July 19, 2010

EHRs, Workflow, and the Patient Experience
By Maura Keller
For The Record
Vol. 22 No. 13 P. 6

Countless businesses are drowning in information. By phone, mail, fax, and e-mail, it washes over them every day—lab results, financial documents, dictation files, memos, and medical histories. Within the healthcare arena, paper document management has become a complex, costly, and time-consuming endeavor. Enter EHRs. These high-tech information management systems are supposed to help streamline how medical professionals do business. The problem? Patients and healthcare personnel both admit that the technology is altering face-to-face communications.

Curbing Communication
Increasingly, competitive advantage within the healthcare market is being driven by innovative records management technology. Traditional paper-based models are giving way to electronic solutions, making documents and their content available at the click of a button.

Nevertheless, only 20% of medical practices use EHRs, according to Barry Greene, CEO of medical technology integrator LibertasMD, who says cost is a key reason for the low adoption rate. “Until recently, quality EHRs were just too expensive for the average practice,” he says.

Financial considerations aside, many physicians voice concern about how EHR use affects their relationship with patients. According to Alexander Friedman, MD, a fellow in maternal-fetal medicine at the University of Pennsylvania, the technology limits patient-physician interaction, in part because it is user “unfriendly.”

“They [EHRs] often require the doctor to focus on the screen because there is so much new documentation that needs to be done,” he says. “If electronic records were easier to use and had more friendly interfaces, attention could be directed more toward the patient. If you want to use an iPhone as a perfect example of user friendliness, many EHRs are on the polar opposite of the spectrum. I used Cerner in the past and I use Epic currently, and both of them demand my attention.”

Friedman says many EHR systems are poorly organized and may actually worsen the quality of patient care by making it more difficult to store and retrieve relevant information. “EHR systems should conform to physician and office workflow,” he says. “Doctors aren’t too complicated; it’s easy to figure out how we work. Other types of business and commercial software can be very thoughtful and helpful. For some reason, many commercial EHR and EHR systems are not. Think about the bugs and inefficiencies and inconveniences of a new Windows operating system launch. Multiply that times 100, and there you have a typical EHR system.”

In a recent study of 60 in-depth interviews from 26 physician practices with commercial ambulatory care EMRs in place for more than two years, the Center for Studying Health System Change found that while EHRs allow doctors to spend more time with patients, they also could reduce real-time communication.

“EHRs were seen by some physicians as a distraction because, [for] some, they had to hunt for information or respond to alerts in the EHR rather than focus on the patient,” says study coauthor and senior researcher Ann O’Malley, MD. “One physician referred to EHRs as ‘gadgets and gizmos that interfere with patient interaction.’”

To address these concerns, EHR vendors are attempting to make the technology more intuitive.

Glenn Laffel, senior vice president of clinical affairs at Practice Fusion, which offers a Web-based system, says significant strides are being made to make EHRs a tool that many physicians simply can’t do without. “Some of these bulkier EHR server systems are frustrating for physicians because their interfaces are bulky and not intuitive,” he says. “You have to click through a lot of areas. And when a physician is in the room with a patient and they feel like they have to look something up, it may take them six or seven mouse clicks to get there. That will interfere with the interaction with the patient.”

According to Greene, Web-based patient portals may change that. “Patients can enter their own specific information at home or in a waiting room kiosk now,” he says. “That allows the physician and patient to spend much more meaningful time together because the history of present illness, medication, and allergy information have already been entered before the doctor enters the exam room. Patient portals help get staff off the phones, specifically those responsible for delivering lab results or leaving appointment reminders.”

Greene points out that Web-based EHRs enhance information exchange. “A colleague of mine who recently reviewed EHRs said that it was like traveling in the valley of the dinosaurs before the asteroid hit,” he says. “Older server-based systems need to be replaced by Web-based EHRs. These Web-based systems will allow physicians to update and have access to patient information wherever they have Internet connectivity, without the cost of hosting and maintaining office servers.”

Laffel suggests that physicians allow patients to view the computer screen during the exam. “The patient comes in and we sit down with them and put their record aside for several minutes—that’s the vital act of listening,” he says. “Active listening with your eyes on the patient—even if it is only five minutes—gives the patient a sense that the physician is there for them. When that five or six minutes are over, open up the electronic record and aim it so the patient can see the screen. Point your finger and explain that this is what you use to capture the info the patient has given you. You want the patient comfortable, and make sure they understand that this tool is being used to help the physician and, in turn, help them. Turn the screen and explain that now you are going to be entering some data and looking up some tests off of this electronic system to make sure you can help them.”

Physicians who adopt EHRs may also want to reconsider their dictation practices. Currently, many dictate all patient encounters at the end of the day. “They record, send off, receive, rewrite, and approve the dictation prior to putting it in the chart,” Greene says. “The time delay, especially when it comes to specialists, can be frustrating for patients awaiting critical information. Many EHRs facilitate faster or even instant dictation to charts, or eliminate dictation entirely.”

Unlike dictation, EHRs allow physicians to enter information electronically while in the room with the patient. “The physician can certainly wait until the end of the day and enter the data into the EHR after the 15 or 20 patients they have seen,” Laffel says. “But at the end of the long day, you are trying to remember what happened with that first patient. We recommend the entry of the patient’s specific information is done when the patient is in the room.”

Ongoing Improvements
Friedman believes there are a few ways EHRs could better serve patient care and physician-patient communication. “One would be to have support staff be able to enter as much of the nonclinical information as possible,” he notes. “Doctors should use EHRs to enter clinical information. Likewise, when EHRs are retrieved or printed out, they should just show the clinical documentation, not all the extra stuff.”

O’Malley and her coauthors at the Center for Studying Health System Change recommend communication skills training for EHR newcomers in order to take full advantage of the technology’s options and to improve such nuances as making eye contact with patients. Also, physicians need to learn how they can engage patients at appropriate times by showing them parts of the EHR screen for educational purposes and to validate information.

“Patients, like everyone else, value attention,” Friedman says. “If a physician seems distracted or inattentive, patients rightfully resent it. Patients want their doctors to be thorough and organized but not at the cost of being distracted. Hopefully, better EHR systems can help us move in that direction in the future.”

— Maura Keller is a Minneapolis-based writer and editor.