Communication Breakdown: Technology in the Exam Room

My heart broke a bit when my normally attentive OB/GYN walked into the exam room with a tablet PC and barely looked up from the screen during my visit. Studies have shown that exam room computers have positive impacts on physician—patient interactions without significant negative effects on other areas, such as time available for patient concerns. Integration of computers into the delivery of care improves patient satisfaction. However, even skilled physicians commonly display troubling behaviors, such as spending too much time looking at the computer monitor, typing while patients are talking about intimate concerns, reading silently from the monitor, using templates to lead interviewing rather than listening to patient narratives, and turning their backs to patients in spite of mobile computer monitors.

Electronic medical records are a wonderful asset and can help prevent drug interactions and allergic reactions by automatically checking patient history. Many malpractice carriers offer physicians a discount for using one. Plus, physician users always have access to their patients’ records, a crucial factor when a patient is taken to an emergency room and cannot give a verbal history, or when a patient is traveling and enters a hospital or visits a different physician. There is also no need to worry about illegible notes and scrawled—and sometimes misread—prescriptions. Electronic medical records have the potential to bring a new level of care to patients while making physicians’ lives easier. So, how can you make the most of what technology has to off er and not compromise your patients?

Learn to type.

This is an obvious recommendation, but it is an important one. Until voice recognition improves dramatically, cost concerns will demand that physicians type their notes or enter them through templates. Your typing speed and accuracy will improve with time, and you’ll be grateful not to deal with your hand-scrawled notes.

Integrate typing around your patients’ needs.

Regardless of your note-taking style— whether you type during the visit, immediately afterward in the exam room, or later in your office—it is important to know when to push the computer screen away. Using an EMR may require a heightened recognition of sensitive psychosocial concerns. Patients need to have eye contact and feel connected to their physician.

Templates are for documentation. Templates are an excellent way to structure notes but can be disastrous when used to structure interviews with patients. Their closed-ended, question-and-answer format allows little room for patients’ narratives to evolve, a key task in patient-centered care. Don’t change your interviewing style to fit a template.

Patients first. Unless a physician reviews notes at the beginning of the day or in the hall before entering the exam room, there may be little chance to focus attention on the presenting patient until after entering the exam room. Try to listen to patient concerns before opening up the EMR to review the last visit’s notes.

Keep your patients informed about what you are doing - as you’re doing it.

If you sit silently looking for information on the computer—opening and closing windows or scrolling though text—you risk alienating your patients. Instead, try to keep talking as you go about the work of both searching for and entering data into the EMR. Let the patient know you are just making a notation or looking something up for them.

Show your stuff. Many patients like seeing their lab results and the charts and graphs that EMRs provide. However, even computer-savvy patients may find that their emotions override their ability to quickly grasp where to look. Use a finger, pen, or cursor to guide the patient’s gaze when discussing data viewed on the monitor. This is a great time for showing, for instance, a trend between rise in body weight and cholesterol to illustrate cause and effect. Patients will sometimes get the message more clearly when shown charts.

Consider asking first.

We’ve all seen the movies with the doctor scribbling in silence. Instead, try saying things like “Would you mind if I typed while we speak?” or “May I show you what I’m doing?” when using an EMR to promote, rather than hinder, the physician— patient relationship.

Look at your patients.

The reality is that even with the availability of mobile screens, many experienced clinicians still stare at the computer monitor. Remember that you are speaking to and caring for the patient, not the EMR. Th e EMR is an inanimate tool to aid patient care and it is the patients who deserve our primary attention. EMRs in the examination room are quickly becoming a reality. Paying attention to how we integrate our clinical styles with the use of this technology will ensure that they are used in ways that best fi t the social, emotional, and medical needs of our patients.

Still without an EMR?

