Making the computer invisible: It's all about the personal contact

Technology in the exam room doesn't have to come between you and your patient. Physicians and others tell you how to make your computer, laptop or handheld fit seamlessly into a visit.

By Mark Moran — Posted Feb. 13, 2006

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It's a common fear of physicians upon introducing technology into the physician office -- computers getting between doctors and patients, with physicians and staff spending time staring at a screen instead of looking into a patient's eyes.

This doesn't have to happen. Many physicians have found ways to bring information technology into the exam room without upsetting patient-physician interaction. In fact, studies have shown that patients are comfortable with the presence of a computer in the course of an examination and that they find its use helpful. Other studies have shown that the computer can enhance good communication between physicians and patients.

On the other hand, studies also have shown that if patient-physician communication hasn't gone well or a visit is poorly organized, a computer in the exam room likely will make those problems much worse.

Making a computer as invisible or as unobtrusive as the sphygmomanometer hanging on the wall, experts and physicians say, involves placing the device in the right spot, making eye contact with your patient more than your technology and perhaps even letting patients see what's on screen.

"Whether you are using a paper chart or a computer screen, you have to engage the patient," said family physician Les Wilson, MD. He and his wife, family physician Vicki Erwin-Wilson, MD, are partners in Wilson Family Medicine in Tallahassee, Fla. "I can swivel the computer screen around and show patients part of their medical record. That really helps engage the patient.

"Technology isn't going to impair the doctor-patient interaction. If you are a good listener, you will be a good listener whether you are in the paper world or the world of technology."

Help or hindrance?

The worries about computers getting in the way of care was described by Steven J. Angelo, MD, assistant clinical professor of internal medicine at Yale University School of Medicine, in an editorial in the March 13, 2002 Journal of the American Medical Association. He describes a Christmas Eve night when the computers went down on the floor of an intensive care unit.

Arriving back at the nursing unit after making his rounds, Dr. Angelo found the station deserted.

"As I stroll down the hallway on my way to the radiology department, I discover where everyone has gone--they have all migrated to their patients' bedsides," he writes.

Then, a half-hour later, the computer system is running again. "Like moths to a light bulb," physicians and staff eagerly returned to their computer screens to check patients' numbers.

"There is a palpable sense of relief," Dr. Angelo writes, "but for me there is melancholy, because for a brief moment, I saw what true patient care could be like, without technology's oftentimes distracting presence."

Even by the time Dr. Angelo wrote his editorial, researchers were checking to see if, indeed, technology was inherently obtrusive. Over time, that research has concluded that computers don't automatically come between patients and physicians, but they can.

In its November-December 2001 issue, the Journal of the American Medical Informatics Assn. published a study finding that compared with control physicians, physicians who used an electronic medical records system "adopted a more active role in clarifying information, encouraging questions and ensuring completeness at the end of a visit."

The study also suggested that EMR doctors might be "less active" than control physicians in outlining the patient's agenda, exploring psychosocial/emotional issues and discussing how health problems affect a patient's life.

In both groups, physicians tended to direct attention toward the computer during the initial portion of the encounter, though in the case of EMR physicians, "the relatively fixed position of the computer limited the extent to which [they] could physically orient themselves toward the patient." It also found that visits with EMR physicians tended to last 37.5% longer.

Nearly four years later, with patients and physicians more familiar with computers in the exam room, JAMIA in its July-August 2005 issue looked again at technology's effects on patient-physician interaction. This time, they found many more positive effects.

Compared with baseline levels, overall patient satisfaction with visits, based on questionnaires completed by 313 patients seeing eight different physicians, was higher seven months after the introduction of computers. Satisfaction with physicians' familiarity with patients, communication about medical issues and comprehension of decisions made during the visit went up as well. And the visits didn't take as long, either. The study concluded that satisfaction went up "without significant negative effects on other areas such as time available for patient concerns."

Family physician Jodie Escobedo, MD, one of four physicians in the Peak Health Group of Santa Monica, Calif., said her experience bears out those studies.

"After working in a practice with an electronic medical record for five years, my skills at communicating with patients are, if anything, better because I spend less time filling out forms," she said. "My eye contact with patients is just as good as it is using a paper chart."

Dr. Escobedo concedes that if a patient really disliked computers, he or she probably would avoid her practice. "Or else they wouldn't come back a second time. But we haven't had any complaints."

A good listener is a good listener

That's a conviction backed up by recent health information technology and communication research at Kaiser Permanente, which showed that when used properly, a computer enhances, rather than detracts from, the interaction between doctor and patient.

The study was published March 31, 2005, on the Web site of the Journal of General Internal Medicine. "Used properly" encompasses such actions as not entering information with your back to the patient, maintaining eye contact and telling the patient what you're doing as you enter data.

"We found that patients were on average more satisfied after the computers were installed and felt that their physicians were more familiar with their medical history," said internist John Hsu, MD, a physician scientist with Kaiser Permanente Northern California's division of research. "Patients also felt that they better understood what happened during the visit and what their options were. ... The computer creates an opportunity for enhanced communication with the patient, when the physician is familiar and comfortable with the computer system and uses it to share information with patients."

That familiarity and comfort, for both the patient and physician, is not a sure thing, though.

"But we also saw examples where it doesn't happen automatically," said Dr. Hsu, the study leader. "It's not like you plug in the computer and everyone gets it right away."

