Making the EHR your partner in patient care

No longer a rarity in patient examination rooms, electronic health records (EHRs) now are found in nearly 72% of office-based physicians’ practices, a 400% increase from a decade earlier, according to the National Center for Health Statistics. For many doctors, however, leveraging the EHR to enhance patient-doctor engagement during an office visit remains an elusive goal.

Most primary care physicians receive no instruction on best practices for using the EHR in an exam room. Instead, EHR training typically focuses on teaching providers to navigate data entry tasks and introduces them to a system’s features. Yet there are ways physicians can help ensure that their EHR enhances the doctor-patient relationship rather than creating a barrier to patient communication.

Jason Mitchell, MD, director of the Center for Health Information Technology at the American Academy of Family Physicians (AAFP), says the first step is recognizing the computer is “a third party in the room.”

“Acknowledging the computer can be a significant distraction from interaction with the patient is absolutely essential,” Mitchell says. “You have to find ways to mitigate that and draw the patient into the interaction you are having with the computer.”

“As you gain comfort using any kind of system, whether it is a piece of paper and pen or a computer keyboard, it becomes more of a tool and less of a concern,” says Jennifer Brull, MD, a solo family practitioner in Plainville, Kansas. Brull now considers her EHR an invaluable partner in patient care, but she admits she did not initially view it that way.

“The discussion around the EHR and computers is because so many physicians of my generation and older generations felt uncomfortable using the computer,” Brull says. “We wound up directing so much attention to the computer that it took attention away from the patient.”

Let patients see what you’re doing on the EHR
In the exam room, Brull allows patients to view the computer screen at all times, which enables patients to easily view charts and graphs as well as double-check that Brull’s note-taking accurately reflects the patient’s words. “I love the tools our EHR gives us,” she says. “I can talk to a patient about weight gain but when I show them a graph of their weight over several years, they can see it. A picture does mean a thousand words.”

William Ventres, MD, a family physician who in 2006 coauthored one of the first tip sheets on doctor-patient communication using EHRs, is not convinced much progress has been made in overcoming the barriers to patient engagement posed by computers.

“The good news, apparently, is that my coauthors and I got to look at these issues early on after EHRs were first introduced,” Ventres says. “The bad news is that it is still common for healthcare systems to plop down computers in front of their clinicians without any training or instruction about how to use them to enhance, and not detract from, the therapeutic relationships between doctors and patients.”

Ventres’ original advice to physicians on how to use an EHR to enhance in-office communication continues to hold true. Those recommendations range from the obvious-learn how to type and master basic computer skills-to overlooked details such as:

• listening to a patient’s concerns before opening the computer screen;

• telling patients what you are doing at the computer when entering information;

• pointing to the computer screen when sharing data or results with patients;

• understanding when it is important to push the computer screen away; and

• encouraging patient participation in building charts.

Filling the knowledge void
Though physicians continue to receive little formal instruction on using EHRs in the presence of their patients, there are signs that the knowledge void may be starting to fill. At its 2013 annual meeting, the American Medical Association (AMA) approved a policy pledging to develop resources for members on effectively using computers and EHRs in patient-physician interactions and to encourage physicians to incorporate questions regarding use of computers and EHRs in patient-satisfaction surveys.

The AMA Board of Trustees’ report calling for the policy change outlined recommendations from Ventres’ 2006 Family Practice Management article and Kaiser Permanente’s tips to its clinicians. Kaiser Permanente uses the acronym LEVEL to foster integration of computers into patient-doctor encounters:

• Let the patient look on: Move the computer screen so the patient can see it, invite the patient to view information, ask the patient to verify information as entered.

• Eye contact: Greet the patient, maintain eye contact.

• Value the computer as a tool: Acknowledge the computer; let the patient know how it improves care.

• Explain what you are doing: Inform the patient about actions and decisions, tell the patient what you are doing, such as ordering labs.

• Log off and say that you are doing so: Tell the patient you are logging  off to safeguard his or her information.

Medical schools also are recognizing the need to teach physicians how to maximize the EHR in patient interactions. At the University of Arizona (UA) College of Medicine-Phoenix, first-semester students are receiving a 20-minute training session on how to use the EHR in a “relationship enhancing way.”

Howard Silverman, MD, associate dean for information resources and educational technology at the UA College of Medicine-Phoenix, says the college’s observational studies showed today’s computer-savvy students make the same missteps as older generations when using an EHR in an exam room such as turning their backs to patients while using the computer, and apologizing for having to use the computer.

