Technology: Making EMRs Work in the Exam Room

When EMR technology joins the patient-provider relationship, it becomes a three-way dance. So says Michigan State University academic internist Michael Zaroukian: “Unless the physician is facile with both the computer and the patient, it’s going to be an awkward dance.”

An apt analogy. Think about it:

Just as you want to avoid looking foolish on the dance floor, you don’t want to fumble for the right key or drop-down list in front of your patients. Patients feel comforted by physicians who exhibit competence and grace with all the tools they use.

That’s even more true for EMRs because they can be disconcerting to some patients, says Zaroukian, whose jobs include director of the university’s medical records system as well as its internal medicine clinic. Questions such as “Why is this intruder here? How do I identify it as an ally rather than a distraction?” may arise in patients’ minds, he says. “Their experience at home may be that they’re not being paid attention to by someone on the computer.”

Successful use of an EMR in the exam room depends on how adept you are with your EMR, the way you arrange your exam rooms, how well you connect with your patients, and whether your patients believe that an EMR will directly benefit them - and is not just some “cool toy” for you. Thankfully, solutions abound. Here’s how to make this three-way relationship an elegant pas de trois and not a toe-stomping tango.

Know your stuff, doc

An early adopter of EMR, Community Care Family Medicine in Clifton Park, N.Y., implemented its chosen system, NextGen, in 1999. Eric Schnakenberg, one of the practice’s family physicians, remembers the patients’ reactions well: “They immediately connected to the fact that we were using a laptop,” he says. “Quality of care immediately went up in their eyes.”

Sarah Corley, a physician who is chief medical officer for NextGen, remembers a similar reaction. However, she says that it’s critical that physicians practice using their new EMR until they are comfortable with the functionality; otherwise, patient reaction could be somewhat negative. A 2002 study by the Mayo Clinic supports this: While 75 percent of people surveyed felt that using computers in the exam room had a positive impact on quality of care, patient satisfaction directly correlated with their rating of a physician’s computer skills.

How you actually interact with your EMR can affect your learning curve. Make sure it works for you. Schnakenberg likes the tablet-style IBM ThinkPad for his practice because it satisfies varying preferences among the staff. “I find the keypad essential,” he says. “One of the nurses uses the dropdown menus.”

EMR vendor MD Logic offers a keyboard-free, mouse-free, and dropdown menu-free alternative solution: touch screens with big buttons. “The way our screens are laid out, it looks like a bartending screen,” says Tom Bierster, CEO of MD Logic.

The idea here is speed. “Look at anything designed for speed these days, like voter booths, or airport check-in kiosks. Everything is a big button,” says Bierster. “[Physicians] can’t afford to slow down just because of technology, especially with reimbursements going down, too. If it slows them down, they’re not going to use it; they’ll deep-six it.”

You don’t need to be an absolute whiz with your EMR before you unveil it to your patients. But ’fess up: Let your patients know you have a new system, and therefore you might be a little slower in finding things, says Corley. “You have to be upfront and honest about it.”

Bierster concurs: “A lot [of success] has to do with educating your patients on the technology, saying, ‘We’re not going to be super-speedy on Day One.’” Whatever system you choose, you’ll have to get through the novice phase. Enthusiasm for the technology, patience with yourself, and honesty with your patients are key to easing the transition.

The importance of presentation

Want to expedite patient approval for using an EMR in the exam room? Position the EMR so you can involve the patient during its use. Maintaining a line of sight with your patient is crucial. “I’ve seen a number of practices where they just set it up on the counter near the sink,” says Corley. “Look at every exam room. You might need different solutions for different exam rooms. It does require some thought. But you absolutely just cannot set it on the counter and turn your back on your patient.”

At Community Care, exam rooms are small - only eight feet by eight feet. The practice reclaimed some critical space by reversing the doors so they swing out. “We have a small table and chair so we can interact with the patients,” says Schnakenberg. “I can flip the screen around and show the patient. I can even bring the laptop to the patient on the exam table.”

Whatever your circumstances or EMR choice, make sure you and the patient can look at each other easily without unnatural body movements. “We designed the rooms so that where we sit we have good line of sight,” says Schnakenberg. Indeed, patient and physician sit knee-to-knee at Community Care.