If you don’t mind a Web-based solution, PracticeFusion is an excellent, and free, EMR. Th e online system allows users to log on from anywhere at any time without installing special hardware or software. Providers can also easily manage patients, their schedules, and all of the communication between staff with Practice Fusion’s Practice Management service. The EMR was designed by physicians and allows users to build charts “your own way” with templates that cover more than 30 specialties, typing, drag-and-drop features, and dictation. Users also have the ability to write prescriptions and refi lls. Support staff will conduct training sessions over the phone as needed, and training videos are available online. Although the software is intuitive enough that not much training is needed, watching the videos will show features that may be missed otherwise. As a free service, PracticeFusion’s site comes with advertising, but it is unobtrusive and medically oriented. Those who find the presence of advertisements too intrusive can opt for the fee-based service without ads.

An oncologist colleague of mine uses the Centricity EMR, a suite of healthcare IT software solutions from GE Healthcare that includes software for independent physician practices, academic medical centers, hospitals, and large integrated delivery networks. The various modules perform practice management, revenue management, medical imaging, and other functions. Because my colleague is a poor typist, he delays his note taking until after the patient leaves the offi ce. He does share fl ow sheets and graphs with his patients, as he states they love seeing the information presented this way.

iPhone users can take advantage of numerous native applications in a variety of categories, including games, business, news, sports, health, reference, medical texts, travel, and now EMRs. Thanks to CareTools, users can now carry their offi ce in a pocket with the $149 iChart program, the first complete handheld EMR system for the iPhone. iChart was designed to act as an electronic “personal medical assistant” and focuses on streamlining the daily “chart, bill and fi ll” routine of any healthcare provider. The convenience of having all your patient data in your pocket cannot be overstated. The program has an intuitive interface and is a pleasure to use.

Users can:

• Track patients within hospital, clinic, or homecare settings.
• Write prescriptions with a built-in drug reference and drug interaction checking.
• Track labs and studies with built-in lab menus.
• Look up and capture CPT4 and ICD9 codes.
• Write SOAP and procedure notes with builtin smart menus.
• Sync data to an online data center for further editing and printing.

Using custom notes or templates is essential to cut down on the amount of data that needs to be added with the keyboard—a tedious process, as anyone with an iPhone/iTouch will tell you. Writing prescriptions is also a pleasure on the HIPAA-compliant iChart, with the entire application and data stored on the iPhone encrypted and inaccessible by other applications on the device or attached to the device. All data transferred in and out of iChart via iChart Sync is encrypted using 128-bit SSL and proper authentication.

Another great EMR is Amazing Charts, which allows you to run your offi ce the way it runs today. It fits right into your office flow, with scheduling, messaging, reporting, and documentation of notes, phone calls, addenda, and more. The electronic chart is quite similar to the paper charts we are all used to. Clicking on the tabs at the top of the electronic chart brings users to the various sections (eg, demographics, summary sheet, prior visits, imported items, and account information) of a patient record. Amazing Charts is designed with consideration of a few critical points that are surprisingly overlooked by most EMRs on the market today. First, users can view all of a patient’s information on one page. When a patient’s chart is pulled, by default, it opens to the most recent encounter; that information is used as a starting point for the current visit. In this way, the patient chart is a progressive record. As items change, users change them in the note. Since most of us document the same review of systems, exams, etc, over and over again during the day, using prefabricated templates makes documenting this mundane information much easier. The included templates allow users to document common history and physical findings, or add/ edit templates with ease.

If you are completely confused on how to start looking for an EMR, visit www.emrconsultant.com, which claims to have assisted more than 7,500 medical practices pick the most appropriate EMR software packages.

Stay engaged Whatever EMR program or technology you decide to bring into the exam room, remember to stay engaged and focused on your patients. No one wants to look at the top of your head while you peck away at a keyboard. You can use the best of modern technology without shortchanging your patients.

Dr. Tice is a psychiatrist with more than 20 years of clinical experience. She has authored dozens of health and technology articles, and specializes in online medicine and patient education.