Turns out there is an unintended consequence of many of the current efforts to standardize the way doctor’s practice medicine. It is called de-skilling. De-skilling can occur when physicians and other providers try to adapt to standardized, new ways of doing things. Examples of such standardization include clinical based care guidelines, electronic medical records (EMRs), Pay for Performance (P4P), Patient Centered Medical Home (PCMH) requirements and so on.
Examples of physician de-skilling were revealed in a recent study which consisted of in-depth interviews with 78 primary care physicians regarding EMR use. EMRs are all about standardization – what data is captured and recorded, how data is reported, how data is used, and so on.
Over the course of the interviews, physicians in the study described significant examples of de-skilling behavior. Most indicated that valuable patient information was being lost given how physicians adapted to using the EMR. Why? The physicians believed that the EMR forced them to change how they “fed their clinical thought processes into a patient’s record.”
The majority of PCPs interviewed reported situations where they or specialists “cut and paste the same exact language and statements, sometimes consisting of entire narratives across different patient records” where patients had the same condition (usually a chronic condition).
The net result was that PCPs believed they were increasingly getting less patient-specific information from specialists via the EMR which hindered their ability to make informed decisions around diagnosis and treatment.
According to these same physicians, this situation did not happen with paper records. That is because paper records forced clinicians to dictate a certain amount of unique verbiage for transcription into a patient’s record.
Time pressures also contribute to physician de-skilling relative to EMRs. Most EMR systems use templates that physicians must modify for each patient. Physicians in the study complained that there wasn’t enough time to edited the EMR templates and then enter the proper patient information. The conclusion, according to researchers, was that “some of the docs just do the bare minimum in terms of putting stuff into the EMR. When you read what’s in the record you’re kind of like, what is this?’’
In other words, some physicians simply didn’t bother to tailor EMR templates to the needs of the patient choosing instead to simply get through the standardized template.
The bottom line is that physician de-skilling has serious implications for patient outcomes and quality of care.
Take Away
Patients need to be aware of and protect themselves from instances of physician de-skilling. How can patient do that? The best way is to ask your doctor to review the patient notes section of your electronic patient record to see what you doctor entered about your condition. Is what your doctor entered accurate? Is it complete? Given that others providers will be relying on the quality of your record for treatment decisions, this is something that everyone, patient and physician, need to be aware of.
Source:
Huff, T. Deskilling and adaptation among primary care physicians using two work innovations. Health Care Management Review. March 2011.
Mind The Gap 
This is an interesting point. As a pediatrician currently working in a paper based records system, I do find that writing my note, often after the patient has left, helps me think about the diagnostic possibilities and treatment plan. The act of thinking about what to write is what helps me think about differential diagnosis. I do fear the loss of this activity with transition to EMR. The opportunity to free text some of this will help. You can still capture data on diagnosis and treatment plan by entering these fields as structured data and keep some free text spots for “medical decision making”.
Its not just Doctors that it happens to, I have students who have serious problems taking a history and obtaining needed information unless an EMR spoon feeds it all to them. The quality of information in an EMR is dependent on the quality inputed. Most EMR’s allow voice dictation rather than cut and paste. Qulaity physicians will exercise this option for complicated problems for the beneift of themselves and their patients.
Kerry and Danielle,
Thanks for the real world validation and insights. I was recently in Stanford’s Simulation Center where they teach new docs and have the latest sims for hospital based care. Curiously nothing in the Sim Lab deals with EMRs and the patient.
Steve Wilkins
As a patient, I have had this happen repeatedly. The specialists claim, for example, that ear canals were patent, when they did not go near my ears. Or that cranial nerves were tested and are normal when those tests were not performed. If the docs did all the tests that are listed as “normal” in their reports, I would have 4-hour appointments. It is a huge problem and will come back to bite them all in the butt if they are ever sued because their records are not accurate and reliable.
points above well taken.
i am a primary care doc who was all for the transformation to electronica, but have found that the reality of them is much different than the abstract, high-minded ideal.
paper allowed thoughts to flow; EMRs force function us into box checking and extraneous nonsense.
i’ve become ever more interested in voice-transcription software and/or the idea of scribes.
