Awhile back, I wrote about how a simple change in office workflow (and a smart office layout) allowed me to get back some of the face time with my patients that I had lost when we transitioned to an electronic medical record (EMR). As a result, I am happier, my patients are happier and I like to think I am providing better care.
Now, a new study shows that my instincts were right on – face time with patients is important. Researchers found that providers using an EMR detected and treated less depression in their patients than those still using paper, although the differences were only found in patients with three or more chronic conditions. The authors theorized that EMR using providers are spending more time looking at the computer screen than at their patients, and missing cues in facial expression and body language that in the past tipped them off to depression in their patients.
…EMRs have been observed to have a negative impact on psychosocial exchange, with screen gaze being inversely related to physician engagement in psychosocial questioning and emotional responsiveness. It is possible that the clinical work flows embedded in EMRs inadvertently encourage physicians to focus on these multiple physical problems and push depression treatment “off the radar screen” even after physicians diagnosed the condition…
…it has shown that physicians often find that EMR interfaces create additional work by forcing them to click through many screens and options as well as imposing tasks previously handled by others, especially when placing orders. Similar effects in primary care may take away significant visit time and reduce physician’s cognitive performance in terms of ability to provide comprehensive care. Such effects are also likely to be significantly greater during visits by patients with multiple chronic conditions than patients with few chronic conditions.
Even with my new work flow, I find that I still frequently have to consciously pull my eyes away from the screen and force myself to stop typing and look at my patients while they talk. This research study has me thinking that I meed to keep tweaking my work flows to see if I can improve face time even more than I already have.
Is it possible that part of the problem is the ubiquity of the computer monitor? What is your opinion of the following ideas:
*) Have a different desk for the computer monitor that does not allow you to face both the monitor and the patient.
*) Shut off the computer monitor while talking to a patient
*) Use a laptop; close the laptop lid when talking with a patient.
*) Switch to a tablet computer that allows you to put the tablet on the table. When the tablet is on the table you can face the patient, but it still has the convenience of having the computer nearby. (A convertible tablet might work very well.)
Sam – All interesting suggestions here are my thoughts on them –
1. That’s what I have now, but still have to pull my eyes away from monitor.
2. Not good – I still need to document. If I don’t do it in real time I’m in trouble. But I’m getting good at typing without looking at the keyboard or screen. Been practicing it all week since I wrote that post.
3. Interesting – but takes too much time.
4. This one I like the best. Tell EPIC to get a tablet version and my emplyer to but mean IPAd and I’m there!
Thanks for your comments.
Peggy
Yes, and the say technology will make our lives easier! It is an interesting problem. I imagine this is problem is extremely common with Geriatric patients. Although not quite there yet, I find it interesting that everything is being filed as we are in our appointments now. Medicine is wonderful. How far we have advanced! I never thought about until now, but almost all my doctors became doctors, before the PC was invented!
How much of the documenting typing are you doing now that used to be done by someone else?
Bardiac –
No one but me ever documents, but documenting with an EMR is much more time consuming that paper.
Info retrieval with the EMR is slower as well. In the old days, I just flipped through my chart quickly = now it takes forever to wade through every note and encounter that is created by the emr whenever anyone enters anything into the chart. Old days it was a sentence or two added to an ongoing paper record. Now its a new encounter – sometimes 3 or more related to a single back and forth phone call trail with a patient on a single issue.
Peggy
As a patient I have a negative opinion of a doctor who seems to be enamored of his/her computer rather than paying attention to me, especially when I am only alloted a few minutes of time per appointment. It is interesting to me what you say about your struggle to deal with EMR and patient relationships, I have a little bit more sympathy for the doctor’s perspective now. When I feel that my doctor is paying more attention to his/her computer than to me, I am less inclined to talk to him/her. Communication comes to grinding halt. I begin to look at my doctor as a dispenser of scripts and nothing more. Lab results are printed up on screen but I as a patient don’t get to view them and draw my own conclusions. Have recently had blood tests for cholesterol etc but have no idea what the results were because they were onscreen and I couldn’t read them. My doctor was busy scanning them and gave me only rapidfire summary (“you need to reduce your cholesterol”). It is frustrating that when an appointment is so short, that time is taken up by the doctor attempting to get through multiple screens to view records and update. Makes me feel like a piece of furniture. Thanks for the perspective.
EMR has its benefits but at a big cost, IMO.
Annie –
You’ll find me in complete agreement with your comments. There has to be a better way -I’m just not sure yet what that is.
All the best.
Peggy
Thank you for your professional opinion on EMRs. I have had some experience with both paper charting and EMRs. My experience with paper charting was very cumbersome and time consuming, but in the description you provided I can see another point of view. I know that geriatric patients, indeed many patients in the hospital, think that the nurses and doctors are ignoring them with all of their little devices and computer screens.
Additionally, thank you for your insight and taking the time to share with the world through your great blog. I have just discovered it today and so many of your topics are relevant to my private, professional, and educational life.
Lisa –
Thank you so much for your comment and your kind words.
I wish I understood how it was in the old days that I seemed to be able to take care of my patients without having to constantly be “in their record” – just a quick look, and a few quick jotted comments and well placed checkmarks was all I seemed to need in those days. We still have a long way to go before the EMR even approaches many of the efficiencies we had with paper charts.Of course, we’ve gained a lot of efficiences, but they seem more that non-MD tasks have lessened, while MD tasks with the chart have only increased.
Thanks again.
Peggy