Am Fam Physician. 2007 May 1;75(9):1385-1390.
My colleagues and I are thinking about purchasing an electronic health record (EHR) system for our practice. I mentioned this to a friend whose physician recently made this transition. Instead of taking a paper chart into the examination room, his physician types notes on a laptop computer. The patient has noticed increased efficiency in retrieving test data and consultation notes; nevertheless, he is considering changing practices.
The patient says that his physician no longer looks at him when he speaks and spends most of the visit typing silently, which makes the patient uncomfortable. When the patient brought up a difficult personal issue, his physician just nodded and continued to type. The interview also felt unnatural and controlled by prompts on the computer screen. Is it possible for physicians to avoid distancing themselves from patients when using an EHR?
In the United States, 28 percent of primary care physicians use EHRs, and another 31 percent plan to implement the system within the next year.1 EHRs have many advantages over paper records and can make data retrieval and management, decision support, population health, and billing more efficient.2 On the other hand, if misused, it can interfere with the personal interaction between the physician and patient, especially given time constraints and demands of clinical productivity. As with many of the other tools new to the clinical arena in the last few decades, physicians are still learning to adjust to EHRs.
Recent research has offered the following conclusions about how the use of EHRs during an office visit may affect the physician-patient relationship:
In general, patients are equally satisfied with physicians who use EHRs and those who use paper charts3; however, some patients feel confused by certain behaviors, such as the physician looking at the computer monitor without explanation.4
How physicians use EHRs during an office visit (and how much time they spend typing on the computer versus talking with the patient) is influenced by their communication style and perception of their professional role in relation to the patient.5
The presence of the computer monitor improves the patient-centered behaviors of physicians who exhibited good behaviors with paper charts; however, the computer monitor worsens the patient-centered behaviors of physicians who had poor interpersonal skills before the introduction of EHRs.6
As EHRs are integrated into practices, what can physicians do to preserve the physician-patient relationship? There are several ways family physicians can address this question. It is important that physicians recognize that integration of an EHR system into clinical practice is not complete when they become adept at navigating the software—it is vital that they also examine how to use the tool with patients. Colleagues shadowing each other while using an EHR can help identify effective strategies. Physicians should regularly and communally review how they use EHRs during patient visits, sharing with other practice members what has and has not been effective.
Involving patients in EHR implementation may be helpful. To encourage this involvement, physicians can thoughtfully acknowledge the presence of the EHR, explain what they are doing as they use the tool, and ask the patient for feedback. Tips on using EHRs while maintaining a patient-focused office visit are available at http://www.aafp.org/fpm/20060300/45ehrs.html.
EHR systems can enhance physician-patient interaction, even in a culture that seems to be moving away from face-to-face communication. Such an effect will not, however, happen spontaneously and should not be assumed to be an easy or unconscious process. With diligent reflection by family physicians on how they use this tool, the EHR can move beyond its current role in information transfer to one of transforming clinical care and keeping patient needs at the center of the therapeutic endeavor.
REFERENCESshow all references
1. Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries. Health Affairs. 2006;25:w555–71....
2. Hersh WR. Medical informatics: improving health care through information. JAMA. 2002;288:1955–8.
3. Solomon GL, Dechter M. Are patients pleased with computer use in the examination room?. J Fam Pract. 1995;41:241–4.
4. Als AB. The desk-top computer as a magic box: patterns of behaviour connected with the desk-top computer; GPs' and patients' perceptions. Fam Pract. 1997;14:17–23.
5. Ventres W, Kooienga S, Marlin R, Vuckovic N, Stewart V. Clinician style and examination room computers: a video ethnography. Fam Med. 2005;37:276–81.
6. Frankel R, Altschuler A, George S, Kinsman J, Jimison H, Robertson NR, et al. Effects of exam-room computing on clinician-patient communication: a longitudinal qualitative study. J Gen Intern Med. 2005;20:677–82.
Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous.
Please send scenarios to Caroline Wellbery, MD, at firstname.lastname@example.org. Materials are edited to retain confidentiality.
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