Most of us went into medicine because we thrive on the personal connection with our patients. A compassionate hand on a shoulder during tough times and a direct look in the eye when giving pointed advice for lifestyle change are part of the art of medicine. But how can we do this when our faces are buried in a computer screen in the exam room?
The electronic health record (EHR) brings incredible benefits for patient care: on-demand access to clinical test results; e-prescribing; analytics capabilities; and, of course, legible clinical notes from colleagues. But it also may jeopardize our patient interactions. In a 2014 Medscape survey, 70% of responding physicians said that the EHR “decreases my face to face time with patients,” and 40% of physicians not using an EHR cited “interfering with the doctor-patient relationship” as a reason.
For many physicians, the interaction with the EHR itself is the biggest frustration. A long stream of billing, legal, and compliance requirements—coupled with imperfect user interfaces—often make us as much tools for data entry as for delivering empathy and compassion.
A 2003 study by Horsky and colleagues showed that users of a CPOE system (computerized provider order entry, one component of an EHR) used twice as much cognitive effort on system operation as on patient-centered clinical reasoning. Imagine if the mere physical act of operating a car (applying the gas or brakes or steering the wheel) required twice as much cognitive effort as figuring out where you were going! This problem may explain the rise of medical scribes, who input data into the EHR while the physician interacts with the patient.
I believe that the benefits of EHRs exceed their drawbacks and that we will continue to improve their usability. In fact, I have devoted the nonclinical part of my career to clinical informatics and to participating in the design, development, and implementation process because I believe that this journey is so important. It is crucial that we as physicians be engaged with vendors and with our healthcare systems to help shape the tools we use every day. We will have achieved success when using an EHR is like driving a car: You only think about where you are going, not about how the car works.
In the meantime, there are ways to optimize your EHR use today to enhance a collaborative treatment relationship with your patients. Here are eight “best practices” that can be adopted with whatever EHR you use today to help achieve this goal:
1. Ensure proper set-up of the exam room.
Make sure the chairs, monitor, and keyboard allow for good eye contact between you and the patient. Pay close attention to where you mount the keyboard tray and monitor. Try to position the keyboard so that you can type while directly facing the patient, so that you do not have to swivel your body or neck. Most exam rooms I have seen over the years orient the keyboard or keyboard tray straight toward the monitor on the desk, which supports good ergonomics if your main interaction point is the computer, but not if you are interacting mainly with the patient sitting off to the side of the computer.
2. Use a widescreen monitor.
This allows you to share information with the patient more effectively without having to crowd too closely around the monitor. It also helps you see more information with less scrolling and clicking.
3. Let the patient see your screen.
Invite them to share the experience with you, and share the fact that you are populating their medical record. On many occasions, my patients have found an error in their chart, either a wrong medical history item or a wrong allergy, as we go through the list together. On other occasions, we have even had bonding experiences while we hunt together through the electronic database for the right glucose test strip order among a list of hundreds of options.
Here are two photos of actual exam rooms (not from any of my current or previous employers) that have ignored the previous concepts. Note that there is no way for a physician to use these computers while simultaneously interacting with the patient. The patient also has minimal opportunity to view the screen.
To be efficient, I am often typing while the patient is telling me her story. Having to do so is disruptive enough without the clackety-clack of a loud keyboard. The flow of conversation is vastly improved with a quiet keyboard.
5. Make sure that the EHR is “teed up” to the right page before you sit down with the patient in the exam room.
Those first few moments with your patient are crucial toward establishing that you are an engaged listener. If you instead spend that time scrambling to log on or hunt for what you need, you will have lost your opportunity for a positive patient interaction. You may also fail to capture important data about what the patient is saying. In fact, if possible, it would be even better to take a few minutes before entering the room to start a note and prepopulate it with some of the latest information.
6. Work with your healthcare organization to determine what makes a good note.
There is a balance to be had between what we capture as “discrete data” or as “free text.” Discrete data are important for data analytics and allow a click-box interface. But they can be responsible for creating notes that feel less human. Free-text notes mean that no decision support or analytics can be run on what is in your note. A good note strikes some balance, capturing crucial data into discrete fields, while allowing for some narrative assessment of the patient. Keeping some narrative in the medical record makes it easier to read others’ notes, improving physician-to-physician communication. In general, notes in the EHR era can be shorter in length because much of the data are easily retrievable elsewhere.
7. Invest in an “optimization” half-day.
After you have used your system for a few months, dedicate 4 hours one day to customize your screen views, tweak your note templates, and learn other efficiency tips so that you can be more efficient in the exam room.
8. During the patient visit, stop typing and look your patient in the eye.
Wait, isn’t this a list of instructions on how to better interact with patients while using the EHR? I think that even if we can reduce physical and mental attention on the computer, there is still no substitute for 100% focus on the patient. For at least part of the visit, stop typing, take your hands away from the mouse and keyboard, push the monitor away from you, and use the physical interactions and skills we all learned as medical students. Every visit needs at least one natural moment when the patient has to be certain that 100% of your attention is focused on her.
I would love to hear about any other tips that other people are using to maintain strong and collaborative relationships with their patients while using an EHR. Share your tips in the comments section!