The introduction of electronic health records is transforming the healthcare industry and patient care. With the advent of EHRs, a physician has a patient's medical history along with access to evidence-based guidelines at his or her fingertips. However, getting this information at a physician's fingertips involves a fundamental change to the traditional patient exam room interaction. Now, physicians or other clinicians must search for and enter information into computers or other devices while treating a patient. This computer-physician-patient interface is taking place every day in exam rooms, and its impact on patient care and patient satisfaction isn't yet fully understood.
The presence of computers in exam rooms can be a mixed blessing. Certainly, having information immediately available to physicians that can inform decision making or be shared with a patient is a positive change. The challenge is: How does a physician's interaction with a computer interfere with the interaction between the physician and the patient? If the physician is too focused on entering information into a computer and not connecting with the patient, that's a problem that needs to be addressed.
Certainly, computer-physician-patient interaction is an area that needs a lot of research and development. Medicals schools are just beginning to explore how care is impacted by EHRs and sharing best practices with their students; much more research should be expected in years to come. For now, though, clinicians should take a "back-to-basics" approach when interacting with patients — and computers — simultaneously.
I believe that a half-moon (semicircular) table with the flat side against a wall and the patient and physician sitting along the curve with the computer monitor on an adjustable arm in the center helps encourage physician-patient interaction. The physician can maintain eye contact with the patient by looking past the monitor and can pivot the screen toward the patient to share test results or educational materials.
Computers should also be placed so that physicians can use them while seated. Several studies have shown that patients rate satisfaction with their physician higher when the physician sits during the encounter rather than stands. In a hospital setting, computers are often placed on movable carts; given that patients prefer physicians who sit, these carts should also adjust up and down. Ensuring a computer is placed on an adjustable cart may seem like a minor modification, but its impact may significantly affect patient experience for the better. If space permits in an office setting, the cart can move along with the physician as he or she sits and takes the patient history and then stands to perform the physical exam. As the physician explains the course of treatment, the cart can again be moved and adjusted to meet the needs of the patient-physician interaction.
If a physician shares the screen with a patient, the physician must be careful to ensure that the patient can see it clearly and knows where to look. It seems basic, but a patient may not feel comfortable telling a physician the screen is too high or not in focus. With electronic health records, the screen can be incredibly busy. If a physician is showing the patient something in his or her record, the physician should clearly point to the information on the screen.
Best practices in computer-physician-patient interaction are just beginning to be explored, and computer placement and room layout is just a piece of the puzzle. Best practices for individual roles and responsibilities when entering information into an EHR are also being explored, though this area too is just in the early stages of research.
As a result, various models of staff and technology are starting to emerge around EHR data entry. In some practices, data entry is divided among a medical assistant or nurse and the physician. Standard, commonly repetitive information, such as basic medical history items, may be entered using native EHR tools such as templates. For more complex and more unique information, such as complicated histories of present illness and psycho-social histories, voice recognition combined with the use of native EHR tools can improve efficiency and accuracy. Additionally, voice recognition "commands" can be used to speed up routine ordering within the EHR.
In other models of data capture, nurses or even non-clinician scribes may be used in various combinations. For example, the physician and assistant each with their own device may both be in the exam room with the patient. The assistant enters new information into the EHR, while the physician uses the computer primarily to view information while remaining focused on the patient-physician interaction. When the physician leaves the exam room, the assistant can remain to review and answer questions about the care plan.
Whatever model you decide upon, it's likely to be a team effort. But, don't make the mistake of just "letting it happen." It's important to delineate what data the physician will be responsible for, versus the nurse, versus the medical assistant. In the future, I expect that the patient will routinely enter a great deal of this information securely before he or she enters the exam room. In fact, this is something we're already exploring at Mercy. The growing popularity of tablet computers and touch screen technology will likely accelerate the evolution of data capture and review.
While we don't yet know for certain the absolute best practices for interacting with patients and computers at the same time, we are beginning to understand the impact this interaction has on patient experience and are accordingly working to better understand how to improve this interaction. As I look to the future, the challenge will not be about ensuring physicians have computer skills — something we struggled with in the past. Instead, the physicians of tomorrow — medical school students and residents today — are already absolute wizards with technology. The challenge will be how to best use the equipment we have to foster excellent interactions and relationships with patients.
Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio. Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.
