The electronic health record (EHR) has become the third wheel in the exam room, often getting in the way of physicians making meaningful connections with their patients.
“Both as a physician and on the receiving end as a patient, I have found that EHRs absolutely can cause certain barriers,” says Johnny Dias, DO, an internist with the Medical Group of the Carolinas in Spartanburg, South Carolina. “By starting to type in the computer, you can feel the disengagement from the patient.”
Payer documentation mandates have forced doctors to rely too much on the computer during exams, says Jack Ende, MD, MACP, an internist in Philadelphia, Pennsylvania and former president of the American College of Physicians. “We are in an age now where we are being required to over-document so we can demonstrate we’ve done things so we can get paid for them, and that’s all part of the problem,” Ende says.
But while finding the right balance between thorough documentation and a successful patient encounter may be difficult, it’s not impossible, physicians say. It requires understanding the doctor’s own style of conducting visits and the quirks of their software and exam rooms, not to mention a good dose of pre-planning and staff support.
The physician leads
While everyone these days can become absorbed in their electronic devices, in a patient exam it’s up to physicians to control the dynamic. A 2015 study in the International Journal of Medical Informatics that tracked the eye movements of doctors and patients during exams found that patient gaze and eye contact followed cues from the physician.
In other words, physicians must establish eye contact and create an inviting, engaging atmosphere for the patient.
Each physician needs to learn their best way of managing the EHR during patient visits. Ende, for example, says he never types on a computer during patient examinations and instead jots a few notes while focusing on the patient. “I will take a history for a new patient the old-fashioned way: with a pad of paper on my lap, making good eye contact and being able to appreciate the patient’s body language,” he says.
He enters lab orders, billing information and other such data into the computer, but typically dictates the narrative portion of the patient note to a staff member. Ende, who is also professor and assistant dean at the Perelman School of Medicine at the University of Pennsylvania, admits that’s a rare method for today’s physicians but says it’s the way he feels he can best connect with the patient.
Melissa Lucarelli, MD, a solo family physician in Randolph, Wisconsin, says that before she walks into the exam room she studies the patient’s data and history to make sure she has the basic knowledge she needs to avoid relying on the computer. Also, she will copy-and-paste patient history information in her EHR to get a head start on the note before the upcoming encounter.
“Ideally, your EHR would become invisible, but what I’ve set for myself as the sort-of gold standard for the computer in the room, is to make it as unobtrusive as a paper chart,” says Lucarelli, a member of the Medical Economics editorial advisory board.
Lucarelli uses laptops on carts in her practice, which lets her position herself to look the patient in the eye regardless of the layout of the exam room.
Dias works in a similar way, doing as much prep work as possible before walking into the room so that he can focus on connecting with the patient. He studies the patient’s history, including what preventive care screenings the patient needs and what lab orders or tests are likely, based on the patient’s conditions.
“You are essentially walking into the appointment with some good background knowledge and really already knowing what you want to do,” he says.
Building bridges with technology
The EHR need not be a barrier: It’s also a tool to potentially increase patient engagement.
The 2015 study found that when physicians look at the computer, the patient’s gaze usually follows. The study’s authors describe this moment as a chance to use the EHR as a “shared artifact,” meaning a way to gain the patient’s attention. What happens next in such instances can either be a missed opportunity or a way to gain the patient’s trust.
“When physicians share information visually from the EHR monitor, patient satisfaction and patients’ involvement in the decision-making process improves,” the authors write.
Lucarelli says she uses data and charts in almost every visit to show trend lines for weight, hemoglobin A1C and other types of discrete and trackable data. In other words, it uses technology to bring the patient into the encounter.
“I’ll show it on the computer and say: ‘Good job, your weight is down.’ I used to be flipping back and forth, looking at their weight at the last appointment. Now we can look at the trend for the last year. That’s the sort of thing the EHR does well,” she says.
Ende typically uses charts and graphs on his EHR near the end of the patient appointment, and says it’s an excellent teaching tool that shows the potential of technology for patient-centered care.
Those instances when you can bring the patient into the medical record are very helpful,” he says. “The availability of the data right there has been a real plus.”