Monday, November 18, 2013

A poignant vignette of rural healthcare

This piece by Dr. Regina Harrell appears on the NPR "Shots" blog, with the sub-head, "policy-ish."  The headline is "Why a Patient's Story Matters More than a Computer Check-List," and in it Dr. Harrell, an assistant professor at the College of Community Health Services, University of Alabama, recounts a visit to an elderly patient in rural Alabama to make the point that her patients' experiences don't always fit neatly into the boxes to be checked on the interfaces of new fangled electronic health records (EHRs).  Here's an excerpt from the piece, which provides not only a critique of EHRs, but also a vignette into rural lives and healthcare delivery:
We chat a moment, then we move on to Mr. Edgars' arthritis. Early on in his dementia he wandered the woods. His wife was afraid he would get lost and die, although the family agreed that this was how he would want it. 
Now his knee arthritis has worsened enough that it has curtailed his wanderings. I suspect that Mrs. Edgars is cutting back on his pain medicine to decrease the chance he'll wander off again. 
We talk about how anxious he grows whenever she's out of his sight, and how one of his children comes to sit with him so that she can run errands. I leave carrying her parting gift, a jar of homegrown pickled okra. 
Back at the office, I turn on the computer to write a note in the electronic health record, or EHR. In addition to recording the details of our visit, I must meet the new federal criteria for "meaningful use" that have been adopted by my office, with threats that I won't get paid for my work if I don't. 
Under history, I enter "knee pain." Up pops a check-box menu: injury-related (surely the chronic wear on Mr. Edgars' knees as a farmer is an injury, but I don't think that's what the programmer had in mind); worsening factors (none apply, as he couldn't give his own history); relieving factors (there's no check box for a sleep-deprived wife who's purposely keeping the dose of acetaminophen low); and so on. Nothing fits, so I exit and type in "follow-up". It cedes a blank screen.
 * * * 
Next is the physical exam. The check boxes ask if the person is oriented to person, place and time. Mr. Edgars is oriented to person and place; he knows his wife and home, and he is happy nowhere else. He no longer cares what year it is. There isn't a check box for that. 
At day's end, I review my meaningful use. I spent more time checking boxes than talking to patients and their families.
There aren't enough physicians to see all the homebound patients in my area, so I try to visit as many as I can safely care for. I could see twice as many patients if I could write their notes at the bedside while visiting with them. I would happily do this using paper or an EHR that took the same amount of time, but these are not options.

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