How to communicate well with a patient while working on an EHR

Recent reports have shown that the number of physicians who have adopted electronic health records has doubled since 2008. Though the potential for this technology to improve care is great, EHRs could be the source of a communication breakdown between patients and physicians.

When physicians who are used to carrying paper charts start using tablets or desktop computers in the exam room, it’s going to be disruptive, said Larry Garber, MD, an internist and medical director of informatics at the Reliant Medical Group in Worcester, Mass. How a physician manages this disruption “can absolutely make or break the relationship between doctor and patient,” he said.

But it’s not only seasoned, paper-based doctors who run into potential problems, said Clarence Braddock, MD, an internist and professor of medicine at Stanford University School of Medicine in California. Students who grew up with smartphones sometimes have habits they are unaware of, such as responding to a text during a face-to-face conversation.

Several medical schools have realized the impact bad communication can have on patient satisfaction and outcomes. They have built communication skill-building into their curricula to help prevent this unintended consequence from technology use. But even absent formal training, it’s not too late for practicing physicians to acquire these skills with a few small steps:

Exam room setup. Many practices are implementing EHRs in spaces meant for paper-based practices, said Glen Stream, MD, president of the American Academy of Family Physicians and chief medical information officer of the Rockwood Clinic in Spokane, Wash. The result is a setup that has the physician’s back to the patient when he or she uses the computer, “which is absolutely the wrong message you want to send to the patients,” Dr. Stream said.

Some practices have implemented a basic triangle design that puts the physician, patient and computer screen at each of the three corners, allowing the doctor to look at both patient and computer screen without shifting his or her body. It can make patients feel they are being looked at even when the physician is looking at the computer screen, Dr. Garber said.

Work-flow design. Vincent WinklerPrins, MD, a family physician and associate professor of family medicine at Georgetown University School of Medicine in Washington, said one thing he had to learn post-EHR implementation was to review a patient’s record on the computer before entering the exam room.

He said the computer terminal should never be the first place the physician goes when entering the room. The doctor should go to the patient first, greet him or her and establish an agenda for the visit. After that is done, the doctor should have some kind of transitional line explaining what he or she is about to do in the EHR, such as, “OK, let me jot down a few notes.”

Employ the LEVEL system. Designed by Kaiser Permanente to help physicians use an EHR in the exam room, the mnemonic tool is an easy way for physicians to remember good practices. LEVEL stands for:

L: Let the patient look on. This goes back to the triangle setup that allows the physician to easily share things on the computer screen with patients.

E: Eye contact. Dr. Garber said there is no hard and fast rule of how eye contact should be measured, but he treats every patient encounter as he would a conversation with a friend or family member.

V: Value the computer. If the physician praises the benefits of the computer, the patient will appreciate its presence. Saying things such as, “With my EHR, I can look that up” or “I can send your prescription straight to the pharmacy,” will help patients think their care is more advanced because of the computer, Dr. Garber said. Sharing visuals on the screen, such as a chart mapping historical cholesterol levels, also will help patients appreciate the computer.

Physicians who struggle with their EHR sometimes vent their frustrations to patients. “That frames the computer in a negative way to the patient,” Dr. Stream said. “Positive framing is really important. Physicians have got to set it up that the computer and EHR [are] there for the patient’s benefit and not describe it as a nuisance or an irritation.”

E: Explain what you’re doing. Dr. Braddock said it’s important for doctors to be transparent about everything they do. Talking through each step — “I’m sending your prescription now” or “I’m looking up those test results” — will make patients more comfortable. It also will help alleviate the perception that the doctor is doing something else, like checking emails or sports scores.

L: Log off. A big fear patients have about technology is the security of their data. Logging off while they are still in the exam room makes them confident the next patient won’t walk in with their information still on the screen, Dr. Garber said.

Just as the Reliant Medical Group adopted the LEVEL system from Kaiser, medical practices should look to one another for tips and guidance on how to handle this training, Dr. Braddock said.

Dr. Garber created a YouTube video explaining the LEVEL process. The video gives “good doctor” and “bad doctor” examples that practices can show to their physicians.

Dr. Braddock suggests that practices use patients or staff who can observe the patient encounter from a nonphysician perspective. The Reliant Medical Group has a shadow program in which observers follow patients throughout their visit and look for things staff members can work on. Communication skills are part of the evaluation. The group also surveys patients about their experiences and asks questions about the physician’s communication skills.

Every physician has to deal with how to work with an EHR in the exam room, Dr. WinklerPrins said. EHRs are here to stay, so every practice has to figure out how to work with them effectively, he said.