Interfaces between electronic medical record (EMR/EHR) technology and people in American medicine: insight. imagination, and relationships in clinical practice.

This paper explores the contexts and relationships in which EMR/EHR technology is used in healthcare settings. It approaches the EMR/EHR as an issue in clinical ethics. The author recognizes the immense contribution that healthcare informatics makes to coordinating and integrating medical care at the level of individual physician, nurse, and institutions. At the same time the author raises a cautionary note about some unrecognized dimensions of the use and experience of the EMR/EHR. The author argues that the EMR/EHR can consciously and unconsciously become an instrument of assembly line-like physician "productivity" and "production reports" that depersonalize patient and physician alike. Construed this way, the EMR/EHR can narrow the clinician's imagination, relationships, clinical decision-making, and documentation into oversimplified, and potentially distorting, clinical narratives and categories such as fit into CPT, ICD-9, DRG, DSM-IV and other codes, EBM protocols, and clinical algorithms. By contrast, the author uses a vignette and one of his own clinical poems to illustrate the rich weave of relationship and meaning that are foreground rather than background in clinical assessment, decision-making, treatment, outcome, and satisfaction. The author concludes with a call to imaginatively use the EMR/EHR as an instrument of physician-patient communication, and to include in it and make available vital narrative data (evidence) about patient, family, culture, occupation, socioeconomic status, physician, disease, and their relationships.