Written by Dr. Anthony Inae, MD
If you are one of many doctors who have just had a new Electronic Medical Record (EMR) system installed, then you now may find yourself spending more time facing the computer than talking with your patient. In fact, you find that the computer was installed in a corner of the room and your patient is behind you! Adding insult to injury, you are spending extra time waiting for the system to pull up your last progress note and cannot easily locate the patient’s recent lab results. I know most clinicians would not allow this to happen if they had a choice. In fact, most clinicians will find a way to make the most inefficient circumstances work. But that doesn’t make it right.
In 1997, I first started using a word processor as a military physician to type out my patient’s notes. For me, I felt it was necessary to have a copy of the note the next time the patient returned because frequently the patient’s chart was not available. It may have been checked out by another department or maybe the patient had to hand-carry it to an appointment at another location. Either way, I had no paper record in my hand when the patient was in my office.
I also liked typing out my notes even though it took a little more time than handwriting, because I could reuse pertinent information specific to that patient, and copy it into my new note for the day, updating the history and physical exam with new information gathered that visit. This saved me time and helped me better manage my patients. By doing this, I also had running history of all my notes for that patient. For the patient, I was able to keep a current problem list, medication list, list of allergies, and had the patient’s preventive service history and upcoming schedule right there on a the page. It was easy to keep track of my patients, even though we did not have an EMR at that time. For each visit, I verified and continually updated that information from visit to visit, then printed the note for the paper chart. We did have computerized provider order entry (CPOE) in 1997, which was used for appointing, order fulfillment and results retrieval. So I simply copied and pasted relevant lab results from the CPOE system into my patient’s progress note.
I was conscientious about how my patients felt about me interacting with a computer during the visit. I was able to move the patient’s chair next to the computer desk, so that I faced the patient and could see my computer screen at the same time. I was able to turn the screen to show the patient their lab results or x-ray reports, while I explained what the results meant. I would not allow the computer to become a barrier between the patient and myself. I made an effort to engage them by interpreting the findings with them while we looked at the screen together. I was also able to pull up diagrams of anatomic images found on the web to help educate the patient on specific physiological conditions. I was usually able to type out their history directly into the computer as they spoke. This is the equivalent of writing on paper during the appointment. Although some physicians like to write up the progress notes during the appointment, others may take simple notes and write up the final progress notes after the patient leaves. I did both, but I tried writing up my progress note while the patient was still in the room, so that I was done with my write up before I saw my next patient. At the end of the day, I was ready to go home and avoided staying later than needed.
By 2001, I had the opportunity to help develop user requirements, as well as design and work with developers to build a large-scale enterprise electronic health record and help roll it out to clinics and hospitals around the world. Over the next few years, individual hospitals and clinics began ordering their own computer workstation furniture for the exam rooms, in preparation for this big electronic medical record implementation. I was surprised to see that in some clinics, although the furniture they purchased was of high quality, they were corner units placed far away from where the patient would be sitting! The desk and computer arrangement forced the provider to face the corner, giving the provider no choice but to have his or her back to their patient while using the system.
Clinicians need to get involved in planning the set up and implementation of their EMR implementation so that these issues can be avoided from the beginning before the investment of expensive furniture is purchased and LAN drops are installed. The face-to-face interaction between the physician, nurse, or medical technician and the patient cannot be compromised. It makes a difference. I am sure whoever ordered the furniture had the best of intentions and the fact that the physician’s back would be to the patient was an oversight. If you are fortunate enough to have a reliable wireless network and use a laptop or tablet, you will have the best of both worlds – your EMR and good eye-to-eye contact with your patient.
My suggestion is that even after furniture is purchased, to take a look around your exam room and figure out the best set up. See if there is a way to rearrange things so that you can face both the patient and the computer at the same time. You might even want to turn the monitor so that they can see the screen with you, to review lab results and other information in the patient’s chart together. Or use these opportunities to show patients how to use Google to find information or exercises that work best for their particular condition. There are always ways to make things work better and smarter, without spending money on new furniture so that the patient is not talking to your back during their visit. You may need to get creative, but I’m sure your patients will be most appreciative and not call you Dr. Back, unless your name really is Dr. Back.