CHAPTER 7

The Skill Sets and the Electronic Health Record

Muriel Hampton walks nervously into Dr. Kumar’s family practice for what she fears will be bad news. She nervously sits on the chair in the exam room. Prominently placed on the table next to her is a large computer screen with a keyboard. The medical assistant walks into the room and sits down to turn on the computer.

Computers have made their way into all parts of the medical system: emergency departments, ambulatory surgical centers, and inpatient acute care units. Electronic health record (EHR) management systems may vary, but one fact holds true across settings: when clinicians are physically with patients, most of them are face-to-face not with the patient but with the computer screen, clicking and typing.

In recent decades, the computer has emerged as the “third person” in the patient-clinician interaction, vividly impacting the patient experience.¹

Our entire society is now a cyber culture in which computer screens have changed the patterns of daily human interactions. We are all familiar with the many technologies people use to communicate with each other such as e-mail, texting, and Twitter. In 2009, the U.S. government invested more than $30 billion to increase the use of electronic health records.² As of 2016, hospital and physician practices combined with federal money have spent an estimated $3 trillion on developing and implementing this technology.

Promise of the EHR

We can easily acknowledge the many advantages of EHRs, including accessibility and legibility of documentation. Studies show that EHRs can improve patient care, safety, and quality of care. Electronic patient records are much more accessible than paper records. Updated medication and allergy listings have improved safety of care in inpatient and outpatient settings. Patients appreciate the e-prescribing feature, which means getting medication more easily and in a timely manner. Research shows us that reminders for health screening have also improved in many practices. Disease-specific programs are now being evaluated, with improvement in the outcomes of some chronic diseases such as asthma, hypertension, and diabetes.

There is no question that the EHR is a permanent part of the exam room and hospital encounter for patients and will continue to enhance aspects of patient care. Yet implementation of the EHR occurred quickly, and in many cases, with little thought given to the dynamics of dyadic clinician-patient communication patterns. Most clinicians train to use the EHR from a technical standpoint and learn what buttons to press while giving only minimal attention to integrating the human dimension of the clinician-patient relationship into the computer-assisted medical visit. This chapter provides a perspective on the EHR from the viewpoints of both the patient and the clinician. It then outlines a model that empowers clinicians to remain relationship-centered while effectively managing the EHR.

Patients’ Perspectives

Let’s go back to the example of Ms. Hampton, the nervous patient who is now sitting in the exam room with a technology-absorbed medical assistant. How does she view the computer-patient-clinician triad? Perhaps this is best explained in a picture drawn by a seven-year-old child published in the Journal of the American Medical Association in an article titled “The Cost of Technology.”³ The crayon drawing of an office visit depicts a mother holding a baby while the physician faces the computer, hunched over the keyboard, with his back to the patient. As clinicians, we frequently walk into exam rooms and go to the computer first. Too often, we appear to concentrate more on typing than we do on speaking with the patient. Researchers estimate that clinicians spend at least 25 percent and as much as 40 percent of their time gazing at the computer screen.⁴ This same study showed that a lack of eye contact between the patient and the clinician is associated with decreased patient satisfaction.

Ms. Hampton is 82 years old with multiple health issues, including arthritis, high blood pressure, and diabetes. Like many older patients, Ms. Hampton is at high risk for social isolation and depression. Treating Ms. Hampton involves not only addressing her diseases but also understanding her psychological issues, thoughts, and behaviors. For example, we know that depression in patients with coronary heart disease is independently associated with increased cardiovascular morbidity and mortality.⁵ When Ms. Hampton comes to our practice and we fail to make eye contact with her because we are preoccupied by the EHR, we may miss critical nonverbal cues she gives us. Furthermore, when we focus on the screen, we miss opportunities to respond with empathy to these sensitive social or emotional aspects that affect her health and wellness (see Chapter 4). Unfortunately, patients with three or more chronic conditions are half as likely to receive treatment for their depression during a visit to a clinician’s office that uses EHRs compared with patients who visit paper-based practices.⁶

