Managing EHRs Without Compromising Patient Care
Showing your patients what you are doing on your computer is a good way to keep the line of communication open.
Electronic health records (EHRs) can improve health care by reducing medical errors and facilitating greater coordination of care. However, these improvements often come at a price. A growing body of research suggests that the burgeoning number of tasks required by EHRs can compromise patient encounters. For example, a recent study of 2237 hospital- and office-base physicians found that most respondents regarded EHRs as having a negative effect on both the quantity and the quality of time they spent with patients.1
To shed light on managing the challenge of staying on top of EHR requirements while also optimizing patient encounters, MPR interviewed Neda Ratanawongsa, MD, MPH, Associate Chief Health Informatics Officer for Ambulatory Services, San Francisco Health Network and Associate Professor of Medicine, Division of General Internal Medicine at UCSF Center for Vulnerable Populations. Dr Ratanawongsa is a physician at Richard H. Fine People's Clinic (RHPC) of Zuckerberg San Francisco General Hospital.
What role do you play in EHR at your institution?
Beyond my clinical responsibilities, I am involved with overseeing the hospital's EHR and I also study ways in which the health record is affecting communication between providers and patients. I've had colleagues say to me, “I wish I didn't have use this EHR because it's making it much harder to bond with patients.” I say, “It doesn't have to be that way, but that's the way it is right now.” So it is important to figure out strategies to minimize the negative impact and maximize the strengths of the EHR.
What are your perspectives on the role of EHRs in patient care?
I don't believe that EHRs are inherently evil. In fact, they can be very important in offering patient-centered care. If it is designed well, an EHR can not only be a way of accessing notes from another clinic or hospital, but also a way of getting information to the patient via patient portals.
In addition, the EHR can help us find out when things are not working well for a given patient. For example, being able to look at the patient's medications as they cross from one setting of care to another is very important. If a patient being treated with medication is discharged from the hospital and must now fill the prescription at a local pharmacy, there may be a difference in formulary between the hospital- and the outpatient-based pharmacy that can be both confusing and dangerous to the patient. The EHR also allows the provider to see if the patient has indeed picked up the medications and, if the patient has not done so, the provider can address the patient's reasons and concerns.
What impact does use of the EHR have on patient encounters?
The need to input certain information can distract you from focusing on what the patient regards as the most important issues to him or her. Most of these systems are oriented more around medical than around psychosocial concerns, so more work needs to be done on these systems to make sure that the patient can voice other concerns and that those concerns are not left behind.
Another impact of the EHR is that some clinicians engage in light chatting with patients to fill the silence while they are typing on the screen. This takes time away from the patient's concerns and these clinicians are less likely to be rated as offering excellent patient care. The computer may not be the only reason for the patient's dissatisfaction but it is an important one. Patients with barriers to care or complex issues may require more research on the part of the providers to find out what is going on. The literature is mixed on this point. But it is clear that there are more helpful and less detrimental ways to use the computer while also engaging patients.
Do you have suggestions for providers seeking to improve patient encounters while also using the EHR?
It can be helpful to share the screen with patients, so they can see what you are doing while you are talking with them. This engages them in the process. Make sure to stop using the computer and look at the patient if he or she brings up something sensitive or concerning. Patients need to feel you have their full attention. While these suggestions have not been rigorously studied, they are common sense tips.
Exam rooms can be set up so that you can more easily share the screen with the patient or, at least, so that you can look at the patient without contorting yourself to also look at the screen.
Transparency is important. If you need to focus on the screen and enter information or write a prescription, explain to the patient in advance why your use of the computer is necessary. Most patients will understand when it is explained, which will facilitate communication. If you need to focus on the screen, you might use that time for the patient to read an educational handout about the new medication you are prescribing or about their illness or recommended action plan, such as weight loss. That way, patients can have their questions or concerns ready for when you finish entering the information on the screen.
Are there alternatives to using the EHR during the patient encounter?
Some providers or institutions use medical scribes to enter the information into the computer so that the provider can look at the patient without needing to look at the screen, and the information continues being recorded appropriately. There are pilot programs exploring wearable cameras that might allow someone in another room to access and type up the patient encounter.2,3 However, some patients may have privacy concerns if a third person is present in the exam room, or if they know that there is a technology transmitting the content of their appointment to a third party in another room. These patients may feel inhibited from talking about sensitive subjects such as erectile dysfunction or personal violence. So those approaches need more research to know how best they can be applied and when they are or are not appropriate.
Medical assistants may play an expanded role, not only as simple scribes but also as high-functioning team members. They can conduct pre-visit assessment of the patient's condition or complaint, ascertain what medications the patient is taking, whether the patient has any allergies, and other relevant information. The medical assistant can also do post-visit education. Patients are often glad when the medical assistant is involved with their care, and the burden on the physician is reduced.
One alternative I do not recommend is taking notes during the encounter and typing them in to the EHR after the last patient has left because it is is a process that takes hours. There is a risk that many providers will be driven away from medicine because it is no longer fulfilling. They will feel they are spending most of their time just keeping up with their computer work and are no longer able to focus adequately on their patients.
Do you have any additional perspectives?
The burden of creating and implementing strategies to address shortcomings in current EHRs should not rest exclusively on the shoulders of physicians and providers. This is a system-wide issue and on a larger systemic level, we have to look at what can improve the role of the EHR in patient care.
- Pelland KD, Baier RR, Gardner RL. "It's like texting at the dinner table": A qualitative analysis of the impact of electronic health records on patient-physician interaction in hospitals. J Innov Health Inform. 2017;24(2):894.
- 15 things to know about Google Glass in healthcare. Becker's Health and IT CIO Review. June 3, 2014. Available at: https://www.beckershospitalreview.com/healthcare-information-technology/15-things-to-know-about-google-glass-in-healthcare.html. Accessed: December 18, 2017.
- Dougherty B, Badawy SM. Using Google Glass in Nonsurgical Medical Settings: Systematic Review. JMIR Mhealth Uhealth. 2017;5(10):e159.
- Adewale V, Anthony D, Borkan J. Medical assistants' roles in electronic health record processes in primary care practices: the untold story. J Med Pract Manage. 2014;30(3):190-6.