EHRs, Communication Can Co-Exist For Doctors, AMA Says

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Computers need not come between patients and physicians in the exam room if doctors think carefully about how they're using electronic health records and interacting with patients, according to a new report from the American Medical Association (AMA) board of trustees.

Doctors who communicate well with patients when they use paper records also tend to have fewer problems talking to patients than other doctors do when they use EHRs in the exam room, the report said.

The board of trustees presented the report in response to a resolution by the AMA's medical student section at the association's annual meeting last year. According to the resolution, the medical student section was concerned about a 2010 study that "found that patients of many clinicians using EHRs believe the presence of a computer in the exam room to have a negative effect on their interpersonal communication with their physician."

Consequently, the resolution asked the AMA to "study the effect of electronic devices, including but not limited to computers and tablets, in the exam room on doctor-patient communication" and "recommend alternatives and modifications."

[ Computers do annoy patients, according to another report. ]

The AMA searched the literature and found that "research has consistently indicated that patient satisfaction does not appear to be adversely affected by the introduction of computers into the examination room," the board of trustees report said. However, patients do pick up on their doctors' attitudes toward computers. The more positive the physician is, the reported noted, the more likely patients are to prefer computer use in their exams.

Several other factors influence patient-physician interactions when doctors use EHRs in the exam room: These include the positioning of the computer monitor or device in relation to doctor and patient; physicians' proficiency in using computers; and features of the technology, such as the processes required to input data and the nature and frequency of clinical reminders and pop-ups.

Doctors who are better at interacting with patients in general fare better at integrating their interviewing of patients with their EHR tasks, the report noted. Technical improvements in EHRs, such as streamlining data input and focusing computer tasks "on activities that meaningfully influence patient outcomes," could improve the physician-patient interaction. But so could the removal of "spatial barriers," such as using mobile monitors or configuring exam rooms to enable physicians to maintain eye contact while using computers.

There's also good evidence, the report noted, that inviting patients to look at the computer screen and share information with the doctor improves the quality of the interaction and fosters shared decision-making.

The report cited behaviors Kaiser Permanente has recommended to help doctors integrate computers into their meetings with patients, including explaining what they're doing as they move through the EHR and pointing to the screen. It also mentioned a Family Practice Management (FPM) article that listed several tips to improve doctor-patient communications when a computer is being used.

William Ventres, an Oregon family physician who was the lead author on the FPM piece, told InformationWeek Healthcare that the biggest challenge in this area is the lack of physician education on how to use EHRs during an exam.

"Most people starting out with EHRs get very little training on how to use them in terms of the doctor-patient relationship," he said. "The computer is put down in front of them and they're told to use it. And there are many different ways of using it, but people don't get that education." This is not only a problem for older physicians who are accustomed to paper charts, he noted. Younger physicians might be more tech savvy, but they're still learning how to interact with patients. "It's hard to learn that relational part at the same time you're tending to the computer."

Mobile devices such as laptops and tablets can help doctors perform these tasks simultaneously, but they don't overcome the inherent limitations of the point-and-click templates in EHRs, he pointed out. Those templates are designed to document physical findings and the answers to yes/no questions, not to record the nuances of a patient's story. "Patients don't talk point and click," he said. "Patients talk story."