Mary Duke Biddle Scholar Reflection - Carson Burns
This spring, the Mary Duke Biddle Scholars Program enabled me to visit the Ecuadorian highlands to participate in clinical care as a fourth year medical student. Joining the teams in intensive care units, hospital wards, clinics and rural outposts exposed me to the wide range of challenges that these patients and physicians overcome everyday. One set of challenges in particular, however, opened my eyes to a new disparity in global health: health information technology.
Joining the teams in intensive care units, hospital wards, clinics and rural outposts exposed me to the wide range of challenges that these patients and physicians overcome everyday.
At Stanford, I had only trained with electronic medical records (EMR), and among EMR types, we used was predominately Epic. Growing up with the computers of the 1990s, my peers and I developed a workflow to adjust to the quirks of the EMR. Despite how much we tend to gripe about computers, we became competent users through trial-and-error fairly quickly. In contrast, my exposure to paper charts was merely stories from wistful older physicians. I can still hear their voices recalling the “better days” when they were “much more efficient” as they desperately searched for required fields and hunt-and-pecked their way through typing each note. Considering that so much of our time is spent on documentation, I frequently wondered if paper charting was really better in certain ways; or have we been merely glorifying the past?
Despite the difficulty to adapt to an EMR back home, the drawbacks of a paper system were obvious in Ecuador. Instead of the chart review function in Epic, certain pages or entire patient charts could be missing. Instead of “care everywhere,” crucial information like home medications or prior assessments could be absent or written illegibly. Instead of dot phrases, interns would transcribe lab results by hand into the progress notes. Even if progress notes were faster to write by hand, I found these limitations with paper charts to be eye opening. I could not help but wonder how the lives of Ecuadorian children could be improved if their medical teams had better health information technology.
My glimpse into the Ecuadorian system also led me to reexamine how I utilize the EMR. For example when handwriting notes, the doctors only included the information directly relevant to that day’s assessment and plan. Conversely with the EMR, the ease of adding extra information with templates and dot phrases leads us to bloat our daily progress notes: the complete medical and surgical history, medication lists, allergies, every lab result in the past 72 hours, and so forth. We are told in medical school, “if you do not document it, it did hot happen.” However, all this information is documented and readily accessible elsewhere in the EMR. We allow a single progress note expand up to five to ten pages. The sheer volume of the redundant data buries the important information for the reader, akin to illegible handwriting or a missing note. I imagine my Ecuadorian counterparts would be equally surprised at what our system has come to. Moving forward, I hope to strike a balance between complete while also concise notes.
My time in Ecuador reminded me how technology can shape the care we provide for our patients.
My time in Ecuador reminded me how technology can shape the care we provide for our patients. A well-implemented EMR, both in the US and abroad, has tremendous potential to improve clinical decision-making and research. In addition to paper charting, Ecuador also built an electronic system to register patients and has begun to track the progress of an iron supplementation program for underweight infants. While many challenges lay ahead, I am optimistic that we can continue to build and use health information technology to collaborate and improve the lives of children worldwide.
Carson Burns traveled to Ecuador as a Mary Duke Biddle Scholar during his fourth year of medical school at Stanford. He is currently a pediatric intern at Seattle Children’s Hospital.