“There’s an assumption the new generation of medical students are computer literate so they will [engage patients] naturally,” Silverman says. “We have very good data [showing that] that is not the case.”

Students need training too
Accordingly, the school developed a training intervention that teaches students to begin an office visit by explaining to patients why the computer is important to the visit, has them reassure patients about confidentiality, and directs them to position the computer screen so that the patient can see the screen to review information such as medication lists, laboratory values, and X-rays.

Students are also told to recognize cues to close their laptops and focus solely on the patient, such as when the patient starts discussing sensitive information or before beginning a physical exam. Another tip involves alerting patients that the doctor’s attention temporarily will be focused on the computer screen before beginning computer-intensive tasks such as recording a patient’s medical history.

“When you shift into that mode, say ‘I am going to ask you some rapid-fire questions. I want to record your answers in the computer because I want to make sure I get this down accurately so I can give you the best possible care,’” Silverman explains. “Now the clickety-clack has been reframed as a positive thing as opposed to ‘I am playing video poker and you don’t know what I’m doing.’”

Silverman is confident that practicing physicians would benefit from EHR training similar to that developed for UA College of Medicine-Phoenix students, which aims to elevate the doctor-patient relationship.

“The issue with EHR ergonomics is not to make the EHR tolerable,” he says. “It is to make the encounter better than it would have been without the EHR. Everybody’s assumption is that the interaction degrades because the computer is there. It could be the same or it could be better. We prefer the better alternative. The question is, how do we get people there?”

The EHR is ‘no longer an alien object’
In his seventh year using an EHR, Salvatore Volpe, MD, a Staten Island, New York-based internal medicine physician, says the computer is “no longer an alien object” in the room for him or his patients.

“Once I learned where everything was on the screen and I got past the gee-whiz-this-is-such-a-great-toy phase, I was able to get back to my old routine, which is listen for a little while, ask questions, digest it and then play court stenographer,” says Volpe, a member of the Medical Economics editorial board.

Patients now expect Volpe to bring a laptop into the exam room and understand how it will be used. “I have many patients who will talk to me for a while and then as I am typing, they will say, ‘Just let me know when I should continue talking,’ which I think is beautiful,” he says. “It means we know the routine. You know I need this machine to keep track of everything but I don’t want to handicap your talking. You also realize I can only type so quickly, and I am paying attention to you and not just robotically writing things down.”

Volpe also believes EHR templates for preoperative exams and other tasks enhance his ability to connect with patients. “I have some predefined data points I have to collect,” he says. “The EHR is a great way to let me do that efficiently. Because I have become more efficient, I can spend more time talking to the patient.”

The benefits of just listening
For Boston internist Chloeanne Georgia, MD, using an EHR effectively in the exam room is an ever-evolving process. While she used to immediately begin taking notes at the start of a patient visit, she now sets the keyboard aside and listens to the patient’s story.

“I’ve found that sitting and listening works better for me because sometimes when I type as the patient is talking, I can’t make sense of the notes I’m taking because they are incomplete sentences or phrases that may mean something or not. I end up going back to rewrite the whole note anyway,” she says.

The AAFP’s Mitchell says the growth of medical devices that automatically transfer data into electronic records also will help strengthen the doctor-patient relationship.

“If you have device integration with the EHR, it helps the interaction with the patient,” he says. “The information is immediately available and can be shown to the patient. To be able to show blood pressure trends over time, to be able to look at lab results together helps tremendously in validating a treatment plan with a patient or showing what is going wrong.”

The role of patient portals
Mitchell also believes that patient portals, which enable physicians and staff to easily communicate with patients and give patients access to appointment scheduling, prescription refills, and their medical history will play an important role in improving patient engagement.

“That after-visit follow-up is now much easier,” he says. “It really strengthens the provider-patient relationship when the patient knows they are cared about. It is not, ‘we have your copay and now we’re done,’ but we care that the treatment regimen we decided on is sustainable for you, is working for you and that you’re not having any other problems.”

Kenneth Hertz, a principal with the MGMA Healthcare Consulting Group, thinks that  EHRs ultimately will fulfill their promise to transform healthcare, though there are hurdles to overcome before that happens.

“I see practices making progress,” Hertz says. “Physicians are working hard at this. Staffs are working hard. A lot of people are working to make this happen. It could be five years before we start to see major transformational change, but I have to believe it is going to happen because it has to happen.”