Seven tips to prevent medical technology from ruining the doctor-patient relationship

Does this sound like something that has happened to you?  You are driving, you stop at a red light, and all of a sudden you find that your iPhone has migrated its way from your pocket or the passenger seat of the car into your hands.  You push an elevator button and pull the phone out of your pocket to glance at it in that split second while waiting for the door to open.  You eat dinner with a group of six friends and everyone is buried in Facebook rather than making eye contact.  In all facets of life, we are quickly becoming more entangled with our machines, allowing them to become extensions of ourselves.  The hallowed walls of the doctor’s office have not shielded out this rising tide.  This “Piece of my Mind” by Elizabeth Toll in the June 20th JAMA eloquently captures what so many of us have been feeling and seeing over the last few months and years.  Here is an excerpt of her opening paragraph and the drawing she discusses:

Dr. Toll goes on to discuss how this particular physician is someone overflowing with empathy for patients and enthusiasm for medicine.  Unfortunately, the computer has now demanded his attention, which he can no longer fully devote to his patient.  I agree wholeheartedly with Dr. Toll and I hope that her article will spark a dialogue about this issue in the medical community.

Part of the problem is the current generation of electronic health record (EHR) systems.  They demand too much cognitive effort to use.  In fact, Horsky et al showed that users of a CPOE system used twice as much cognitive effort on system operation as on patient-centered clinical reasoning.  This balance has to shift.  Nobody wants her physician wasting his energy and focus like this.

This improvement in EHRs will happen.  As was pointed out on Twitter this morning by @ReasObBob: “#EHRs will get better. Poor EHRs are not the problem but the symptom. New approach needed. We’re working on it.”  Bob is right.  The current generation of EHRs has been built to meet the demands of a healthcare system that is focused on compliance and billing.  We got what we asked for.  This time around, let’s ask for what we really want.  Let’s ask for EHRs that are sleek and streamlined, easy to use, and that augment the high-quality and high-empathy medical care we want to provide.

What are physicians to do in the meantime?  I have spent some time in the last few years thinking and reading about this.  How can we best maintain the doctor-patient relationship in the age of the EHR?  I offer you seven tips:

1) Set-up your office properly, with placement of the chairs, monitor, and keyboard to best support good eye contact between you and the patient.  Don’t allow your office to become like this drawing, where your chair could put your back to the patient.  This is common sense, not Feng Shui.  (I will post some photos of exam rooms at the bottom of this blog piece to allow you to start to think about what works and what does not work)

2) Get a quiet keyboard.  If you think this sounds trivial, try this: Spend one day in your clinic using a loud keyboard and then switch to a quiet one.  You’ll see.

3) If you can, spend thirty seconds preparing the electronic visit before you walk in to see the patient so that you are ready to hit the ground running.  You want to be immediately ready to let a patient start talking to you without interruption to start the visit.  Visits get off to a bad start when they go like this: “So, what brought you in here?”  “Well, my thyroid…” “Hold on a minute, I have to log-on and get a new progress note open so I can write down what you say.”

4) Let the patient see your screen.  Hopefully you are not reading ESPN.com when you are talking to your patient.  Let them share the experience with you, and share the fact that you are populating their medical record.  I have on many occasions had this lead to bonding moments with my patients when we are both hunting through the CPOE (computerized provider order entry) system for a particular type of glucose test strip prescription or some other seemingly hidden or obscure task.

5) For part of your visit with the patient, stop typing, take your hands away from the mouse and keyboard, and use the body language we learned how to use as first year medical students in Introduction to Clinical Medicine.  Every visit has at least one natural moment when the patient has to be certain that one-hundred percent of your attention is focused on her.

6) Practice.  Seeing patients while using an EHR is a learned skill.  None of us were able to handwrite a perfect note while talking to a patient the first day of medical school.  The new generation of medical students will learn how to talk to patients while typing from day one.  At UCSF, the new Kanbar Teaching and Learning Center has simulated exam rooms to help medical students learn this (although, embarrassingly, you’ll notice in the photos on their website that the computer monitors are buried in the corner of each exam room, assuring the “back-to-patient” syndrome).

