A Counterintuitive Tool for Connected Care

Abstract

A young man with recently diagnosed HIV was admitted yesterday with pleuritic chest pain. He declined antibiotics, was rude to the nursing staff, and frustrated the night team with all of the attention he required. As a result, he was labeled a difficult patient. This morning on rounds, I found him simmering with distrust and reluctant to speak. Shortly after I got a strained conversation started, I asked him, Can I show you something? I pulled the computer monitor toward the bed and brought up the computed tomography scan of his chest. This is your healthy lung, I said. And thisthis is what I m worried about. His gaze darted to the screen and settled on the impossible-to-ignore rimmed emptiness, stark and arresting amid the expanse of healthy lung. I watched as his masked expression slipped just a little. He glanced at me with a question in his eyes. It was a start. It was an opening. Many observers worry that the electronic medical record (EMR) has taken us away from our patients (1), and several time-motion studies have measured how much time physicians spend working on their computers (2, 3). Although the implication is that time spent with the computer is directly decreasing time spent with patients, reality is more nuanced. The EMR has centralized indirect patient care, which means that clinicians spend a lot of time with their computers, but that does not necessarily mean that they spend less time with their patients (4). Indeed, most hospital work has occurred away from the bedside since the 1950s (5, 6). Every clinician should know that the EMR, as imperfect as it is, can create new opportunities for connecting with patients. In the material that follows, we have consolidated best practices proposed by others into an integrated plan for creating these opportunities and taking advantage of them in both inpatient and outpatient practices (7, 8). Prepare. The clinician should review the medical record before meeting the patient. The first few minutes of the encounter should focus on the patient, not the EMR. The clinician can integrate information from preparation into these first minutes, aim to establish rapport and trust, and identify immediate concerns. Set up. After the first few minutes, the computer screen should be repositioned to form an imaginary triangle defined by patient, clinician, and computer. This triangular setup makes it natural for patient and clinician to look at the screen together and make eye contact periodically, especially if sensitive topics arise. Educate. The computer should be used as a window into the patient s health record. Clinicians should leverage the wealth of EMR data to educate patients about themselves. They can show laboratory trend lines, display images, and highlight parts of notes from consultants. Viewing the EMR together empowers the patient, which improves the interaction. Chart together. The clinician and patient should start a draft note together; this collaboration clarifies priorities, improves accuracy, and builds confidence. When the clinician reconciles medications and then places orders with the patient present, it helps the patient learn how to participate in his or her care. In addition, placing orders together supports collaborative medical decision making by stimulating questions and encouraging patients to express their preferences. Review. Near the end of the encounter, the clinician should break the triangle and face the patient directly. Together they can address remaining concerns and ensure that the diagnosis and plans are clear, especially for interventions. Each of the steps in this plan facilitates greater transparency and a patient-centered approach while allowing more time with the patient. It builds on the demonstrated successes of open notes by increasing patients perception of control and encouraging them to engage in their own care (8). Collaborative computer use requires minimum standards for EMR usability and patient room layout. The plan will not work if the computer interface is awkward and the environment distracting. Patient view modules with larger fonts and links to educational resources will also help. When all of these relatively simple yet powerful work and design features are in place, we believe that the EMR can become an indispensable tool for providing high-quality patient care. Collaborative computer use also requires that clinicians have both expertise and comfort in using the EMR. Even the most technologically savvy clinician needs targeted training to be effective (9). For example, best practices may include talking out loud while typing and being able to convince patients to participate in chart creation (7)skills that few clinicians have without training. Finally, we believe that aligning financial incentives with this type of clinical work will be necessary to expedite effective change. The time clinicians spend talking directly with patients needs to be well reimbursed for these opportunities to be realized. When the stethoscope was first introduced in the early 19th century, physicians were afraid that it would distance them from their patients. It is therefore ironic that today the stethoscope is one of our most effective reminders of the best aspects of clinicianpatient interaction. Maintaining optimism in the face of today s frustrations with the EMR is difficult. Having learned a lesson from the stethoscope, we can imagine a future in which the EMR allows clinicians to spend more time with their patients while providing more effective care.