Does using an EHR get in the way of a doctor-patient interaction?

The question as to whether using an Electronic Health Record (EHR) system in clinical practice enhances or interferes with the doctor-patient interaction is one that has been raised, and merits commentary. There are those who believe that insinuating an EHR into patient encounters can negatively impact patient-doctor communication.

Let me comment from the perspective of a clinician who has been in primary care practice for many years, and has used both paper charts as well as EHRs (deployed on wireless notebook computers that are brought into the exam room in lieu of paper charts). I have been in the position of training mid-level practitioner interns, as well as mentoring newly-trained physicians entering into private practice. What I have observed is that the doctor-patient relationship is a result of the personal approach that a physician develops as his/her clinical skills mature. It is neither enhanced nor impeded by using a tablet computer or a paper chart – if anything, I have seen physicians “hide behind a paper chart” just as much as “hiding behind a computer.”

In California, where there is a statewide Pay For Performance (P4P) program for medical groups and IPAs that take risk and are delegated for implementation of HMO contracts, a large percentage of P4P money is based on patient satisfaction. This is gathered by a survey (the Consumer Assessment Survey, or CAS) that is sent to HMO enrollees (patients), and used to stratify the experience patients have with different physicians and health delivery systems. Many participating groups, not surprisingly, have devoted resources to finding ways in which the patient experience in their physician’s offices can be improved. Hill Physicians (where I had served as a medical director for many years) even engaged a consultant to do Continuing Medical Education (CME) programs, as well as help individual practices with coaching and shadowing, in order to improve the satisfaction of the patient experience.

One of the take-home lessons from this applies regardless of whether paper charts are used or computers are used in the exam room: when entering a patient exam room (knock first), put down the chart (either the paper chart, or the notebook computer), sit down, put one’s hands on one’s lap, engage the patient eye-to-eye, and have a conversation (guided, but not interrupting). A 5-minute interaction like this will “feel like” 15 minutes. By contrast, coming into the exam room, keeping one’s nose in the chart (whatever kind), remaining standing, keeping the chart in one’s hands, avoiding eye contact, and interrupting, will be perceived by the patient as “not enough time was spent with me” regardless of the actual time spent. These are matters of personal style that are developed with maturity in one’s clinical role, and are not affected by whether the chart is on paper or on a portable computer.

In fact, when it comes time during the patient exam to review data in the chart together – like reports from consultants, or imaging results, or recent lab results or trending – being able to quickly click on the computer and find the desired information is much more satisfying than flipping through pages of a paper chart, and getting frustrated at not being able to find the desired information. Some times, if a patient brings in some medication or herb not known to me (e.g. something from Mexico), I can actually do a quick Google search on it and find information about it together with the patient (in a guided way) – this simply could not be done without an internet-connected notebook in my hands.

An then, of course, there is the patient satisfaction that comes from being able to e-Prescribe from the exam room directly to the pharmacy. So long as the pharmacy responds by noticing the eRx, and fills it promptly, the patient enjoys simply showing up and picking up the already-ready Rx on the way home after the office visit.

So, back to the original question: does using an EHR get in the way of the doctor-patient interaction? No – the relationship is based on factors of personal clinical style, not technology per-se. However, access to information, finding everything one needs at one’s fingertips at the point of care, is dramatically improved by having a well-designed EHR (like Practice Fusion) in one’s hands.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.