A second report, appearing in the August 2005 issue of the Journal of General Internal Medicine, was a qualitative analysis using videotapes of regularly scheduled primary care visits by 54 patients to nine different clinicians (six of them physicians), at three separate times: two months before, one month after and seven months after the introduction of computers.

The study found that the introduction of computers affected the visual, verbal and "postural connection"--the way physicians and patients were facing, or not facing, each other--in four domains: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the exam room.

The study also appears to bear out assertions that a doctor with good communication skills before computerization is likely to be a good communicator afterward, just as poor skills of another physician are likely to be exacerbated by computer technology.

One videotape shows a clinician consulting with a patient who has had several recent trips to the emergency department for panic attacks. The clinician notes that the patient recently started a medication with side effects known to be a risk for panic. He tilts the computer toward the patient so both can consult the notes, then offers the hypothesis that the medication might be causing the symptom. Finally, the clinician reinforces the message by pushing away the computer screen, re-establishing eye contact and checking to see that the patient understands the message.

Meanwhile, another videotaped clinician hovers over his written chart, speaking little and rarely looking up, leaving the patient in silence for long periods. With a computer in front of him, the same physician stares into the computer screen and turns to look at the patient only infrequently, even after the patient volunteers information. At last, as the patient continues speaking, the doctor turns his gaze from the computer screen and says, "Yeah?"

The study noted that one critical factor was the placement of the computer and monitor. In the study clinic, the computers were placed where they were most convenient to an outlet, a common occurrence. In some cases, that meant physicians had little choice but to turn their backs to patients when using the computer.

The study also conceded that "the visual and cognitive attention required for a clinician to enter and retrieve data while maintaining the flow of the visit can be complex." Physicians good at multitasking likely would be much better at handling computers in the exam room. But the study also noted that no one yet knows what effect this multitasking could have on "physicians' levels of stress and coping."

Most studies on computers in the exam room note that research into this topic is still new, and the topic needs further investigation. These studies also say research has been confined to outpatient settings, so it's not yet known whether computers in the inpatient setting can be more problematic, as Dr. Angelo described.

For now, technology advocates such as Dr. Escobedo say doctors can, and should, be able to find ways to make the computer in the exam room a help instead of a hindrance. "It isn't the patients who have the problem with EMR," she said. "It's the doctors."

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Keeping your eyes open

Specific behaviors appear particularly conducive to maintaining a good relationship with patients even while the modem is humming. Experts offer tips to physicians on how to enhance interaction with patients so technology doesn't get in the way:

  • Describe what you are doing when typing or reviewing data.
  • Avoid periods of silence.
  • Maintain intermittent eye contact with the patient when using the computer.
  • Avoid sitting with your back to the patient when using the computer.
  • Use the clinical information on the computer screen as a teaching tool.

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Good -- and bad -- computer etiquette

A study appearing in the August 2005 issue of the Journal of General Internal Medicine examined videotapes of six physicians, two nurse practitioners and one physician assistant as they used computers in the exam room. The researchers broke down what they saw as "good" and "poor" results in four categories, noting that if these skills weren't mastered before computers, technology isn't going to make them better:

Spatial organization and communication

Good: Computer rests on the wall next to the foot of the exam table. Patient is able to watch the screen during clinician's computer use. Clinician either stands in front of the patient or is turned only slightly toward the computer to type. Clinician and patient sit close to each other.

Poor: Clinician's screen is out of patient's view and can't be tilted in patient's direction. Clinician's eyes never leave the computer screen. Patient attempts to lean over to see what's on screen and nearly falls off the exam table.

Organizational skills and communication

Good: Clinician introduces the computer, explains confidentiality of information in the electronic medical record before "eliciting an agenda" from the patient. Patient and clinician talk first before clinician looks at the computer screen. Clinician interrupts typing when patient requests he check a spot and gets back to his computer only after confirming to patient the spot was not cancerous.

Poor: Clinician doesn't set formal agenda and becomes confused between concerns the patient raises and information on screen. The conversation turns to what's on screen the moment the clinician looks at the computer, often displacing the ongoing topic of conversation. Patient is confused, and length of visit is extended.

Verbal and nonverbal skills in communication

Good: Clinician sees a patient who has suffered from panic attacks. The clinician consults the computer, then notes that the patient recently started taking medication known to produce panic attacks as a side effect. Clinician tilts the computer screen so the patient can see the information. Clinician reinforces message by pushing away the screen, re-establishing eye contact with the patient and checking to ensure the patient understands the discussion.

Poor: Clinician logs onto computer about halfway through the visit and spends most of his time thereafter staring at the screen. When patient volunteers information about his pharmacist's recommendation to lower his cholesterol, clinician looks up briefly but makes no comment. The patient continues to talk, but the clinician continues to gaze at the screen.

Computer mastery skills and communication

Good: Clinician shares data with patient and his wife. They go over histograms of blood pressure readings over the past two years. Then the clinician quickly retrieves patient's hemoglobin A1c test results over the same period after patient's wife expresses concern about husband's blood sugars. Use of the computer is seamless and natural.

Poor: Clinician pays little attention to patient while navigating screens, searching for information. Patient attempts unsuccessfully to try to provide information about her medications as clinician struggles with computer. Both get frustrated with the process, which takes a long time.

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