I sat in the exam room, looking across the table at Madelyn.  In front of me was an immaculately printed electronic health record (EHR). 

"This is quite a medical record", I said to Madelyn as I reviewed page after page of  printout, "it looks like the doctor was very thorough..."

Unknowingy, I figuratively had walked into a propeller blade...

Madelyn's face and tone flared angrily..."Thorough?" she said.  "He didn't even listen to me".  He was more interested in the record than my problems!

True enough, page after page of print-out was computer generated, and on a second-review of the records, I found I was actually reading boilerplate printouts and was struggling to  to find out what the doctor was really thinking.  

One caveat I must mention at first:  We use an EHR in our office, and there are many advantages to doing so.  We have a good EHR. And yet, the EHR poses a hidden danger for physicians in general, and allergists in particular.  These concerns are often swept "under the rug" in the ongoing enthusiasm over EHR's.  

1.  EHR's are ideally suited for the single-problem, fixed-onset, acute illness.  In that respect, emergency visits to the doctor can readily be translated into EHR "speak":  Broken leg.  This AM.  Pain on movement.  Etc.  However, when a patient comes into the office with chronic, multiple complaints, it's an entirely different story. History taking for the chronically ill, polysymptomatic patient is a messy business.  In this situation, patient's don't "speak template" to the EHR in an orderly and disciplined fashion. In a highly charged emotional atmosphere and seeking help desperately, I find they often can ramble, get times and dates mixed up, retract prior statements, add crucial pieces of information about one problem when talking about a completely different problem, etc.  A simple question like "when did your asthma begin?" might first elicit a response like "when our daughter Elmira was pregnant".  

When I'm taking a history on such a patient, I use a simple pad and paper.  It works for me.  I jot down "sound bites" as they occur from the patient, and organize the jumbled collection of info with arrows, circled statements, etc.  Templates, check boxes, bullet lists, drop-down menus are for later.  In short, patients present their data to us in analog fashion, and the EHR wants it in digital fashion.  There's a difference...

2.  The allergy history is about one thing...relationships.   Relationships between the patient and...diet, biological aeroallergens, chemicals, hormones, etc.  EHR's are patient/body centered.  An allergy history is relationship-centered.  There is a cataclysmic difference between the two.  The EHR may print out a diagnosis of "Bronchial Asthma", but the real diagnosis might be "bronchial asthma seriously exacerbated by indoor air quality impairment in a home from mold, complicated by a hidden milk allergy.  Try to find a drop-down box for that!  

3.  The EHR doesn't like "open ended questions".  It's hard to find a checkbox for them. There's a danger in "thinking like the EHR" and becoming more computer-like in your history taking, limiting questions to digital "yes or no" responses.  Some of my favorite questions for patients include things like "Have you taken a trip recently, and (if so) did you feel better and (if so) what was different about the trip?"  "Have you noticed feeling any different when you went on a weight-loss diet, and if so, tell me what was different? etc. etc. etc.  

4.  Listening is an active, difficult process for the physician.  It takes all of our concentration. Not 90%.  100%.  What is this patient actually telling me?  What does their body language tell me?  With the EHR, clicking boxes and using dropdown menus means there is a subtle temptation to be "documentors" first, and "listeners" second.  It must be the other way around.  We have to constantly guard against this temptation.

5.  One other temptation:  staring at the computer screen instead of the patient.  Eye-to-eye contact can be diminished.  Does the patient sense we are spending more time with the computer than themselves?   

As one physian stated in a recent op-ed piece in the New York Times, we are  creating "iPatients" with the EHR.   The danger is thinking that the iPatient is "the patient".  There is no drop-down box that fully explains a patient's issue of not taking immunotherapy because they were too busy caring for their terminally ill mother who has cancer, and their anxiety and depression related to their situation.   

So for Madelyn, she perceived that the other allergist had made her into an "iPatient" and not a true "patient".  The challenge for allergists is to use the EHR as a tool, and not an end-in-itself. Filling out a good EHR but not listening to the patient's concerns is like a student answering the questions on their paper but not understanding the assignment.  The result?  A EHR with massive boilerplate printout full of Sound and Fury, but signifying nothing.  Me?  I'll keep using the EHR...but with a good paper and pen in-hand also.  The EHR doesn't think.  I do. Sometimes we forget that.

Later, Dude