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

                     

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.

EHR Go-Live Footwork

I wear a Fitbit digital pedometer, a gadget my colleague Dr Aaron Neinstein wrote about recently. Below is what our EHR go-live night looked like in terms of footwork, with the “T minus 2 hour” midnight mark at far left, and “T plus 22 hours” at far right. Fitbit’s online graph insists on displaying calendar days so the afternoon and evening run-up to the go-live does not show here. The stretch of inactivity at midday is me getting some sleep. Graph of pedometer readings for UCSF Epic EHR go-live

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.