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Has the Contemporary Electronic Medical Record (EMR) Made the Comprehensive Hand Examination Obsolete?

Jupiter, Jesse B. MD

Techniques in Hand & Upper Extremity Surgery: September 2017 - Volume 21 - Issue 3 - p 75–76
doi: 10.1097/BTH.0000000000000170
Editorial
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Techniques In Hand & Upper Extremity Surgery, Weston, MA

Conflicts of Interest and Source of Funding: The author reports no conflicts of interest and no source of funding.

Address correspondence and reprint requests to Jesse B. Jupiter, MD, Techniques In Hand & Upper Extremity Surgery, Weston, 02493 MA. E-mail: jjupiter1@partners.org.

A recent article in the Atlantic magazine (www.Theatlantic.com/health/archive/2016/03/end-of-stethoscope/47/888/) titled “The end of the stethoscope?” raised the question of whether or not new diagnostic technology has eliminated the need for this iconic medical tool. Are we witnessing a similar transformation as to how our trainees are using data entry “templates” created in most electronic medical records (EMRs) to supplant a carefully documented multisystem hand examination?

Contrast our traditional information data sheet for a new patient examination (Fig. 1) with a first-visit patient evaluation “template” found in our EMR (Fig. 2).

FIGURE 1

FIGURE 1

FIGURE 2

FIGURE 2

Our Hand and Upper Extremity Fellowship fortunately attracts outstanding orthopedic and plastic surgery–trained residents from training programs across the United States. Yet, I am continuously struck by the wide variation in the adequacy of patient examination, in part, by the amount of information that is filled into their “templates.” Perhaps by virtue of the limited space often provided for review and documentation of numerous data, such basic measurements as grip or pinch strength or specific joint motion measured with a hand-held goniometer may or may not be documented because of the format of their template.

A patient presenting for the first time with complaints of limited digital and wrist mobility following a prior distal radius fracture should have a documentation of active and passive joint mobility, assessment of intrinsic tightness, and the distance of the finger pulp or nail in flexion to the midpalmar crease. I hope that your trainees are routinely measuring and documenting these parameters—regrettably. I often do not see this as trainees come on my service, whether it be the first month or the last month of their fellowship. Do your standard templates provide prompts or space for these data?

A middle-aged auto mechanic evaluated for hand pain and vague numbness may or may not have a documented timed Allen test to rule out an ulnar artery thrombosis, unless, for some trainees, a prompt or space is provided in the template. In a perverse way, the EMR “template” has become a license not to examine.

Although we have a critical obligation to educate our trainees on becoming more skilled surgeons, the importance of maturing into a careful diagnostician without the reliance on technology should not be deemphasized. Yet, ever-increasing patient volume combined with time constraints creates some real impediments to observe and carefully monitor the adequacy of every “template” during the busy clinic. Perhaps a reflection of the decreased clinical experience in some training programs with diminishing emphasis on the importance of a clinical examination, I regrettably find myself at times observing major deficiencies in the data entered by some trainees into their LMR templates when seeing a patient for an office visit.

I feel very fortunate to have trained under Dr Richard Smith who instilled upon all of his residents and fellows the importance of observing and documenting the many aspects of a hand and upper-extremity examination. I hope in some small way to similarly impress this upon my own trainees. EMR cannot be the death of the hand examination!

Jesse B. Jupiter, MD

Techniques In Hand & Upper Extremity Surgery, Weston, MA

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