Doctors focused on entering data into electronic health records during visits are putting physician-patient relationships at risk as well as potentially the safety of patients.
So argues Regenstrief Institute investigator and Indiana University School of Medicine professor Richard Frankel, Ph.D., a medical sociologist who has studied exam room computer use and conducted extensive interviews with physicians. The problem is that some doctors spend more than 80 percent of the visit time interacting with the computer screen instead of their patients, according to Frankel.
“Computers have been used in the back room for probably the past 20 to 25 years, but only recently migrated into the exam room. However, unfortunately with that migration there hasn’t been very much education of physicians on how to use the computer,” says Frankel, who sees patients, doctors and computers as a “triad” with the computer serving as the third party in the exam room.
To address these concerns, Frankel developed a model—through a grant from the Department of Veterans Affairs—for reinforcing good exam room computer-use by doctors.
Called POISED (Prepare, Orient, Information, Share, Educate, and Debrief), these best practices are designed to foster good physician-patient relationships and better health outcomes:
- Prepare—review electronic health record before seeing patient,
- Orient—spend 1 to 2 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 a physician does not enter information gleaned from the patient into the 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 what was said or meant,
- Educate—show a graphic representation on the computer screen of information over time, such as 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, and
- Debrief—exam room computers provide ideal opportunity to use “teach back” or “talk back” formats for doctors to assess the degree to which recommendations are understood by the patient and correct as necessary.
“There are several things that conspire to make computer use less than ideal,” adds Frankel. “One is the physical placement of the computer.” If it’s a fixed workstation, it most likely will be in a corner of the room that “necessitates the physician having his or her back to the patient.” That is a particular no-no.
According to Frankel, there are gender differences when it comes to exam room computer-use. Female physicians typically look up from the screen approximately every 30 seconds or so, making eye contact with the patient to signal that they are still actively engaged in the relationship, and return to typing. However, male physicians tend to lock on to the computer screen and rarely look up to signal engagement, Frankel says.
Not surprisingly, patients prefer doctors who they believe to be paying attention to them. As a result, Frankel believes the need of physicians to electronically document must be balanced against the need to build and maintain relationships with patients. “The computer can be a handicap,” he concludes, “but there are ways in which that handicap can be overcome through good and appropriate education and use.”
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