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February 5th, 2014

Electronic Medical Records, Eye Contact — and Dogs

Louie looking at youA few thoughts on the importance of eye contact during patient care, no doubt inspired by my puppy’s first birthday, and his insistent and adoring (at least that’s how I see it) gaze:

  • Long piece in the New York Review of Books — all doctors subscribe, of course — by Arnold (Bud) Relman, describing his experience as a 90-year-old who survives a fall. Riveting, moving, and typically curmudgeonly stuff from the ex-Editor-in-Chief of the New England Journal of Medicine. But this line deserves emphasis:  “During the day I was visited on rounds by teams of physicians. They spent most of their time outside my room, studying and discussing the data on their mobile computers.
  • How do interns spend their time in the era of electronic medical records? Let’s look at the data — “Interns spent 12% of their time in direct patient care, 64% in indirect patient care, 15% in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40% of interns’ time.
  • Or, for a more poetic description, read Abraham Verghese’s brilliant description of the “iPatient”:  “On my first day as an attending physician in a new hospital, I found my house staff and students in the team room, a snug bunker filled with glowing monitors … the demands of charting in the electronic medical record (EMR), moving patients through the system, and respecting work-hour limits led residents to spend an astonishing amount of time in front of the monitor.”
  • One of my colleagues in General Medicine, Jeff Linder (who parenthetically does some nice ID-related work too), found that the number one barrier to use of electronic medical records during an outpatient visit was loss of eye contact with patients  — which does not surprise me a bit.
  • The solution? Get a medical scribe to join you in the exam room so you can actually look at the patient while taking the history. This is the money quote from this wonderful New York Times piece:  “For decades, physicians pinned their hopes on computers to help them manage the overwhelming demands of office visits. Instead, electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer.” FYI, after reading this piece, every single colleague of mine wants a scribe now.
  • The hospital periodically receives patient surveys from these guys. The leading complaint, of course, is parking — this is Boston, after all. But in the Top Five Complaints is also something along the lines of, “That doctor seemed more interested in the computer than in me.”
  • Department of Oversharing:  I recently saw a doctor for an eye issue, and he was very competent and nice. He spent 90% of the visit (aside from the exam part) entering what I was telling him into his electronic medical record. The computer was situated far to his left, so he was facing away from me the entire time; I could have put on this hat, he never would have noticed.

OK, so I’m nearly done. Except to comment that we used to be able to take notes while facing our patients, and that this allowed a kind of organic eye contact that seems all but impossible in the electronic medical record era. Note that I won my 8th Grade Typing Competition (72 words/minute, thank you), so don’t blame inadequate keyboarding skills.

And since this started with a dog (dare you to click on the image above) and eye contact, I might as well say that they run rings around both cats and us electronic medical records-obsessed doctors when it comes to this skill.

Enjoy more dog magic in this wonderful documentary:

12 Responses to “Electronic Medical Records, Eye Contact — and Dogs”

  1. Joel Gallant says:

    It’s incredibly frustrating, but in the outpatient setting, where I now spend all my clinical time, I’ve learned to imitate “the old ways” as much as possible. I use the computer to open the patient’s chart at the beginning of the visit, and to order what I need at the end of the visit. In between, I face the patient, make eye contact, and scribble notes on a pad of paper. In the days of paper charts, documentation waited until after the patient left the room, so there’s no reason it can’t wait now. It takes a little more time, but it’s worth it!

  2. David Ferris says:

    I invite the patient to join me as we look at the computer screen together, reviewing the labs, updating the problem list, ordering tests, cursing the insurance company + the pharmacy benefits manager as a doctor-patient team: helps build the therapeutic alliance. If the patient can type, even better!

  3. Loretta S says:

    I do pretty much what Joel Gallant said. I use the computer to order tests and Rxs, to check the vitals that the MA took, to look at the patient’s list of problems (still don’t like that term), review labs old and new, maybe take a peek at an older note written by a colleague, and that is about it. I don’t open up the EMR until I have at least faced the patient and asked “so, what brings you in today?” and get an answer. I then scribble on a notepad, making as much eye contact as possible. My patient’s body cues are often important pieces of information I would otherwise miss. I still often put down even the pad and pull my rolling seat up close to the patient and just listen and discuss. The upside is my patients feel like I am paying attention to them and I feel like I am not missing important cues (or completely giving up my soul). The downside is my colleagues who type on the computer are done with their visit notes way, way, way before I am. :( As in, as the patient walks out of the room. Sigh.

