You would have thought that my hospital was preparing for the imminent coming of the messiah. Digital countdown clocks posted around the hospital ticked down the weeks, days, minutes, and seconds till the vaunted day. For months, every medical, logistical, academic, and intrapersonal transaction was beholden to April 1.

That the hospital had chosen April Fools’ Day to transition hundreds of thousands of patients and their clinicians to a new electronic medical record (EMR) was either a cosmic oversight or some techie’s idea of wit. But on April 1, our old system with its 20 years of painstakingly accrued data was put out to pasture and we entered the new world of Epic, which is now the predominant electronic medical record in the U.S.

A hospital is more than a building. Some liken it to a beehive, but it’s more like a Borgesian labyrinth with an unimaginable number of functionalities. A hospital is designed to attend to everything from kidney stones and paralysis to psychosis and sore throats. It has to juggle blood transfusions, premature labor, insurance forms, ingrown toenails, cardiac arrests, and diabetic meals.

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So it’s no surprise that the electronic medical systems that accommodate a hospital’s dizzying variety of tasks are monstrously complex beasts. In order to go live on April Fools’ Day, the thousands of employees who occupy hundreds of different cogs in our hospital’s machinery all had to be trained to learn the gargantuan system.

The transition was, shall we say, epic. Patients were frustrated by the inevitable slowdown of an already overburdened medical system. Clerks, medical assistants, nurses, doctors, phlebotomists, social workers, billing specialists, and others labored over their computers, struggling to fit the human patients standing before them into an unyielding electronic pegboard.

Cheerful, red-shirted, 20-somethings flooded the hallways to field questions, exasperations, and occasional full-fledged breakdowns. (Among the many metrics used to judge a hospital’s function, one surely ought to be the number of times each quarter that a fully licensed, board-certified physician breaks down in tears in the exam room.)

Six months in, now that I’m used to Epic’s kinks and quirks, a new reality has set it. It’s not so much whether one EMR is better than another — they all have their breathtaking assets and their snarling annoyances. What is really becoming clear to me is the uncomfortable realization that there are actually three of us in the room now: the patient, me, and Epic.

What started out as a tool — a database to store information more efficiently than the paper chart — has inserted itself as a member of the medical team. What used to be a tango between the doctor and patient is now a troika.

But unlike the doctor or the nurse or the physical therapist, the electronic medical record system undergoes no medical training. Unlike the blood pressure cuff or the pacemaker or the MRI, it does not have to meet any federal safety standards. Unlike the cholesterol medication or the antibiotic, the EMR doesn’t have to undergo any clinical trials to ensure that its harms don’t exceed its benefits.

There is a voluntary federal certification process that most electronic medical record vendors participate in, though this process focuses mostly on the functionality of individual pieces of the software. It isn’t set up to investigate the impact of these systems — which are made by for-profit, privately held entities — on patients’ health.

Yet here it is, a full-fledged member of the team. The EMR influences how doctors approach their patients and how they make medical decisions. It dictates clinical priorities and workflows.

But does the EMR actually improve medical care?

One study of hospitals found that EMR use had no effect on medical complications, hospital readmission rates, or overall mortality over the course of three years. Another study that focused on small- and medium-sized medical practices noted that EMR use was “associated with the ability to generate reports — but the reports did not necessarily support quality improvement initiatives.”

Electronic medical records were initially developed for billing purposes, not patient care, so it’s not surprising they’ve been shown to improve hospital efficiency. There’s also a suggestion that they improve financial margins, though this may be because enhanced data gathering makes it easier to qualify for incentive payment programs.

There’s no doubt that electronic medical records are a godsend for storing data. (Younger doctors have no idea how much pavement pounding was invested in tracking down lost X-rays, missing charts, and elusive hematology consults.) Retrieving that data, however, is another story. Trying to find the exact needle you need in the EMR haystack is far more time-consuming than it should be. While the paper chart inspired succinctness, the EMR’s endless “requirements” result in an exploding amount of useless e-fluff, rendering the haystack even more opaque and unwieldy.

The electronic medical record shows the most promise for population health. It can help health systems figure out, for example, how many patients smoke but have never been screened for lung cancer, or how many nutritionists to hire given the number of patients with diabetes. It can offer data on how long it takes to get an appointment with a pediatrician and contrast that with how many kids end up at urgent care. This type of bird’s-eye view, which was laborious (and usually inaccurate) in the paper-chart days, is now essential for allocating resources and planning ahead.

For the health of individual patients, however, the results are less clear. Studies focused on diabetes, sepsis, and advance directives have shown mixed results — certainly not the exponential improvements that EMR evangelists promised.

