The computer insertion into healthcare in the late 1990s and early 2000s changed forever the aspect of patient-focused care. It soon became the bane of staff, switching the total patient record to the EPIC computerized charting system. Many long hours of training went into the process of educating all of the hospital patient care staff in the use of the EPIC system, 20-30 hours per person was a big undertaking to bring us “online.”
The effect on patient care was easy to see from the get-go. The most glaring difference that I noticed was the patient is no longer the focus of the nurse when entering the room to provide care. Nurses must log in to the computer, checkboxes, bring up profiles, switch to different screens, and find specific sections for charting. The focus is on the screen, then the patient. It’s a back and forth and at best, dividing attention. At its worst, the computer in the room is overshadowing the person in the bed, the individual with individual needs, one of those being a sense of connection and a need to be seen and heard.
Nurses were instructed to chart at the “point of care.” This means using the computer and charting entries in the patient’s room while providing care. Realistically, with the patient assignments typically 5-7 patients throughout a shift, standing in the room with a dropdown laptop on the wall and recording each encounter is not feasible. There just isn’t the time to do the nursing duties at the bedside and then stand there, charting it all. The hospital unit doesn’t wait for charting, there are patients in pain, on their call lights, needing medication, never mind the active, fall-risk patient next door whose bed alarm is ringing.
This was one of the downsides of computerized charting, another is the distraction of the screen. The eyes are off the patient. The reason for the encounter in the room becomes clouded due to the dominating data processing equipment. No longer is the nurse interacting with their patients, looking into their eyes and observing the responses to their questions. The nurse stares at a computer screen, looking to the next query and parroting it, waiting to hear a response. Many minutes can go by, with eyes glued to the screen filling out forms and managing data. It’s easy to see patient-focused care slipping into screen domination.
Admitting a patient to the hospital was often the first time to connect, to have a hands-on assessment which begins with taking vital signs, listening to lungs, asking health history questions, and learning a vast array of information in a short period of time. The patient was the objective, they were important and the focus of the interaction. During this admission process the nurse conveyed a sense of care and concern for the patient’s overall well-being, the foundational bedrock of the healthcare experience.
This whole admitting of the patient changed with the computerized charting system. The screen is where the eyes are now, and the hands are on the keyboard, not comforting with a touch to the shoulder or a pat on the back. Healing hands are being wasted spending time typing data and filling in the endless blanks on the screen. Nurses have tried to compromise, charting at the computer out in the hallway and recording reams of patient activities and healthcare information while running in and out of patient rooms.
The electronic record is here to stay. Protocols are developed for ease and insurance that all is done according to the standards. They help with moving through the disease process, if the patient presents with “X” then we do “Y & Z.” It’s helpful to have these intentionally designed risk-managing treatment protocols, but not to the exclusion of individuals. The patient should not be put in a cookie-cutter design of health care. One size does not fit all. Practicing on autopilot is a danger for all aspects of patient care.
My experience with my mother at her previous doctor’s appointment made this very clear to me. He has been her primary care physician for over 5 years and is a trusted healthcare provider. He was on autopilot, following a standard protocol for care that wasn’t appropriate for my mentally ill mother. The severity of the disease has been devastating to her middle and later years of life. He didn’t see her. He saw the screen, addressing us from the protocol standpoint, missing the individual altogether.
I had to argue my point, my mother was not a candidate for dialysis as her kidneys continued to fail. A referral to a nephrologist for a discussion of dialysis was not needed. She had been weakening over the last several months. We had stopped her long course of electroshock therapy because it no longer controlled her anxiety and psychosis. I had requested an advanced directive form (POLST) at an earlier appointment, ensuring that the do not resuscitate order was filed in her chart and at her Adult Family home. Her physician wasn’t thinking about the patient, he was focused on the protocol.
He questioned my judgment, seemed shocked that I wouldn’t have her put on dialysis, and actually stated “You’re going to just watch her die?” Yes, doctor, I am. Just as I’ve watched her live, cared for her, and made sure that she had the best available care every step of the way. Following protocol is the standard but are all patients standard? It’s up to loved ones, and advocates for patients to ensure standardized care protocols are appropriate and necessary for the patient, the doctor could be functioning on autopilot.