Bringing the EHR into the Physician-Patient Relationship

Like many other middle-aged physicians, I used to have recurring negative thoughts about my practice's EHR:

"Please make it go away."

"Maybe I'll retire before I really need to start using all aspects of the EHR."

In their article in Family Practice News, November 2010, authors Dr. Skolnik and Dr. Wilkinson raised many excellent questions in regard to the use of the EHR:

1. Will technology interfere with the humanism and patient interactions that form the heart and soul - if not the science - of medical care?

2. Will placement of a screen in the room divert the physician from giving direct attention to the patient in favor of inputting required data?

3. Will the "narrative" of the illness - the description of the patient experience - be lost as the representation of the disease is narrowed to discrete data fields?

The EHR, in some form, is here to stay. However, when it comes to the use of computers, many physician practices clearly lag behind the rest of the world and society as a whole.

Here are a couple of typical statements I've heard from patients:

"I didn't tell the nurse I was suicidal because she never looked at me when she asked the question. I figured she didn't really care."

"I want to see a different specialist. He just kept his head down typing the whole time. He's a computer doctor, not a real doctor."

I've tried hard to not allow the EHR to adversely affect the physician-patient relationship. Here's my approach after settling in with the EHR over the last few years:

1. Every visit still starts and ends with a personal interaction. It doesn't take long to briefly socialize by asking about a patient's family, occupation, and/or hobby. I also always make sure to include short periods of non-computer use because eye contact with patients and an understanding nod are not part of the EHR.

2. I evaluated the physical design of my exam rooms. I've seen some offices in which the physical layout of the room is less than optimal, due to the physician having his back to the patient and/or the family members at times. Obviously, a layout such as this does not allow for ideal non-verbal communication.

3. If I sense tension in the room or am in the midst of a difficult patient encounter, I've found it best to move away from the computer. Unless I move away, the tendency is to keep my head down looking at the monitor for answers that usually aren't going to be found on the computer screen.

4. I remember that it's an advantage and a disadvantage for patients/families and others to easily read my records, compared to hand-written notes from "the old days." Medico-legally, if it wasn't recorded it wasn't done. But, the corollary is also true: If it wasn't done, but was recorded, it's fraud. I make sure to delete parts of a template that were not done, not addressed, or not needed.

5. Technology is a tool that I utilize for patient care; it does not and should not replace the fundamentals of patient care, or common sense for that matter. A long and impressive looking office note with no "substance" helps no one. If an acute visit, for example, only needs a short note, I will only free text a short note.

6. I try to never complain about the EHR to the patient, and also try to explain and show how the use of the EHR can improve patient care. Getting the patient to look at something on the monitor such as the tracking of blood pressures, for example, is an excellent way to do just that.

A study in the Canadian Family Physician (Jan 2010) found that there was a correlation between patient satisfaction and their perception of the doctor's skill with the EHR software. Also, patients who felt the office was positive about EHR use were also more likely to be happy with the visit.

Change is never easy. As Woodrow Wilson said, "If you want to make enemies, try to change something." It's in the best interests of our patients to try and get along with the EHR. If I've been able to do it, anyone should be able to as well.

I think the real challenge for the future is trying to figure out the best way to combine the tech-savvy expertise of many young physicians with the excellent communication skills of many tech-un-savvy older physicians. I know I can teach young physicians a lot about communication skills and I know they can teach me a lot about technology.

I love the following quote by Michael Kirsch, MD: "Patients admire Dr. House's diagnostic acumen, but many still want Marcus Welby as their own doctor." That's exactly what I want when I see my own doctors, as a patient.

William T. Sheahan, MD, is the medical director for the Home-Based Primary Care Program at the VA Medical Center in Orlando, Fla. He completed a residency in family medicine and a fellowship in geriatric medicine at Riverside Regional Medical Center in Newport News, Va., and is board certified in family medicine. He may be reached at editor@physicianspractice.com.

This article originally appeared online in the Physicians Practice website, July 2012.