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EHR Etiquette

I had an interesting juxtaposition of events. While waiting in Peets, a coffee shop in Lexington Center, I watched the friendly discussions between the baristas and customers. I then went to a doctor’s appointment, where a nurse stood typing at a laptop asking me a series of questions, including “Are you in pain?” and “Do you feel safe at home?” 
She didn’t look at me once as she read and typed.

Eye Contact with the Patient, Not the Computer, Is Paramount

Shouldn’t the intimacy of these questions mandate more eye contact than the less consequential discussions about today’s special roast and the weather? This is not jumping on the “customer” bandwagon, which has extended to some schools using “customer” instead of “student”. This is a matter of respect when asking personal questions and effectiveness at eliciting a meaningful response.

Ted Eytan, MD, MS, MPH, empathized with my experience. After his practice implemented an EHR, a patient told him, “You’re the only doctor who has looked me in the eye in the last 6 months of coming here.” Ted said, “It was like a dagger in my heart to hear that, and I am sure it would be for any other clinician.”

Computers in the Examining Room Should Not Be “Mysterious Intruders”

Danny Sands, MD, had great insights on what happens when a computer is introduced into the examining room. He said, “Interacting with a patient alone is a two-way conversation.  However, when there is a computer in the room, it is part of the conversation.  It both processes and provides information, and, because of that, it must be positioned in such a way that it can be a part of the conversation without being an imposition, just like if there was another person in the room. Ideally, with a laptop or desktop computer, the computer would be at the apex of an equilateral triangle with the human participants at other vertices.  With a tablet computer, the computer should be held by the user as they sit side-by-side.  In either case, the screen should be easily visible to both (but it should be possible to temporarily shield it from the patient when necessary). Too often, as in the situation you describe, the computer is a mysterious intruder in the room, and the goal of the clinician is to interact with the patient only as a means to the end of entering the appropriate information into the computer program.  This can be blamed on poor room layout, bad user habits, and badly-created user interfaces. Some would also blame the bizarre reimbursement system that rewards quality documentation above quality care.”

EHR Etiquette Should Include “Emotional Contact”

Pamela Katz Ressler, RN, BSN, HN-BC, similarly, believes medical professionals have prioritized information gathering over communication. She said, “While it is essential to collect information to arrive at a correct diagnosis, simply collecting information without addressing the human experience creates disconnection instead of connection; often leading to dissatisfaction by both the patient and provider.”

Joe Kvedar, MD, agrees with Pam about distinguishing between collecting necessary data and connecting with patients. When patients invest so much to get to and be in a doctor’s office, he believes, they deserve emotional contact including eye contact. Joe and I discussed telemedicine and how the “technical artifact of how cameras are placed on laptops” limits gaze awareness.

The different technologies for physician-patient communication all convey different types and amounts of information, Joe went on to say, and too much focus is on tools, rather than human communication. I remember when airports first used kiosks for check-in, and I answered questions on a screen about transporting packages that had been given to me by strangers. While I appreciated the speed of check-in, I felt less safe boarding a plane, hypothesizing that trained airline personnel might detect terrorists by tone of voice, facial expression, or body language. Just like, as Joe said, doctors obtain an enormous amount of information from looking at their patients.

Beverley Kane, MD, who teaches about EHR etiquette and worked with Danny on the first email guidelines for physicians, agrees. She noted the irony of how people tell their hairdressers more than they tell their doctors. Beauticians are often far more responsive and more sympathetic.

EHR’s Do Not Inherently Dehumanize; It Depends on How They Are Used

Following my experience with the nurse, the doctor walked in, shook my hand, and looked at me almost the entire time. He looked up one piece of information on the laptop in the corner – no triangle here – but it took under a minute.

My day ended at my acting class, where, coincidentally, we did exercises that focused on eye contact. In one, we tossed a ball at someone only after establishing eye contact; another was about the impact of physical distance and observation on intimacy. These exercises increased my own sensitivity to how powerful eye contact is, and how different stimuli, like touch and sight, can reinforce each other. Ultimately, better healthcare outcomes will come from verbal and non-verbal communication that is as attentive as in the coffee shop – or at the hairdresser’s.

Lisa Gaultieri is Adjunct Clinical Professor in the Health Communication Program at Tufts University School of Medicine. Lisa teaches Online Consumer Health and Web Strategies for Health Communication. A social media user herself, Lisa (Twitter, LinkedIn) blogs on health and is Editor-in-Chief of eLearn Magazine, where she blogs on healthcare.

