This month’s column takes a point/counterpoint format between Dr. Ajamian and Robert Pinkert, O.D., medical director of Barnet Dulaney Perkins Eye Center, in Phoenix.
Dr. Ajamian: Many new technological advances are changing the way we practice. Electronic medical records are certainly on everyone’s radar right now. EMR has many advantages, and we’re all going to convert to them eventually. However, there could be some significant disadvantages, both short and long term. For example, when you do a case history with EMR, you’re basically filling in the boxes or clicking the answers, rather than writing out a detailed narrative. This “filling in the blanks” approach could dull our ability to take and record a meaningful clinical history.
Dr. Pinkert: Not necessarily. Either method—writing out the history or using EMR—has the potential for error, but the types of errors are different. When you’re writing records, you could commit an error of omission—you forget to write something down. When you’re using EMR, it prompts you to answer, so you’re not likely to commit an error of omission. On the other hand, you may be more likely to commit an error of commission—the program automatically fills in the field and you neglect to change it. Does it make you lazy? Maybe, but without question, the efficiency of EMR far outweighs the downside of potential errors.
Dr. Ajamian: Another problem with electronic medical records, in my opinion, is that they don’t allow you to draw a corneal ulcer, a retinal detachment or, most importantly, the optic disc. Sure, you can take a photo and do optic nerve or retinal imaging instead. But, I think there’s no substitute for a careful drawing. Stereo disc photos are ideal, but how many practitioners actually do them? A detailed optic nerve head drawing is extremely useful and always will be. It’s an important adjunct to a two-dimensional photo. Also, you apply your clinical observation skills as you make the drawing.
Dr. Pinkert: I agree that the inability to draw the optic nerve head is a potential problem with EMR. Some EMR systems do have limited ability to draw the optic nerve head, but it’s a cumbersome process.
Dr. Ajamian: So, are we now training a generation of doctors who won’t even care about drawing discs because they can just click a mouse on a cup-to-disc ratio, or take a photo with the camera? Isn’t that making us lazy clinicians?
Dr. Pinkert: It very well might, because you could say, “I don’t need to look at the retina. I’ll just get an OCT and look at it that way.” Doctors are starting to rely on the information gathered from these high-tech instruments as a substitute rather than as an adjunct for clinical data gathering.
Dr. Ajamian: I’m aware that a lot of retinal specialists, ophthalmologists and optometrists say, “Yeah, there might be something wrong with the macula. Let’s get an OCT.” But what did we do before this technology was available? We looked, and then we looked a little harder. We’re starting to rely on this technology to replace observational skills, but it doesn’t.
Dr. Pinkert: Right, but let’s not throw out the baby with the bathwater. Yes, the potential exists for us to rely on these instruments too much and become lazy in our physical exam. But the clinical benefits far outweigh the risks.
Dr. Ajamian: So, we agree on this point. For me, I take photos, but I also rely on my drawings of the disc in conjunction with the photos. I may do a GDx, but I force myself to look at the nerve fiber layer while doing the fundus exam. An OCT is great for documentation and follow-up, but I still take pride in finding a preretinal membrane or cystoid macular edema using a fundus lens. It’s not a choice of using only one or the other.
Dr. Pinkert: I totally agree. Do both, and stay vigilant.
