Do Computers Get in the Way?

In a New York Times commentary last week, Dr. Danielle Ofri, an internist, laments about computers getting in the way of interacting with her patient during visits. She writes:

“Both physically and psychologically it has placed a wedge in the doctor-patient relationship.”

Dr. Ofri then describes the process she followed when using a paper chart — jotting notes down occasionally while looking at the patient as she completed the handwritten note. She contrasts that with her current practice of looking at the screen for lab tests, images, prior notes… and how these activities take her away from engaging with patients.

These are real issues that need to be addressed, but let’s not forget all the interruptions that occur in the paper world. While handwriting a note may not seem to be a barrier to interacting with a patient, I can think of several things that do:

1. Flipping through the chart to find past test results.
2. Calling medical records for hospital discharge summaries.
3. Stepping outside the examination room to find a prescription pad.
4. Searching the bins in a wall-mounted document holder for the correct laboratory ordering form.
5. Trying to decipher the handwriting of consultants/colleagues/staff.

These are all distractions that, at least in theory, should be reduced by the introduction of EHRs.

It might be tempting to speculate how an EHR-enabled office visit might be improved with computer tablets, a different screen/computer/desk arrangement, different EHRs, voice dictation… and so on. While experimentation with different arrangements certainly has some merit, perhaps we’re stuck in a model of office practice and traditional patient engagement that needs to be re-evaluated. Modest changes to how we interact with patients and computers can lead to more active involvement of patients in the process of chart documentation. Rather than become a barrier, EHRs can help engage and inform patients (and families) while leading to better clinical care.

Consider the following:

1. Greet your patient, shake hands, and sit down with/at your computer.
2. Sign in while making small talk and indicate that you’re bringing up the patient’s chart.
3. Verify with the patient that you have the located the right chart by checking a date of birth, address, or some other identifier such as phone number (which is a good way to make sure your staff are capturing the correct information).
4. Take 30–60 seconds to scan the problem list, medications, allergies, any alerts about health maintenance issues, last visit, etc. and verify key elements with the patient and review the highlights with the patient.
5. Start a new note.
6. Look away from the computer and start your history by asking about the reason for the visit.
7. Don’t interrupt the patient or for at least 60 seconds, if not longer.
8. For complex stories with dates/unusual symptoms, keep a small pad and pen nearby to jot down key points in any abbreviated fashion you see fit to use (as the paper will be tossed in a HIPAA-compliant way at the end of the visit).
8. Ask clarifying questions about the concerns voiced and expand the history-taking.
9. When you’ve heard enough to get a general understanding, indicate that you’d like to start capturing the patient’s story in the EHR and turn to your EHR.
10. Ideally, if working with a flat screen, turn the monitor so that both you and the patient can see what you are doing — and semi-narrate as you enter the information verifying key points as you go along. In this way, the patient contributes to the record and helps make sure that what is documented is accurate!  If using a table, sit side-by-side so both of you can see the screen.

With rare exception, patients appreciate being part of the documentation process and seem to gain interest as I review/renew/update their medication lists, assure that the allergies listed are accurate, show them their laboratory test results, and document the agreed upon plan of action and follow-up. They even enjoy the occasional frustration I express with the system, but more often they are impressed with all the information collected and available through the EHR.

Will this work in every setting for every patient? No. But I hope that we don’t use the current inefficiencies of hardware and EHR documentation limitations to create barriers between us and our patients. In fact, it is conceivable that technology will continue to create new opportunities to engage patients (and their families when appropriate) in partnership to improve their health.

For others’ thoughts on this topic, see EHR Etiquette from The Health Care Blog; for a more academic analysis of usability testing, see this HIMSS 2009 document entitled “Defining and Testing EHR Usability: Principles and Proposed Methods of EMR Usability Evaluation and Rating.”

Question: How do you prevent the EHR from getting in the way? Or, to put a more positive spin on the question: how do you use your EHR to help engage patients in the office visit?

This post is the personal opinion of the author and does not necessarily reflect the official policy or position of the American College of Physicians (ACP). ACP does not endorse a specific EHR brand or product and ACP makes no representations, warranties, or assurances as to the accuracy or completeness of the information provided herein.


3 responses to "Do Computers Get in the Way?"
  • September 15, 2011
    David L. Kaufman,MD

    Why not simply do both. Have an EHR but use old fashion handwritten input which can be digitized either as written or converted to text. I totally agree with Dr. Ofri and would add that it’s not just that keyboard/screen input gets in the way, it impairs the thought process, changes the way (?we) record our thoughts, discover patterns, etc. I need the flexibility of paper and pen combined with the power of EHR.

    • September 16, 2011
      Michael S. Barr, MD, MBA, FACP

      Thanks, Dr. Kaufman. Excellent point. Computers do change the way clinicians work, think and discover. This potentially has an effect on the safety of care, too – something I raised in my December 20, 2010 post.

  • September 22, 2011
    William W. Reed,MD

    You have raised several topics in a short time.

    The post of December 20, 2010 is a succinct monolog about a real issue for those of us who have witnessed errors enabled by poorly designed and inadequately trained and supported software hardware configurations. Be careful out there.

    On another thought, may we may be moving from the confines of linear thought as represented by a pen and paper to multidimensional associations and beyond. With the aid of a display with the bandwidth capability to receive the requested data one could arrange it in a meaningful display (flexibility) so as to make more sense of it; that is, see the pattern(s) more easily as on a smart board on a wall the size of a 42 inch flat screen TV or larger? Then use a wireless key board to tabulate the diagnoses and plan. Displaying this on a smart board with the patient watching and adding to the input may engage the patient in the visit in a very active way.

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