    Love the squid hat! And Louie, of course. Awwww.

    P.S. Sent the New York Review of Books article to many colleagues when it was first published online. it should be required reading for nurses and physicians alike.

  4. CT Lin says:

    Surely you don’t suggest returning to days of paper, with charts missing 30% of the time, illegible handwriting sparking frustration, medical errors of omission and commission.
    There are courses on Physician-Patient communication, now built to include EHR’s in exam rooms (disclaimer: I teach one of these workshops). I maintain it IS possible to engage the patient AND use the computer to improve care. Frankel and others have shown that having a computer in the room can improve patient satisfaction. I find that true in my practice: currently I will:
    -have the patient sit side by side with me as we look at the computer (triangulation)
    -jot a few words in the HPI while the patient speaks (full sentences are added later)
    -put down the keyboard and mouse for crucial conversations
    -review previous notes, results and flowsheets on the screen together
    -order meds, tests together
    -jot a few personalized instructions and/or use templates for common advice into the Patient Instructions section that prints out to go home with the patient.

    This works well, patients often use my printed instructions to complete their “homework” and the cycle begins again. It CAN work.

  5. It’s amazing how often we grasp at technological fixes to solve problems when the real answer is within ourselves.

  6. Paul, A BWH alum is looking to remedy this problem. Check out the above web site to see what happens when doctors design EMRs instead of computer programmers (well, the programmers helped a little).

  7. Sorry, don’t think the website published. Here it is: http://www.modmed.com

  8. Neil Siegel says:

    I’m a practicing family physician. For nine years in the pre-EMR era I taught “Intro to Clinical Medicine” small groups at our academic medical center. As they learned interviewing skills, some med students kept their faces buried in the paper chart the entire time to make sure they asked “all the right questions”. They wouldn’t have noticed your hat either. Other students kept perfect eye contact the entire time, but left the room not remembering key details of what the patient told them. And then others found the “sweet spot”, jotting down occasional notes while still engaging the patient.
    EMR is just a new tool, much more powerful than pen and paper. It doesn’t HAVE to change effective doctor-patient interaction, except for the positives that Dr Lin and others outline above. Instead of venting negative energy against the tool, let’s focus on promoting best practices to maximize the patient’s experience AND quality of care.

  9. Sous says:

    I do something similar to what David Ferris does, my fellowship clinic is at the VA. I love CPRS, I only need to include what it’s important, not what’s billable.
    I turn the screen to face them, we review labs and other data together. The patient sees the history to make sure I am getting everything right, and we go over the plan together as I am writing it. The visit is more of a conversation with the computer screen in the middle, it feels more like a partnership. I wish I can do the same on inpatient rounds. It’s better patient care and I would not be finishing my notes at midnight.

  10. Janaki Kuruppu says:

    I do a similar process to what David Ferris and Sous describe, and I really find that the EMR allows me to have BETTER eye contact with my patients, in part, thanks to my 7th grade typing teacher.

    if i couldn’t touch type, it would be a hindrance.

    i enter the exam room (most of my time is spent in clinic), and spend the first 1-5 minutes – depending on the encounter – directly facing the patient. once we get into information that I want to make sure i don’t forget, i open up the patient’s electronic chart – usually, using EPIC, it’s already open, but secured by the nurse who did the medication reconciliation, so it’s just a matter of unobtrusively entering my username and password). usually, i accomplish this without the patient being bothered by it. it doesn’t feel intrusive.

    sometimes, my goal in opening up the chart is to share lab results, and, i turn the screen to the patient, so we can both view it easily. i keep the screen so that the patient can see, as i enter information inother areas of the history, or the PN itself. i like that the patient gets the message that I have nothing to hide – there’s no secret documentation, it’s legible, and i’m open to the patient correcting anything they see that is not correct in the chart.

    and, i can maintain eye contact almost the whole time, more so than i could with paper and pen before.

  11. OK, the hat broke me up.

  12. When medical documentation is created efficiently outside of the exam room, clinicians can better engage with patients and be present in the moment during exams. Clinicians aren’t distracted by having to key in medical data into a computer system, improving the patient experience.

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