.
“If I keep growing like that, I’ll be 6 feet tall?” he asked.
Maybe, replied Cohan. “We won’t know until you’re 18.”
Isaac’s mother, Vera Schneider, says she doesn’t care whether the record is paper or electronic, as long as the doctor maintains a “good relationship, a good way of speaking to the patient.”
Cohan’s practice began using electronic records in 2006, and he likes the ease of obtaining data. “If there’s a question about blood tests done two years ago, I can press a button, bring it up, and there’s less paper-shuffling at the visit,” he says.
But for him and other physicians, a major problem is that there’s not a one-size-fits-all system. The software he uses allows him to access information from the Brigham and Women’s Hospital, Massachusetts General Hospital, and Massachusetts Eye and Ear Infirmary.
Children’s Hospital is not on the same system, so if his patients go there for treatment, he cannot easily obtain that record, even though he is on the staff.
Dr. Fred Basilico, a cardiologist, went to electronic records two years ago and says he’s now a believer. “Initially, it was very, very hard,” says Basilico, who is chairman of the Department of Medicine at New England Baptist Hospital. “It slowed down patient time. I could see fewer patients in a day, and each patient took a lot longer to see.”
But he wouldn’t return to paper records. He appreciates the efficiency of the computer data, the fact that it reduces paper use and eliminates having staffers file and access information.
Like Cohan, Basilico has shifted his physical presence in the exam room because of the technology.
“I used to be able to sit with the patient and look him in the eye,” he says. “Even while I was taking notes, we would be sitting and chatting.” Now, he has his patients sit next to him as he enters data.
Though doctors say their patients get used to a computer in the room, not all patients embrace it.
“Honestly, I don’t like it,” says Tara Tomany, 47, of Groton. “My concern is that it’s more time-consuming, and the physicians have to be more concerned with logging and coding correctly while at the same time trying to converse with the patient. I think it’s an intrusion on the privacy and intimacy between the patient and the doctor.”
Tomany’s dermatologist, Dr. Eileen Deignan, has been using electronic records for several months, and feels it frees her up to spend more time with her patients. Deignan uses Electronic Medical Assistant, which was developed by a fellow dermatologist.
The system requires an assistant with an iPad to enter the information that the doctor gives verbally. With a few clicks, the notes are done, the lab tests ordered, the prescription sent to the pharmacy, and patient instructions printed out.
Deignan, who practices in Concord and Cambridge, says most of her patients think the technology is beneficial. “I think people expect there will be a computer in the room,” she says.
Jane Tufts, a breast cancer survivor who lives in Milton, says her physicians use computers, and she approves.
On a recent weekend, when she called her primary care physician for help with her allergies and asthma, she says, he easily pulled up her computerized records, which made for an easier diagnosis and treatment plan.
“The screen is between us, but it’s not hiding their face,” she says. “I still feel they’re interacting with me personally and getting things down more accurately, rather than some scratchy notes where if the doctor leaves no one else can read them. Just go to the computer and it’s all there.”