Additional factors, such as literacy levels and socioeconomic status, can influence how EHR use impacts patients. For example, Ms. Hampton raised six children and left high school early to work in order to help support her family. She presently has poor eyesight and a ninth-grade reading level. Research conducted in safety-net clinics showed that there was lower patient satisfaction in outpatient settings where there was high EHR use.⁷

The EHR also adversely affects interpersonal patient interactions in the inpatient setting. Dr. Abraham Verghese wrote eloquently about how medical practitioners doing hospital rounds are more focused on discussions about the “iPatient’s” results than on examining actual patients and listening to their concerns.⁸ Healthcare team rounds now often occur in conference rooms where clinicians talk about patients and their x-ray reports, lab values, and consultant opinions with only brief bedside encounters. We observe a detachment of clinicians from patients and a diminishment of the potentially powerful therapeutic presence provided by a strong patient-clinician relationship.

Clinicians’ Perspectives

We know that patients feel separated from clinicians who rely heavily on EHRs. Many clinicians also express dissatisfaction with the increased burden of EHR documentation. Clinicians complete an estimated 200 clicks during a typical outpatient visit. In one study, physicians spent approximately 53 percent of their time on direct clinical face time with patients and 37 percent on the EHR and deskwork. In addition, physicians noted spending one to two hours a day beyond office hours on EHRs.⁹ This correlates with a study showing that the prevalence of physician burnout was significantly higher among physicians who used EHRs than among those who did not, independent of their reported satisfaction with the technology itself.¹⁰

There are more concerns than just with the increased time spent on documentation and order entry. When we are simultaneously typing, interviewing, and developing a diagnosis, what happens to our cognitive processing abilities? Let’s compare a clinician who is seeing a patient while simultaneously typing to another common multitasking event: texting or talking on the phone while driving. Research has shown that texting and driving causes a 23-fold increase in crashes; using a cell phone and driving reduces the brain activity toward driving by 37 percent.¹¹ For pilots in the aviation industry, errors are more likely with increasing numbers of complex tasks.¹² Although there are now some data on types and frequency of errors with the use of the EHR, we are still learning about this topic.¹³ When we begin to recognize the cognitive impairment that EHRs can cause, we may want to dispense with them altogether. But this may not be advisable, given the many benefits EHRs provide. The question becomes: How can we decrease this risk while improving patient-clinician interactions? Part of the answer lies in decreasing communication barriers imposed by the EHR and learning skills for managing the relationship while using technology.

Models of Relationship-Centered Care with the EHR

Currently, we can implement strategies to strengthen the patient-clinician relationship while using the computer during the encounter. These steps can relieve some of our documentation burdens and provide improved patient experiences.

As of now, there are no consensus “best practice” statements for how to integrate use of the EHR into the office setting. We formulated a research-based model that embeds discreet EHR-related skills into relationship-centered interactions with patients.¹⁴ These steps maximize benefits of the EHR while intentionally equipping clinicians with skills to mitigate the ill effects of the screen gaze and multitasking linked to EHR use.

Let’s go back to the example of Ms. Hampton and identify how the EHR can improve her care without taking away her personalized experience or creating an overwhelming burden of documentation for Dr. Kumar.

SETUP

Ms. Hampton sits in one of two chairs, with a computer screen on the sidewall between the chairs and an exam table nearby.

If we take some time to think about the setup, we can arrange our exam rooms to specifically accommodate the patient-clinician-computer triad. It’s important that both the patient and the clinician are able to easily see the screen. We can achieve this by using a mobile computer/movable screen, or rearranging the room so both parties can see a fixed screen. What’s critical is that the setup encourages patient participation by allowing the patient to join in or initiate discussion while looking at, pointing to, or highlighting items on the computer screen. In this way, clinicians will never be gazing at a screen with their backs to patients, inadvertently sending a strong message of exclusion.