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A mixed blessing
The presence of computers in exam rooms can be a mixed blessing. Certainly, having information immediately available to physicians that can inform decision making or be shared with a patient is a positive change. The challenge is: How does a physician's interaction with a computer interfere with the interaction between the physician and the patient? If the physician is too focused on entering information into a computer and not connecting with the patient, that's a problem that needs to be addressed. Certainly, computer-physician-patient interaction is an area that needs a lot of research and development. Medicals schools are just beginning to explore how care is impacted by EHRs and sharing best practices with their students; much more research should be expected in years to come. For now, though, clinicians should take a "back-to-basics" approach when interacting with patients — and computers — simultaneously.
Back-to-basics best practices
Clinicians must continue to make eye contact with patients, especially while the patient is speaking, to show they are listening to what the patient has to say. Because clinicians may need to enter information while the patient is speaking or shortly after, it is helpful to have the exam room arranged in a way that allows the clinician to enter information without sitting with his or her back to the patient. This can be a challenge because often exam rooms are retrofitted for computer equipment, not designed with it in mind.I believe that a half-moon (semicircular) table with the flat side against a wall and the patient and physician sitting along the curve with the computer monitor on an adjustable arm in the center helps encourage physician-patient interaction. The physician can maintain eye contact with the patient by looking past the monitor and can pivot the screen toward the patient to share test results or educational materials.
Computers should also be placed so that physicians can use them while seated. Several studies have shown that patients rate satisfaction with their physician higher when the physician sits during the encounter rather than stands. In a hospital setting, computers are often placed on movable carts; given that patients prefer physicians who sit, these carts should also adjust up and down. Ensuring a computer is placed on an adjustable cart may seem like a minor modification, but its impact may significantly affect patient experience for the better. If space permits in an office setting, the cart can move along with the physician as he or she sits and takes the patient history and then stands to perform the physical exam. As the physician explains the course of treatment, the cart can again be moved and adjusted to meet the needs of the patient-physician interaction.
If a physician shares the screen with a patient, the physician must be careful to ensure that the patient can see it clearly and knows where to look. It seems basic, but a patient may not feel comfortable telling a physician the screen is too high or not in focus. With electronic health records, the screen can be incredibly busy. If a physician is showing the patient something in his or her record, the physician should clearly point to the information on the screen.
Best practices in computer-physician-patient interaction are just beginning to be explored, and computer placement and room layout is just a piece of the puzzle. Best practices for individual roles and responsibilities when entering information into an EHR are also being explored, though this area too is just in the early stages of research.
Data entry as a physician responsibility?
A physician's responsibility to enter patient information, diagnosis and treatment information into an electronic health record is increasingly being questioned. Many physicians are starting to say they feel like data entry clerks, and they don't want that role. For older physicians who may have never used a computer prior to EHRs being introduced into their practice, their entering information may not be very efficient.As a result, various models of staff and technology are starting to emerge around EHR data entry. In some practices, data entry is divided among a medical assistant or nurse and the physician. Standard, commonly repetitive information, such as basic medical history items, may be entered using native EHR tools such as templates. For more complex and more unique information, such as complicated histories of present illness and psycho-social histories, voice recognition combined with the use of native EHR tools can improve efficiency and accuracy. Additionally, voice recognition "commands" can be used to speed up routine ordering within the EHR.
In other models of data capture, nurses or even non-clinician scribes may be used in various combinations. For example, the physician and assistant each with their own device may both be in the exam room with the patient. The assistant enters new information into the EHR, while the physician uses the computer primarily to view information while remaining focused on the patient-physician interaction. When the physician leaves the exam room, the assistant can remain to review and answer questions about the care plan.
Whatever model you decide upon, it's likely to be a team effort. But, don't make the mistake of just "letting it happen." It's important to delineate what data the physician will be responsible for, versus the nurse, versus the medical assistant. In the future, I expect that the patient will routinely enter a great deal of this information securely before he or she enters the exam room. In fact, this is something we're already exploring at Mercy. The growing popularity of tablet computers and touch screen technology will likely accelerate the evolution of data capture and review.
While we don't yet know for certain the absolute best practices for interacting with patients and computers at the same time, we are beginning to understand the impact this interaction has on patient experience and are accordingly working to better understand how to improve this interaction. As I look to the future, the challenge will not be about ensuring physicians have computer skills — something we struggled with in the past. Instead, the physicians of tomorrow — medical school students and residents today — are already absolute wizards with technology. The challenge will be how to best use the equipment we have to foster excellent interactions and relationships with patients.
Kenneth Bertka, MD, is a family physician and vice president of physician clinical integration at Mercy, a seven hospital and physician group system based in Toledo, Ohio. Mercy is a member of Catholic Health Partners, the largest healthcare system in Ohio.
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