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.

22 replies »

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  3. 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!

  4. 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 ability to enter, research, and review the appropriate data.

  5. 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.

  6. 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 think if the healthcare worker can give themselves just a few minutes in between they can easily chart any necessary information upon exiting.

  7. 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 the patients very frustrated. I teach new nurses out in the field, and one of the first things I teach is ettiquette and documentation. There is a way to do an assessment and cover many questions while interatacting with eye contact in conversation. This information can then be entered in a system in short spurts of time without being totally focused on the computer. Making eye contact with patients not only makes them feel safe, cared for and comfortable, but in return it allows us to gain more information from them allowing us an easier time to make a diagnosis and treat properly. The patients feel they are getting their needs met and trust us more, and we are able to do our jobs more effectively. We are not saving time by burying our heads in our computers, in fact the opposite is true.

  8. 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.

  9. “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.

  10. 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.

  11. 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.

  12. 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.

  13. 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 at the screen for a moment or two. I suspect they spend a few minutes finishing up their data entry in the system after I’m gone.
    Overall, I think that providers can and should make the patient feel comfortable during the encounter. Some patients may require the provider’s complete attention to feel comfortable, whether the provider has to ignore a paper chart, a tablet, or a cart-mounted PC. Others, like me, tolerate a little data entry during their exam because they know that leads to things like having my meds waiting for me by the time I get to the pharmacy. I’m sure that some providers have a hard time acquiring this new skill, and that many existing EHRs are ‘clunky’. The potential benefits to the health of all of us from quality electronic documentation are great – I think we all have to work through this awkwardness to get to where we need to be.

  14. 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 workstation on a desk that requires me to face away from the patient. Although the software is much more robust than what I had created on my own the, hardware and ergonomics interferes with the patient interaction. I don’t think this is an electronic healthcare records problem I think this is a hardware selection problem and an ergonomics problem.
    Steven Zeitzew, M.D.
    Orthopaedic Surgeon

  15. I think the general point of maintaining interaction with the patient is extremely important and usually overlooked. The suggestions from Dr. Sands are excellent. However, and unfortunately, the time constraints of seeing all of one’s patients while trying to ‘figure-out’ the EHR screen and trouble-shoot the notebook and share the information and talk to the patient have eroded the doctor-patient connection. Perhaps when the day comes where we aren’t reimbursed for the quantity of patients we see, we will be able to spend more time establishing the relationship.
    Engaging patients by having them fill-out their own info in a kiosk or online does help to bring them into the process and alleviates some of the manual entry. Additional roadblocks are that the ‘standard’ exam room is not ergonomically set-up for seeing patients with the addition of electronic media, hopefully this will change. In addition, not everyone can afford or has access to computers in rooms and the idea about the double-sided screen…if HI-TECH money will pay for it, fine, but right now our IT costs are the largest and quickest growing portion of our overhead.

  16. @Margalit: Not only weren’t patients offered paper charts to look at, they were sometimes reprimanded for doing so on their own. My mother once hat a negative encounter with a nurse who tried to berate her for looking at the chart sitting right beside her. I agree completely: tools are used or misused by people, not the other way around. Some doctors will be rude and insulting, even if they were stripped of everything and sent back to the days of clay tablets. Others will always try harder, and use whatever tool works to help their patients. Technology is a tool, no more, no less.
    Do different tools offer different opportunities for abuse? Of course. For example, radiation in large doses over time has the potential to do great harm. But in limited doses, x-rays can and do offer many health benefits. Throwing the baby out with the bathwater is not a constructive way of debating merit. We have to find ways to find weaknesses in whatever we do, assume someone will try to exploit them, and do what we can to decrease risk.

  17. I do understand what you are saying it has happened to me. Although, it happens no matter whare you are today. There are not too many instances where I feel that people in these positions are truly interested in the person.

  18. The questions are dictated by JCAHO. The nurse asks them like a robot because he/she is an extension of that robot. There are screens that require attention in the EHR that were never part of the paper chart, so they are not the same, Margalit.
    It is not the computer, but the do-gooder that has taken over the nurse’s job to determine what is important for that patient encounter. Too much useless bureaucratic meddling, brought to the bedside by the wonder of electronics.
    With paper it was too cumbersome to see if the RNbots had gathered the fluff.

  19. Here’s an idea: two-sided screens on laptops. The physician can share what is in the record as it is being typed, without having to situate things at a weird angle.

  20. So here is something I don’t understand: Why is the computer considered such an obstruction and the Paper Chart is not?
    We all experienced the nurse laying the chart on the counter and writing stuff in there, with her back turned to the patient sitting on the edge of the exam table. Maybe she would look at the patient while taking vitals and adjusting the BP cuff, and then it’s back to the paper chart.
    When done, she would take the chart and put it in that little plastic thing outside the door, where the doc would pick it up from and read enough to pretend he knows who the patient is, or read nothing if it’s a frequent flier.
    At that point, it’s up to the doctor’s personality. Some would chat and listen, others would open the chart and flip around and then start writing stuff down. I saw one doc dictate the entire note, write the scripts and lab orders, while the patient just sat there on the edge of the exam table covered with a big Kleenex. I also saw doctors who insist on a conversation in their office after the exam, when the patient is humanized again by sitting across the desk fully dressed.
    And just recently, I observed a doc that just moved to EHR and wasn’t confident with his tablet just yet. He didn’t even bring it into the exam room, but then I realized that he never brought the paper chart in either.
    Unless your doctor can flip pages, read and write on paper while looking at you, I would submit that EHR or paper is irrelevant. It’s about the doctor’s personality and the way they always practiced.
    Maybe initially, it takes a little time to get used to the change, but there are ways around that and sharing a view of the EHR with the patient is interesting and I’ve seen it done, but I don’t recall anybody letting patients browse their paper charts.
    So barring the fact that EHRs are still in the clunky stage, I am not sure what the inherent problems due to the sheer presence of computers really are.

  21. One way to address this would be to share the screen with the patient. Engaging the patient in what is being captured I think is a great way to be more transparent and to make the computer part of the experience instead of a distraction.