John,
Thanks for your input! Scribes sure seem like an expensive proposition.
Steve Wilkins
Are we talking about Skills or Knowledge? The reason I ask is that computers and Internet access enable outsourcing of knowledge-based jobs. If you want to extrapolate this trend, read http://www.mhealthtalk.com/2011/09/what-do-you-want/.
I had another thought. Why don’t the primary care physicians fight back? Why don’t they say, “Dr. X, there are so many tests listed as normal on your report that I can’t be sure which ones were actually performed.” Primary docs are the “gatekeepers.” Together they form a market that could demand that specialists provide clear and accurate information.
I agree with all of the above points. EMR puts the patient secondary to the data and billing hence, the medical care becomes second rate. Health care providers spend more time inputting data mainly to satisfy the billing department. The exam the Abby didn’t receive is just the provider trying to justify the time spent with the patient and justify the complexity of medical decision making so that the amount of money the insurance company pays the office reflects actual costs. If her provider actually charted what was really did he would only get $25 for that visit–based on EMR coding. This hardly pays for the lights, medical assistant, receptionist,etc.
(Let me be clear–I do not in any way endorse charting for things not done, upcoding, or in any way, fraudulently billing–I am just giving an explaination of why something might be done)
In regards to Wayne’s comments and reference to his article: As a PA, I do not need a supercomputer to help me make medical decisions or arrive at a diagnosis. Nor do Nurse Practitioners (I assume that nurses in the article meant NP’s–there is a huge difference between the two). I am well trained to make most medical decisions. In fact, in many practices it is us “mid level” providers who are seeing the bulk of patients, but I digress.
EMR’s are here to stay but are still stuck in 1980’s programming. The best EMR would do the following: 1) Be user driven not programmer driven. That is, what I handwrite gets placed in the appropriate spot on the EMR not the other way around. Key words would be placed in the narrative where appropriate. Much like what happens when you place an order at Amazon. 2) Have a GUI with touch screens similar to an iPad–we still use a pen or mouse to input data. 3) Eliminate the stock narrative and go back to the old SOAP format–concise, informative, tried and true.
Very interesting! I supposed it’s not shocking that templating systems result in more standardized patient charts (though is “de-skilling” the appropiate word?). The question becomes: what can be done about this? EMR systems aren’t going anywhere, and without templates of some kind the burden of charting becomes overwhelming. Have there been any suggestions about alternatives that would improve specificity?
One interesting observation (totally anecdotal) is that practitioners seem to write much longer and “wordier” notes when using EMRs. Paper charts tend to be quite short (a couple of sentences) and use a lot of short hand. For some reason, I’ve seen shorthand disappearing to some degree when people switch to typing notes rather than hand-writing. This observation may be anomalous, but in any case it seems that there may be some advantage to developing a more robust “stenographer” system of shorthand which would allow quick charting without as much reliance on templates… or a templating system which employed something more akin to auto-complete (so a user could easily pull up many more-specific mini-templates/phrases) rather than one or two long full-visit templates.
Anyway, thanks for the interesting article.
“If her provider actually charted what was really did he would only get $25 for that visit–based on EMR coding. This hardly pays for the lights, medical assistant, receptionist,etc. ”
Trying not to be too naive, here, but that is fraud. Medicaid and Medicare prosecute for less.
I don’t think that the doctors here seem to realize the legal, moral, ethical, and, yes, practical problems that come with creating and passing on inaccurate records. Garbage in, garbage out.
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The problem is getting quality data into the EMR: no one has come up with a cost and time efficient solution.
Charting time is not part of an office visit, but rather a tedious but necessary task the doc must perform. If the MD uses time that you are paying for to do data entry in the exam room, you are being robbed and should vigorously protest!
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