PREVIEWING AND PREPOPULATING THE CHART

Dr. Kumar has previewed the EHR before entering the room. In Dr. Kumar’s office, the medical assistant has undergone training with the EHR and sits down with Ms. Hampton to type in the reason for the visit, review the medication list, update allergies, and record health maintenance information. Dr. Kumar confirms the accuracy of the information by showing Ms. Hampton the lists or verbalizing them when he is in the room.

It’s true that previewing a patient’s chart will add extra time to the beginning of a visit. But when we skip this step in the name of time management, inadequate preparation can come back to haunt us: our visits tend to be less organized and less satisfying to both parties, and ultimately tend to take longer.¹⁵ When quickly previewing the patient’s EHR, we gain familiarity with the patient, the most recent clinical notes, laboratory results, and medications. In an office setting, other members of the team could potentially perform some of these tasks and help patient flow.

GREETING

Dr. Kumar enters the room after knocking and says, “Hello, Ms. Hampton! It is so nice to see you today.” (Handshake) “I hope you did not have trouble getting here today. Did your daughter bring you?” (Pause for patient response) “I’m going to sit down at the computer and log in while we talk.”

In the first two minutes of a medical encounter, the patient is deciding whether or not to trust and respect the clinician (see Chapter 3). Social psychologists tell us that people look for both features of warmth and competence upon meeting someone new.¹⁶ Therefore, when entering the patient’s space, it’s always appropriate to extend a greeting. There may be cultural variations of what this entails: in U.S. culture, we often shake hands. Greetings do not take long (15–20 seconds, typically) and should be done before turning to the computer. The introduction continues with some nonclinical small talk to establish a human connection. In addition to the usual greeting and introduction phase (see Chapter 3), we recommend explicitly introducing the computer in an effort to help the patient understand why it is being used during the visit. Although this practice may become obsolete as computers become more commonplace in the exam or hospital room, this step remains valuable for reducing communication barriers caused by the use of the EHR.

SETTING THE AGENDA

Dr. Kumar works with the computer right away by using summarizing statements and briefly touch-typing the agenda as it is created. Dr. Kumar first asks for the patient’s concerns, which include elevated blood sugar, some fatigue, and the need for prescription refills. Then Dr. Kumar adds his own agenda items, which may include the arthritis pain and a flu shot for today’s visit. Dr. Kumar maintains eye contact with Ms. Hampton when not typing and pauses to allow time for Ms. Hampton to respond.

Agreement on a visit agenda between patient and clinician helps in both outpatient practice and inpatient settings (see Chapter 3). In our example, Dr. Kumar forms a relationship with the patient as he collaborates on the agenda, while simultaneously managing the computer. This step may seem awkward at first, but can ultimately lead to improved satisfaction and time efficiency.

OPENING THE HISTORY OF PRESENT ILLNESS

After creating an agenda, Dr. Kumar explores the first topic. While Ms. Hampton speaks, Dr. Kumar makes periodic eye contact, nodding his head and looking at the computer occasionally while typing. Dr. Kumar explains his use of the computer with statements such as, “I’m looking up your lab results.” Lastly, Dr. Kumar provides a brief verbal summary of what he typed so that Ms. Hampton knows he was listening.

Real-time typing helps save clinicians time. Doing this while minimizing screen gaze is challenging. Often clinicians use scribes, dictation programs to minimize typing, or master touch-typing skills. The clinician must use eye contact to observe for a patient’s potential emotion or distress. If we are always gazing at the computer, we can miss this key aspect of relationship building. Active listening skills—including continuers, echoing statements, short requests, and short summaries (see Chapter 4)—can all accompany typing on the computer. We can also use signposting, where we tell the patient what we are doing as we transition to the computer to type or look up data points. When Dr. Kumar says, “I’m looking up your lab results,” he is still attending to Ms. Hampton while letting her know that he is making a shift to the computer. Finally, Dr. Kumar reads back what he has written and then turns and looks at Ms. Hampton to ensure accuracy and demonstrate active listening.