What is not in doubt, however, is the erosion of doctor-patient communication. A typical medical visit these days consists of the doctor wrestling with the computer while the patient gazes at the supply cabinet. I try valiantly to maintain eye contact with my patients, but it’s virtually impossible with the demands of the EMR. Unsurprisingly, patients participate less in the interaction when their doctors are ensconced in the EMR, and they acutely feel the diminishment of eye contact.

Sometimes I invite my patient to pull her chair next to mine so we can attempt to be on the literal same page. But, of course, we’ve now lost any hope of eye contact.

Patients, though, seem remarkably forgiving of their doctors and nurses, and most see the positive potential of the system. Many tell me how much they love the new patient portals, which make it far easier to contact their doctors, request medication refills, and view test results. Quite a few, though, comment on the unpleasant and impersonal nature of the system.

Most substantially, patients have noticed how the electronic medical record decimates staff morale, and recognize that this is not without consequence for their health.

On the clinician end of the things, the EMR has had a massive impact, as medical care has devolved into data-entry drudgery. While the EMR can streamline workflow and make life easier for some specialists, for generalists it has skyrocketed the workload. Primary care doctors now spend an average of six hours a day doing data entry (twice as much as they spend on direct patient care). And many routinely clock in additional hours of charting at home. This is a prominent contributor to burnout, which in turn is a prominent contributor to medical error.

Doctors are particularly pummeled by the tyranny of the in-basket. That quaint-sounding term incongruously suggests aged brie and checkered napkins rather than iron manacles and the ceaseless labors of Sisyphus that it represents to practicing physicians. No matter how assiduously you work, you can never, ever be done; the tasks pile on relentlessly. Heavier loads in the in-basket correlate with physician burnout, the brunt borne largely by those in the primary care trenches.

The electronic medical record is here to stay, and I don’t know anyone who wants to turn back the clock. On balance, it is vastly superior to the old paper chart. It is a technological wonder — there’s no doubt about that — and there is great potential for working with populations of patients.

For the day-to-day realities of individual patients and medical professionals, however, the prognosis is still guarded. It may be that artificial intelligence will improve things in the future, but for the moment we have to recognize that the EMR has decisively realigned how doctors and patients connect.

The twosome is now a threesome. As with any ménage-à-trois, there are always consequences.

Danielle Ofri, M.D., is a physician at Bellevue Hospital, a clinical professor of medicine at the New York University School of Medicine, editor-in-chief of the Bellevue Literary Review, and author of the forthcoming book “When We Do Harm: A Doctor Confronts Medical Error” (Beacon Press, 2020).

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  • You accurately describes the tyrrany of the inbox and of the EMR in general. I know it will never go away, but I disagree with you about wanting to go back to the paper chart. I think there are many of us who are dismayed with the “troika” and how it has destroyed the doctor patient relationship. Any system that causes PCPs to spend 6 hrs in data entry is just wrong. I agree that care has not improved, and I believe it has worsened due to the loss of that one to one relationship with the patient. Hospital notes now are incomprehensible, with screen after screen of cut and paste tests. Office notes are an exercise in fraud – who does all those complete exams in one day?! Worse yet, now a portion of my pay is dependent on ‘in box metrics”, a euphemism for how fast I empty the box. No, it will never go away, but the EMR sure hasn’t helped the individual physician do a better job.

  • Well written and true.
    We have to remember that EMRs have to serve our patients and the medical staff not the other way round.
    EMRs have to be developed in this direction as fast as possible.

  • Beautifully written and impeccably balanced article. There is no going back but control has to be wrested from the machine and the system and returned to the clinician. The ability of an EMR to hide information is daunting and the tyranny of a “task” driven system likewise. ” Perfection is achieved, not when nothing more can be added but when nothing more can be taken away ” Antoine de St. Exupery.

  • Wonderful piece. Amazing prose. Was never taught of ‘Borgesian Labyrinth’. But that’s what it is. I’m so glad Dr. Ofri is optimistic. I find the “copy, no need to paste, yet bill” culture to have dumbed down the whole enterprise with repetitive notes of many pages lacking substance. But I’ll never allow a computer in my exam room or patient space. It is okay, right around the corner, within the labyrinth.

  • Sometime, in the not too distant future, I think that EMR data entry in the one on one setting especially, i.e.: the physician’s office, will be voice activated. Siri. Alexa, et al. The no eye contact problem will be solved.

  • As we learned from Boeing, implementing electronic controls can have catastrophic results. Yet nobody is suggesting that a modern airliner can be flown without the help of electronic controls.

    I for one would not want to go back to paper medical records with notoriously cryptic physician-handwriting on reams of paper. There will be an arduous, perhaps painful, road ahead for EMRs; but there is no road back.