Bierster of MD Logic recommends attaching a flat-screen monitor to an expandable wall bracket so that the physician can pull it over to the patient - a workable solution for a touch-screen.

Another option is to purchase mobile carts for your EMR computer, although they can be costly. A little creativity can stretch hard-earned dollars. Corley says, “We spent about $35 and had these custom-made little shelves made so we could make eye contact.”

Can you hear me now?

Connecting with your patients is always important, but when you add an EMR to the mix it becomes even more so. “The nature of having a human being interact with a computer is innately unnatural,” says Lawrence Schilder, oncologist at and director of the Midwest Center for Hematology and Oncology in Joliet, Ill. “Patients are very happy we’re on top of things. But they’re unhappy that we have to sit at a computer terminal.”

This unhappiness can spring from many sources. Schilder, whose practice uses IMPAC’s oncology-specific EMR, describes one encounter that occurred when he was busy entering some critical information into the EMR. “The patient got quiet - really quiet,” he says. “I finally turned and asked why. She said, ‘I don’t want you to make a mistake.’”

If your EMR is new to the practice, take some time to “introduce” your patients to it. Explain its basic purpose. Answer their concerns about privacy.

Even if you’ve had your EMR for awhile, don’t assume that all your patients are happy with the way you use it. Seek that critical connection with a patient “almost every moment,” Zaroukian says. “You have to know whether or not you’re connected to the patient, and every time you’re not looking at them, you could miss it.”

An EMR can be a fantastic tool for reaching into a patient’s sensibilities if the time is right. Zaroukian calls this an “aha!” moment. For example, if you have a patient who smokes and you show her a screen that explains how her risk of a heart attack decreases dramatically over 10 years if she stops smoking now, this can be a very teachable moment. But you have to be connected to the patient enough to perceive any underlying reasons why the patient smokes in the first place, such as she’s living in an abusive situation, and smoking is a coping mechanism. “You have to have the common sense to know when a patient is being logical,” says Zaroukian. “Then looking at an EMR together is fine. When their comments are emotionally charged, that’s not the best time to look at a screen.”

Finally, it can be easy for patients to blame an EMR for “capturing” a physician’s attention. But your own personality and practice style will largely dictate whether this complaint arises. “In the past, you could always get buried in the paper chart just as easily,” says Zaroukian.

What’s in it for them?

Show a patient how he can personally benefit from you using an EMR during an exam, and you’ll likely gain quick approval. Tell your patient that keeping a complete, accessible, and secure medical record will help you to deliver better care, and that the EMR will help to expedite traditionally slow activities, such as receiving lab reports or consult letters. Also, gain buy-in by keeping patients apprised of what the EMR is doing while you’re ensconced in an office visit with the patient. “It’s important that the physician involve the patient,” says Corley. “Right now the system is checking for drug interactions, or projecting their cholesterol levels over time.”

Finally, think about patient compliance, which by some estimates runs less than 20 percent. Perhaps it’s partly a memory problem. You might prescribe a medication that can be taken only with food, for example. You explain this “but patients are often nervous in an exam room and can’t remember what you’ve told them,” Corley notes. Then they go to the nurse and ask, “What’d he say?”

Your EMR can print out patient-centric information and a summary of the day’s visit. Schnakenberg says that all patients leave his office with a detailed printout. With elderly patients this is particularly beneficial, as “they can give it to an ER physician in Florida,” he says. It’s not a complete note, but it gives an unfamiliar physician a reasonable idea of what’s going on with a particular patient, from health concerns to drug usage.

Surely, an EMR offers many advantages to both your patients and your own practice operations. But, as Schilder says, “There are no unmixed blessings.” Spend the necessary time and attention to ease your patients’ concerns about this powerful but rather daunting piece of technology. Your patients will be glad you did.

Shirley Grace, senior writer for Physicians Practice, holds an MA in nonfiction writing from The Johns Hopkins University. Her articles have appeared in numerous publications, including The Washington Post and Notre Dame Business magazine. She can be reached at sgrace@physicianspractice.com.

This article originally appeared in the February 2008 issue of Physicians Practice.