7) Remember that this is our chance to take back the medical record.  Let us not forget that, even with paper charts, the medical chart has increasingly become about legal protection, billing, and reimbursement.  The EHR gives us a clean slate, a new opportunity that brings us legible notes and notes that are immediately visible to colleagues.  Take advantage of this.  Write good narratives.  Tell your patients’ stories.  Make the medical record useful again.

Sample photos of exam rooms

                     

Charting on the Problem List

Still in its early stages at UCSF, one week old as of today, is inpatient documentation centered heavily around the Problem List.  This has been used by some providers in the ambulatory setting over the last year, but is now being used nearly universally on hospitalized patients.  Rather than writing an assessment and plan as free text at the bottom of an admission, progress, or consult note, each relevant item on the hospital Problem List will now have a unique assessment and plan note written specifically about that item.

This has several potential beneficial effects:

1) Sharpening a physician’s diagnostic thinking.

2) Improved continuity-of-care and ability to review a patient’s chart.  Currently, if a patient named Bob has COPD and you want to find out what has been done over the last ten years for his COPD, you have to sift back through every old note in the chart, looking for the ones where COPD was discussed.  Very time-consuming.  With the Problem List approach, Epic allows you to “View All Notes” for any given item on the Problem List.  This means that with a single click, you can conjure up every assessment and plan note written specifically about Bob’s COPD, whether from the ED, ambulatory clinic, or inpatient setting, going back through time.

We think this is a very powerful tool and are excited to see it begin to improve care.

The Go-Live Progression

The go-live progression:

Day 1: “What’s NoteWriter?  I want UCare back.”

Day 2: “Do I have to use NoteWriter?  I want UCare back.”

Day 3: “Which NoteWriter templates do you think are the best?”

Day 4: “I think I can do this NoteWriter thing.”

Day 5: “Let me show you this cool NoteWriter macro I made!”

Housestaff learn quickly.

The endless creativity of the user

Before flipping the switch and releasing a live system into the wild, you build and rebuild, meet and discuss, plan and prepare, train and cajole.  You think you have a good idea of how your end users will interact with the system.  Then you go live.  And thousands of people start using the system.  Those people provide more eyes, ears, and brains in front of the system, trying to get their daily jobs done.  Just as water cuts its own path through sand and stone, cleverly, but purposefully meandering towards a final destination, so do the users.  They are endlessly creative, figuring out ways to use the system that often could not have been anticipated and that are often ingenious.  In a system that is both as deep and broad as Epic, there truly are many ways to do any one thing.  So, it is often worth sitting back and watching what people figure out for themselves before jumping in to try to teach them “the right way” to do something, because hey, we might learn a better way.

The go-live support physician “melting pot”

One of the fun parts of go-live the last few days has been interacting with the physicians who have come here from around the country to provide go-live support.  There are both endless similarities and differences in the ways that individual institutions choose to deploy every small aspect of Epic.  Being able to bounce ideas off of this community of physicians who is visiting San Francisco to observe and assist with our go-live has been very useful.

Business as usual…

The remarkable thing about providing go-live support today is that things around here seem to mostly be business as usual.  Spending several hours in the medicine resident work-room, I noticed that the main topic of conversation was not the new EHR, but patient care.  A good indicator of the positive attitude of the housestaff and the thus far relatively smooth transition to Epic/APeX.

You know you’re using an EHR when…

I just had my first “yup, we’re now using an EHR” moment.  I was working on populating Epic Problem Lists for the patients on the medical service I’m currently covering.  A not un-common “problem” we see here is the ever-familiar “waiting for placement.”  As we’ve all known for years, this is not considered a real diagnosis, and there is no ICD9 code.  We’ve always skirted the issue somewhat uncomfortably by continuing to write it into our text-based notes, knowing that it is “not real medicine” and yet at the same time knowing that it best reflects the reality of the situation.

And so, populating an Epic Problem List in the wee hours of the morning, I tried this:

There is no fooling a computerized database of ICD9 codes.  Welcome to the EHR.  I’m curious to see how we all work out a solution to “waiting for placement” that both reflects the clinical reality and the economic/billing realities.

(Side-note: I am Aaron Neinstein, a fellow at UCSF in Endocrinology, and a guest blogger invited by Dr Cucina to participate in his live-blog of Epic go-live.)