BUILDING THE RELATIONSHIP

Ms. Hampton has known Dr. Kumar for a long time and confides in him today that she feels sad and alone. She is tearful as she relates this to Dr. Kumar, who moves his chair away from the computer and closer to Ms. Hampton in order to look at her directly. Dr. Kumar will type this part into the EHR after the visit or while Ms. Hampton is getting onto the exam table.

Empathy given both verbally and nonverbally is therapeutic and improves patient satisfaction and adherence (see Chapter 4). Conversely, the EHR has been shown to obstruct connections with our patients and negatively impact emotions. When a patient opens up and begins talking about something emotional, research has emphasized that we can make a strong connection with our patients and show support by removing our hands from the technology, pushing the monitor away, and moving our bodies and eyes toward the patient to offer our undivided attention.¹⁷

SHARING DECISION-MAKING AND INFORMATION

As the visit comes to a close, Dr. Kumar turns the computer screen to Ms. Hampton. On the screen is a graph showing that her HbA1C has increased slowly over the past year. They strategize on how to control her blood sugars and discuss increasing her medication.

The computer can help provide additional educational support for the treatment plan. It is important that we verify literacy, primary language, and visual acuity to optimize computer use. Examples of what the EHR can provide at this stage include preloaded patient handouts (or website references) and information about community support services, medication side effects, and follow-up appointments. Prepopulating the computer using commercial and public sources will make this step more efficient. When we reposition the screen closer to patients and point to relevant areas, they can learn important medical facts while gaining a feeling of collaboration. In this mode, we can also use the computer to decide on a treatment or care plan. Research has shown that when we involve patients in treatment planning, it improves their adherence and outcomes (see Chapter 5).

CLOSURE

As Ms. Hampton and Dr. Kumar arrive at a plan for the next visit, Dr. Kumar asks Ms. Hampton to state what she understood the plan to be, and Dr. Kumar types Ms. Hampton’s words into the after-visit summary. As the clinician visit ends, Dr. Kumar introduces a medical assistant to review the written information about diet and to reinforce the goals that Ms. Hampton and Dr. Kumar have discussed. Dr. Kumar leaves the room and takes about four minutes to complete the visit note. He then previews the next patient’s chart, and the cycle repeats with the goal of maximizing patient care and lessening the burden of documentation.

There are three major goals in closing the visit: checking understanding, arranging follow-up, and providing support (see Chapter 5). The computer is useful in providing clear follow-up instructions, printouts of disease management information, information on medications, and referrals. All of this information can be easily printed and handed to the patient by the clinician or someone on the staff team. In addition, some organizations provide follow-up support with patient care portals for communication via the EHR. Communication on portals can include the patient’s follow-up questions or concerns, important health information, and copies of test results.

The Future

In order to improve healthcare experiences for patients and clinicians alike, it is critical that we teach trainees and experienced clinicians relationship-centered communication strategies to manage computer use. The EHR comes with obstacles. Overcoming them requires a commitment to more research (such as time-and-motion studies to evaluate the effectiveness of interventions), use of scribes or advanced care teams in redistributing the work of the EHR, and innovations in improving technology platforms that decrease the burden of documentation for the clinician.

Conclusion

The strategies discussed in this chapter are concise, skills-based, and supported by research. They include: ensuring proper setup of the exam room, previewing the chart, greeting the patient before going to the EHR, minimizing screen gaze during the encounter, intentionally turning to the patient during emotional or complicated interactions, and when possible, using signposting or nonverbal cues to stay connected with the patient during the interview. At the end of the interview, steps to simplify closure and document clear follow-up include sharing on-screen information with the patient and preloading disease and medication information. These skills will help clinicians manage computer technology while simultaneously engaging in more meaningful face-to-face time with patients.