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http://tinyurl.com/gwen-8153940796Chris RiveraNabeelUsed laptopsDesert River Recent comment authors
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http://tinyurl.com/gwen-8153940796
Guest

I found this specific blog post , “EHR Etiquette | The Health Care
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Chris Rivera
Guest

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Nabeel
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Used laptops
Guest

I would like to appreciate the work of blog author that the person provided us with an extremely excellent information regarding the topic. I really learned something from this blog and started to contribute my ideas via commenting on this blog. Keep it up!

Desert River
Guest

The balance between doctor-patient and doctor-chart interaction is something that has been an issue for a long time. Whether a paper file or EHR system is used, it is imperative that practitioners do not view their patient as a number or case. This being said, I for one would prefer that my doctor use every available technology to it’s fullest potential. If this means a little less face time, so be it. I do agree with some of the above comments that a shared display would provide the patient with a sense of involvement while not encroaching upon the doctor’s… Read more »

Sree
Guest

I totally agree. No technology can provide emotional support to the patient who is in great distress. We must encourage the doctors to consider the emotional aspect too.

Danielle E.
Guest
Danielle E.

The comparison made between a hairdresser and healthcare worker is as simple as communication. The hairdresser is focusing on you and conversing while the healthcare worker begins to be more focused on the computer and questions needing to be asked than what the patient is in deed feeling. I certainly agree that entering information into the computer system in short spurts can definitely gain more trust between the patient and the healthcare worker. More time should be spent focusing on the patient’s needs. Most of the charting can be done before the patient enters the room (Patient history) and I… Read more »

Lisa Z.
Guest
Lisa Z.

As a nurse in homecare practice, I use a PDA for documentation. I cannot tell you how any of my patients complain that nurses and doctors come into their homes and spend more time clicking and pointing at the computer during a visit then actually paying any attention to them. Most of these patients believed that they didn’t matter, that they didn’t feel the nurse or doctor paid much attention to their needs or concerns, and that they felt rushed through an exam in order for the nurse/doctor to get enough information to fill out the computer criteria. This leaves… Read more »

Adam Gross
Guest

This conversation points to an potential ROI model for an EHR designed to maximize engagement (e.g. encourage eye-contact, screen-sharing, and interaction). Isn’t there data that correlates patient trust with the likelihood of a malpractice suit? The excellent EHR etiquette ideas advocated here and elsewhere would all increase trust.

Wendell Murray
Guest

“I spoke with him recently and he had just installed a 32 inch LCD panel so his patients could see what he was charting, etc.”
One possibility, although I like the idea of using cuneiform on clay tablets better. That is a very slow means of recording data, but can last a long time and provides entertainment to some archeologist thousands of years hence to try to decipher the cuneiform. Of course the cuneiform would be used to encode HL7 messages, so it will be that much more difficult for the archeologist.

Graham Chiu
Guest

I have considered installing a 46″ LCD behind the patient so that I can chart while looking at the screen, and easily make eye contact with the patient.
And just like the empathic hair dresser, I’ll ask the patient to tilt their heads down so I can see when they are blocking parts of my screen.

InfoMark
Guest
InfoMark

My former doc in New Mexico installed an EHR, aided in small part by one of my final acts as an EHR adoption program manager, before I fled the state. I spoke with him recently and he had just installed a 32 inch LCD pannel so his patients could see what he was charting, etc. He is an exceptionally patient centered practitioner. I wish more, many more, were like him.

Joseph Stevens, MD
Guest
Joseph Stevens, MD

Alas, an othopaedic surgeon who participates in conversation with patients, or is he deceiving himself?
The author is miss clicked. The new etiquette, actually: The professionals see the computer as the patient whereas the patient sees the computer as the doctor. The doctor and hospital see the patient as grist for the cash register.

Sandwich Generation
Guest

I think this article addresses a common problem with the implementation of any kind of technology that is intended for use during direct customer interactions. I work for a large integrated provider org, and I’ve had varying experiences with providers here as a patient. Our exam rooms are set up so that the provider can move the PC and screen around if they choose. Some providers are very comfortable touch-typing and make intermittent eye contact with me while getting all the info into the system all at the same time. Other providers make eye contact and then switch to looking… Read more »

Steven Zeitzew, M.D.
Guest

This is not an artifact of the EHR software it is an artifact of the hardware and the ergonomics. I began creating electronic medical records in 1983 after the 1st true laptop computers became available (a Data General One). I found I was able to maintain much more eye contact with the patient I was interviewing than I had with paper and pen, because I could touch type and maintain eye contact throughout the encounter. Here at the VA I am required to use the VA supplied hardware, software, and network in a VA designed clinic room. There is a… Read more »