Conquering the computer in clinic

Despite obstacles encountered when incorporating the electronic health record into bedside manner, a simple mnemonic can help physicians learn how to maintain proper patient communication.


Computers have changed the markers of good patient care, Wei Wei Lee, MD, MPH, told attendees at yesterday morning's session on “Computer and Patient: Competition or Collaboration?”

“In the good old days, we used to think about your bedside manner,” said Dr. Lee. “This day and age … I want you to think about how your computer-side manner is.”

Dr. Lee, an assistant professor of medicine at the University of Chicago, has been researching the effects of computers on physician-patient relationships since her health care system implemented an electronic health record (EHR) in 2012. “We found that a lot of our seasoned providers and faculty had a lot of trouble,” she said.

To better quantify such troubles, she and her colleagues conducted a literature review on the impact of EHRs on patient-physician relationships and communication, which was published in the May 2016 Journal of General Internal Medicine.

The negative behaviors they identified included physicians keeping their backs to patients, maintaining poor eye contact, allowing long silences, not making the screen visible to patients, typing during sensitive discussions, and letting the computer guide questioning. Explaining the last finding, she said, “There are many pros of using drop-down menus or checklists that the computer can generate for us, but that really takes away from the conversational style.”

Despite these obstacles, she also found that patients had overall positive impressions of EHRs. Dr. Lee and colleagues interviewed 108 patients for a study published in the November 2016 Journal of General Internal Medicine and collected comments such as, “They can see all the notes from the other doctors and they really work together as a team. I love it.”

Of course, there were negative comments, too, and many of them focused on the communication behaviors identified in the review. The next step was to develop solutions, which Dr. Lee offered as a mnemonic: HUMAN LEVEL.

The first step is to Honor the “golden minute.” Dr. Lee explained, “The studies show that that first minute you have with the exam room is incredibly important to build rapport.” It's fine to log into the computer immediately upon entering the room, but then spend the next minute greeting and catching up with the patient away from the computer.

When it is time to turn the computer, Use the triangle of trust. That means arranging the encounter so that the patient can see the screen, with the physician, patient, and computer representing the three sides of a triangle.

Next, Maximize patient interaction during computer use. “If you are needing to review some studies, invite the patient in,” said Dr. Lee.

The next tip should be implemented before entering the room: Acquaint yourself with the chart. Some physicians prefer to do this the night before, but Dr. Lee spends a couple of minutes immediately before she sees the patient reviewing the last visit and any other relevant info.

Physicians should also know when to Nix the screen. “This one is about those moments when your patient is talking about something that is important to them,” said Dr. Lee. Any time the conversation becomes serious, face the patient with your hands off the keyboard, she advised.

The first step in LEVEL, a component of the mnemonic originally developed at Kaiser Permanente, is to Let the patient look on. Dr. Lee recommends saying something like, “This is your medical record, this is your chart, why don't you follow along with me?” Then, whenever possible, maintain Eye contact. “It's hard not to get locked down into the tasks we're doing,” said Dr. Lee.

The next step may also be difficult for clinicians frustrated with their EHRs: Value the computer. “It's important that you are not badmouthing the computer in the room with the patient,” said Dr. Lee. “That actually can leave a lasting impression on the patient.” Instead, physicians should mention the benefits of EHRs, such as the ability to send a prescription directly to the pharmacy or see specialists' notes.

That task could be covered by following the next instruction: Explain what you're doing. “Talking out loud as you're doing something is incredibly important,” said Dr. Lee, noting that such transparency makes patients more comfortable with EHRs.

Finally, when the visit is over, Log off. “Some patients are concerned that their health information may not be secure,” she explained. “I say, ‘I'm going to log off your chart right now.’”

Dr. Lee has also worked on teaching students, residents, and physicians to implement these best practices. Addressing this topic early, even before medical students have begun their clinical exposure, is important to prevent the development of bad habits, she said.

Medical students, and even veteran physicians, at the University of Chicago have been taught these skills using standardized patients and objective structured clinical examinations (OSCEs). “We actually had our faculty do an OSCE, which we were very afraid of,” said Dr. Lee. “Our fears were unfounded.” The standardized patient encounter observed by clinician peers was the highest rated part of the faculty training, she reported.

A 15-minute training on communication tips has also been incorporated into the health system's EHR orientations.

Now the program has moved on to training patients about optimal EHR use. “We got a small grant to work with a comic artist,” she said. The resulting comic offers patients ABCs of advocating for themselves in the exam room: Ask to see the screen, Become involved, Call attention to any issues of concern. The comic was found to increase these behaviors both during the visit and in patients' later health care encounters.

Whether it's a nudge from a patient or more formal training, Dr. Lee urged clinicians to seek out opportunities to improve their ability to work with computers and patients simultaneously. “There are curriculum and training that exist. Many of them can be as short as 15 minutes to an hour,” she said. “Sometimes, we need reminders.”