Communication Breakdown: Technology in the Exam Room

Nancy Tice, MD
Published: Wednesday, Dec 10, 2008
My heart broke a bit when my normally attentive OB/GYN walked into the exam room with a tablet PC and barely looked up from the screen during my visit. Studies have shown that exam room computers have positive impacts on physician–patient interactions without significant negative effects on other areas, such as time available for patient concerns. Integration of computers into the delivery of care improves patient satisfaction. However, even skilled physicians commonly display troubling behaviors, such as spending too much time looking at the computer monitor, typing while patients are talking about intimate concerns, reading silently from the monitor, using templates to lead interviewing rather than listening to patient narratives, and turning their backs to patients in spite of mobile computer monitors.

Electronic medical records are a wonderful asset and can help prevent drug interactions and allergic reactions by automatically checking patient history. Many malpractice carriers offer physicians a discount for using one. Plus, physician users always have access to their patients’ records, a crucial factor when a patient is taken to an emergency room and cannot give a verbal history, or when a patient is traveling and enters a hospital or visits a different physician. There is also no need to worry about illegible notes and scrawled—and sometimes misread—prescriptions. Electronic medical records have the potential to bring a new level of care to patients while making physicians’ lives easier. So, how can you make the most of what technology has to off er and not compromise your patients?

Learn to type.

This is an obvious recommendation, but it is an important one. Until voice recognition improves dramatically, cost concerns will demand that physicians type their notes or enter them through templates. Your typing speed and accuracy will improve with time, and you’ll be grateful not to deal with your hand-scrawled notes.

Integrate typing around your patients’ needs.

Regardless of your note-taking style—whether you type during the visit, immediately afterward in the exam room, or later in your office—it is important to know when to push the computer screen away. Using an EMR may require a heightened recognition of sensitive psychosocial concerns. Patients need to have eye contact and feel connected to their physician.

Templates are for documentation.

Templates are an excellent way to structure notes but can be disastrous when used to structure interviews with patients. Their closed-ended, question-and-answer format allows little room for patients’ narratives to evolve, a key task in patient-centered care. Don’t change your interviewing style to fit a template.

Patients first.

Unless a physician reviews notes at the beginning of the day or in the hall before entering the exam room, there may be little chance to focus attention on the presenting patient until after entering the exam room. Try to listen to patient concerns before opening up the EMR to review the last visit’s notes.

Keep your patients informed about what you are doing - as you’re doing it.

If you sit silently looking for information on the computer—opening and closing windows or scrolling though text—you risk alienating your patients. Instead, try to keep talking as you go about the work of both searching for and entering data into the EMR. Let the patient know you are just making a notation or looking something up for them.

Show your stuff.

Many patients like seeing their lab results and the charts and graphs that EMRs provide. However, even computer-savvy patients may find that their emotions override their ability to quickly grasp where to look. Use a finger, pen, or cursor to guide the patient’s gaze when discussing data viewed on the monitor. This is a great time for showing, for instance, a trend between rise in body weight and cholesterol to illustrate cause and effect. Patients will sometimes get the message more clearly when shown charts.

Consider asking first.

We’ve all seen the movies with the doctor scribbling in silence. Instead, try saying things like “Would you mind if I typed while we speak?” or “May I show you what I’m doing?” when using an EMR to promote, rather than hinder, the physician– patient relationship.

Look at your patients.

The reality is that even with the availability of mobile screens, many experienced clinicians still stare at the computer monitor. Remember that you are speaking to and caring for the patient, not the EMR. The EMR is an inanimate tool to aid patient care and it is the patients who deserve our primary attention. EMRs in the examination room are quickly becoming a reality. Paying attention to how we integrate our clinical styles with the use of this technology will ensure that they are used in ways that best fit the social, emotional, and medical needs of our patients.

Still without an EMR?

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