A Stranger in Your Exam Room

It is often difficult for patients to discuss personal issues with their doctors. Thanks to electronic records, it just got a whole lot harder.

Electronic Medical records have been a major disappointment. In survey after survey doctors tell stories of unmet promises and unexpected failures. While electronic prescribing, data collection and legibility of records are a positive, patients tell of doctors never looking up from the computer screen and of more time waiting and less time with the doctor. Doctors feel detached from patients, are stressed when they fall behind, and wonder when the promise of easily accessed data from other doctors will ever be realized. Some of these difficulties are understandable but there is one negative aspect of electronic records that is particularly troubling to patients, especially those dealing with intensely personal issues such as mental health and family conflicts. Many doctors are hiring “scribes”, people whose job it is to enter data into the computerized record on behalf of the doctor.

For some physician’s this is a matter of survival. Inefficient medical software and limited computer and typing skills have resulted in plummeting physician productivity. Declining reimbursements and rising costs make it impossible for doctors to cut back on volume to allow them to enter data themselves. They see no choice but to hire someone to do the work for them. When paying someone $25 an hour to enter data allows you to see an additional 6 patients a day, the math is easy. Spending $200 to make $600 is a return on investment that cannot be ignored.

While physicians are comfortable with an extra person in the exam room during the interview, patients are not always in agreement. Privacy laws and confidentiality policies do not change the fact that this extra person may learn things about a patient's marriage, sex life, depression or drug use that the patient wishes they hadn't. There is a real risk that as a result some patients may withhold information crucial to their care.

So what can be done? At the moment options are limited. Patients have a right to ask that a scribe not be present, but this may strain the relationship with the physician as it is essentially asking the doctor to fall behind in the office.

Some physicians have addressed the problem by charging extra fees to patients to cover the costs of longer visits. I have seen physicians charge from $900 to $3000 dollars a year per patient to be a part of a practice that schedules fewer visits per day, giving more face to face time with the doctor. Unfortunately these membership fees are not covered by insurance and out of the reach of many families. Doctors who participate in HMO plans are contractually banned from charging such fees.

As with many medical conditions, there is no readily available treatment or cure. For the moment, doctors and patients will need to learn to live with the pain and hope things get better over time. I am not sure they will.

-          Bart

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