Electronic health records (EHRs) and various devices bring countless benefits to the healthcare experience, but evidence is mounting that EHRs also threaten quality and patient satisfaction when clinicians spend too much time looking at a screen instead of the patient. The high-tech tools are here to stay, so hospitals must find ways to ensure that patients still feel they are getting the personal attention they deserve.
Research indicates that physicians in a patient encounter typically spend 80% of their looking at a computer screen and only 20% interacting with the patient, says Richard M. Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine and an investigator with the Regenstrief Institute, both in Indianapolis. His research is focused on clinician-patient communication and its effects on quality and safety, the effects of exam room computing on physician patient communication and effective organizational change strategies.
Quality of care also is affected by how much a clinician focuses on a screen, Frankel says.
“It’s not just a matter of being nice and respectful to the patient,” he says. “The outcomes of care are jeopardized by acting one way or another with computers and patients. This is an area of growing concern as more and more patients have negative experiences.”
Research with the Jefferson Scale of Physician Empathy (JSPE) indicates that a clinician’s level of empathy affects quality of care and outcomes, Frankel notes, and one element of empathy is eye contact. Patients with diabetes have statistically better outcomes when treated by physicians who have a higher degree of empathy as measured by the JSPE, and those high empathy scores correlate with the physician spending more time interacting with the patient instead of the computer, he says.
As doctors and other clinicians are increasingly focused on computers, laptops, and tablets, research shows that patients rate their encounters lower as the screen time increases. Recent research by Neda Ratanawongsa, MD, MPH, associate professor in the Division of General Internal Medicine at the University of California, San Francisco, indicates a clear association between screen time and patient satisfaction. She and her colleagues studied patient interactions at clinics in San Francisco serving people with limited proficiency in English and low health literacy, recording 71 encounters among 47 patients and 39 clinicians. Compared with patients in low computer use encounters, patients in high computer use encounters were less likely to rate their care “excellent” — 48% vs. 83% of the low computer use group.
Patients in high computer use encounters also engaged in more “social rapport building,” such as asking the doctor if she liked wearing her hair that way. That probably indicates that the patient felt ignored and was trying to engage the clinician in conversation, Ratanawongsa says. (The study is available online at http://bit.ly/1TywyMM. See the story later in this issue for similar research.)
Physical layout is important
The solution involves attention to both physical layout of the examination room and some do’s and don’ts of how to use devices with a patient, she says. Frankel agrees, noting that the placement of the computer in an exam room is one of the most vexing issues for physicians. The most common placement is in a corner of the room, which means the physician’s back is to the patient when using it, he notes.
“Just the geography of the room can be a real problem in terms of creating barriers to engaging with patients,” Frankel says.
A better design has the computer on a stand in the middle of the room so the physician can use it while facing the patient, or the physician can use a tablet or another portable device to enter information. Frankel just finished reviewing 400 exam rooms at a hospital switching to a new EHR, with the CEO instructing that he wanted the new EHR terminals placed in the best possible configuration for patient-centered care.
“That is a triangle, formed by the physician, the patient, and the computer,” Frankel says. “A quality professional could easily get involved with configuring rooms for ideal care delivery for patients.”
Some compromise is needed, Frankel notes, because avoiding computer use altogether during the visit is not ideal either. Important information may be overlooked or not documented if the clinician waits until after the encounter to enter data. One popular strategy is to have a nurse or other staff member act as a scribe, entering information in the system as the physician talks with the patient. While effective, scribes necessitate additional staffing and expense.
Follow best practices
Engaging the patient with the computer also is effective, Frankel notes. Research has shown that patient satisfaction improves when the clinician introduces the patient to the computer, describes how and why it is being used, and uses the computer as an educational tool to show illustrations or medication instructions, for example.
Frankel also encourages quality leaders to study how EHRs and other devices are used in patient encounters to identify those clinicians who seem most effective with striking a balance with patient interaction. There may be tips and tricks unique to the hospital’s particular EHR, or clinicians may have developed habits that can be emulated. Those best practices can be formalized and implemented throughout the hospital. (Frankel has developed a set of guidelines that can be used to address the issue. For more on the guidelines, see the story later in this issue.)
Hospitals should find a way to incorporate communication training in the ongoing education of clinicians, reinforcing what they were taught in school and addressing any practical issues that may be interfering with good patient interactions, Ratanawongsa says.
“There has to be training for doctors in how to listen to their patients and how to disengage from the computer when needed, such as when a patient is talking about depression or alcohol use, or when they are talking about something embarrassing like erectile dysfunction,” Ratanawongsa says. “Those things need to be cues that tell the provider to stop entering data, take their eyes off the screen, and pay attention to the patient. There is a lot of movement in medical schools to teach communication skills, but those skills are pushed aside in practice by the demands of everyday work requirements.”
The healthcare visit also should be structured in such a way that it allows time for the clinician to enter data but still have time to engage directly with the patient, she says.
“There are policy-driven factors to consider when you’re trying to free up time for the provider, having other people enter data or do medication reconciliation, so the provider can focus on what the patients want directly from them, like advice about their health and recommendations,” Ratanawongsa says. “The move to electronic health records is a useful thing, but some of the ways it was done were not based on things that matter most to patients and their healthcare teams.”
SOURCES
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Richard M. Frankel, PhD, Professor of Medicine, Indiana University School of Medicine, Indianapolis, IN. Telephone: (317) 988-4000. Email: [email protected].
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Neda Ratanawongsa, MD, MPH, Associate Professor, Division of General Internal Medicine, University of California, San Francisco. Telephone: (415) 206-8494. Email: [email protected].
POISED Model Improves Patient Experience
Clinicians can improve their patient engagement while using computers by following six steps, suggests Richard M. Frankel, PhD, professor of medicine and geriatrics at Indiana University School of Medicine and an investigator with the Regenstrief Institute, both in Indianapolis.
He developed the POISED model for reinforcing good exam room computer use by physicians:
Prepare: Review the electronic medical record before seeing the patient. Time pressures result in many physicians not looking at the record until entering the room, and a common complaint from patients is that physicians spend five minutes or more staring at a computer before even understanding who they are and why they’re being examined.
Orient: Spend one or two minutes in dialogue with the patient explaining how the computer will be used during the appointment.
Information gathering: Don’t put off data entry, as patients may question how seriously their concerns are being taken if the physician does not enter information gleaned from patient into computer from time to time.
Share: Turn the computer screen so patients can see what has been typed, signaling partnership and also serving as a way to check that what is being entered is accurate.
Educate: Show a graphic representation on the computer screen of information over time, such as the patient’s weight, blood pressure, or blood glucose, so it can become a basis for conversation reinforcing good health habits or talking about how to improve them.
Debrief: Exam room computers provide an ideal opportunity to use the “teach back” format for a doctor to assess the degree to which recommendations are understood by the patient and correct as necessary.
