The most glaring problem with implementation of EHRs (electronic health records) in the exam room is that it lessens eye contact with the patient thereby decreasing the doctor-patient relationship. There are patients that complain of seeing more of the top or back of the doctor’s head, than the doctor’s face as the patient describes symptoms and pours out one’s heart.
Dr. Neinstein has simple advice to this problem which he explains as follows:
1) Set-up your office properly, with placement of the chairs, monitor, and keyboard to best support good eye contact between you and the patient. Don’t allow your office to become like this drawing, where your chair could put your back to the patient. This is common sense, not Feng Shui. (I will post some photos of exam rooms at the bottom of this blog piece to allow you to start to think about what works and what does not work)
2) Get a quiet keyboard. If you think this sounds trivial, try this: Spend one day in your clinic using a loud keyboard and then switch to a quiet one. You’ll see.
3) If you can, spend thirty seconds preparing the electronic visit before you walk in to see the patient so that you are ready to hit the ground running. You want to be immediately ready to let a patient start talking to you without interruption to start the visit. Visits get off to a bad start when they go like this: “So, what brought you in here?” ”Well, my thyroid…” “Hold on a minute, I have to log-on and get a new progress note open so I can write down what you say.”
4) Let the patient see your screen. Hopefully you are not reading ESPN.com when you are talking to your patient. Let them share the experience with you, and share the fact that you are populating their medical record. I have on many occasions had this lead to bonding moments with my patients when we are both hunting through the CPOE (computerized provider order entry) system for a particular type of glucose test strip prescription or some other seemingly hidden or obscure task.
5) For part of your visit with the patient, stop typing, take your hands away from the mouse and keyboard, and use the body language we learned how to use as first year medical students in Introduction to Clinical Medicine. Every visit has at least one natural moment when the patient has to be certain that one-hundred percent of your attention is focused on her.
6) Practice. Seeing patients while using an EHR is a learned skill. None of us were able to handwrite a perfect note while talking to a patient the first day of medical school. The new generation of medical students will learn how to talk to patients while typing from day one. At UCSF, the new Kanbar Teaching and Learning Center has simulated exam rooms to help medical students learn this (although, embarrassingly, you’ll notice in the photos on their website that the computer monitors are buried in the corner of each exam room, assuring the “back-to-patient” syndrome).
7) Remember that this is our chance to take back the medical record. Let us not forget that, even with paper charts, the medical chart has increasingly become about legal protection, billing, and reimbursement. The EHR gives us a clean slate, a new opportunity that brings us legible notes and notes that are immediately visible to colleagues. Take advantage of this. Write good narratives. Tell your patients’ stories. Make the medical record useful again.
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The computer monitor can be used as a teaching aid to help patients understand their conditions and cause of their symptoms. Understanding this and treatment options allows not only for a more open line of communication between the healthcare provider and patient,but also ensures a much greater patient compliance in following the advised treatments.
Let’s take a team approach between patient and doctor. Do you have one?
