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Exam Room Computing and the Physician-Patient Relationship

The author acknowledges the contributions of the following Richard L. Roudebush VA HSR&D Center of Excellence on Implementing Evidence-Based Practice researchers to this article: Mindy Flanagan, Ph.D., Alissa Russ, Ph.D., Marianne S. Matthias, Ph.D., Scott Russell, B.S., Angela Harris, B.A., and Jason Saleem, Ph.D.

Mr. Dan Deacon,* the medical director of a large VA facility, recently received a letter of complaint from Patrick Pawlson, 72, a Veteran who receives his care at one of the facility's outpatient clinics. Mr. Pawlson complained that his physician, Dr. Eric Salter, "was more interested in the computer screen he was typing on than me and my medical problems. To be honest, it made me feel unimportant and uncared for." Dr. Salter is a general internist who has worked for the VA for three years. Soon after he started working at the facility it went "paperless" and new computer workstations for the Computerized Patient Record System (CPRS) were installed in all the clinic's outpatient exam rooms to facilitate the transition. Dr. Salter is familiar with the use of computers to document clinical interactions in an electronic medical record, but he was new to using computers in the exam room with the patient present. Mr. Deacon's job is to give Dr. Salter some constructive feedback to help him better integrate his use of CPRS while seeing patients.

Patient-Centeredness and the Electronic Medical Record

In one of its most widely cited and influential reports, the Institute of Medicine (IOM) asserted in 2001 that patient-centered care was one of six domains of quality in medical care, the others being safety, effectiveness, timeliness, efficiency, and equity. The report went on to state that the absence of patient-centeredness is associated with outcomes such as: lower patient satisfaction, poorer adherence to medical recommendations, poorer blood pressure control, higher glycosolated hemoglobin A1c, and greater propensity to sue for medical malpractice in the face of an adverse event.

A lack of patient-centeredness is clearly the focus of Mr. Pawlson's letter of complaint and should raise awareness of the entire health care team. At the same time, it is important to note that Dr. Salter has had no formal training in how to use CPRS with patients in the exam room. Recognizing that a gap in knowledge and skills may account for the complaint, Mr. Deacon decides first to give Dr. Salter a copy of the IOM report. He also suggests that Dr. Salter consider using a "communication coach" to help guide him in how to better integrate the computer into his daily practice, citing a study that showed communication coaches were effective in improving patient satisfaction in a health care organization similar to VA.¹

Computer Placement

One of the most interesting and challenging aspects of implementing CPRS into clinical workflow is the physical placement of the computer screen.² There are currently no national guidelines for optimal placement and there is a great deal of variation in the geography of exam rooms. Our research team is currently working on an HSR&D Investigator Initiated Research (IIR) (08-300) to study the overall effects of CPRS use, including placement, on physician-patient interactions. Unfortunately, the computer screen in Dr. Salter's office is in a corner of the exam room forcing him to turn his back on his patients when using CPRS. Mr. Deacon suggests that Dr. Salter explain what he is doing in CPRS and apologize for having to turn away to use CPRS. Dr. Salter states that he will look into rearranging the exam room to optimize CPRS use.

Non-verbal Behavior

One powerful way to communicate caring and concern is through non-verbal behavior. Body orientation, eye contact, gestures, and touch are all elements of non-verbal behavior that can affect the course, direction, and satisfaction with care.³ Reframing Mr. Pawlson's complaint in terms of non-verbal behavior, Mr. Deacon explains to Dr. Salter that too much time using CPRS will be seen by patients as a preference for the technology over the person. He recommends that Dr. Salter make it a habit of making eye contact every 30 seconds or so to reassure the patient that he is listening and personally attending to all concerns.

Typing Skills

Many older physicians grew up in an era where typing was not a required subject and where dictation substituted for having to type. While younger physicians may be proficient typists, it is not usually with an audience present. Many physicians report poor typing skills and embarrassment at having to type in front of patients. Mr. Deacon asks Dr. Salter if this a problem for him, learns that it is, and offers to pay for a self-paced typing tutorial that will improve speed and accuracy.

Partnership

Much technology in the exam room is physician-centered. The blood pressure cuff, otoscope, and stethoscope all give the physician information that may or may not be shared with the patient. One of the precepts of patient-centeredness is that care is based on partnerships, and partnerships, in turn, are related to sharing information. The same holds for CPRS. As an educational tool, CPRS can be a rich source of information and guidance. Mr. Deacon reminds Dr. Salter that the word "doctor" comes from the old French "docteur," meaning teacher, and describes how CPRS can be used to partner with, and educate patients.

Conclusion

Mr. Deacon and Dr. Salter's meeting lasts 20 minutes, about the length of a routine clinic visit. Dr. Salter is amazed to learn about the literature in this area and is appreciative of not being judged on the basis of a skill that he was never taught. He is also grateful for the concrete evidence-based feedback and suggestions and is eager to try them out. Mr. Deacon, for his part, feels reinforced in his job and is pleased that Dr. Salter is receptive to the feedback. Both are grateful to Mr. Pawlson for his letter and intend to tell him so at his next visit.

*All names and events in this commentary are fictitious.

References

1. Stein T, Frankel RM, Krupat E. Enhancing Clinician Communication Skills in a Large Healthcare Organization: A Longitudinal Case Study. Patient Education and Counseling 2005; 58(1)4-12.
2. Frankel, R. M., A. Altschuler, et al. The Effect of Computers on Clinician-Patient Communication in Outpatient Visits: An Example of Digital Amplification. Journal of General Internal Medicine 2004; 19 (Supplement 1): 216.
3. Hall, J. A. (1995). Affective and Nonverbal Aspects of the Medical Visit. The Medical Interview. M. J. Lipkin, S. M. Putnam and A. Lazare, (Editors). New York, Springer-Verlag: 495-503.