Vox Medicus

DON’T LET THE EMR INTERFERE WITH THE PATIENT VISIT

Martha Moulton, MD
Kenneth Pellegrino, MD
Brookfield Family Medicine

"It seemed like the doctor spent most of the time typing on the computer."

If you were a patient you wouldn’t like it if your doctor spent the visit focused on a computer screen rather than on you. Our EMR system has required us to change our workflow and while we need to collect and accurately enter data, we can't forget the impact - and the impression - this makes on our patients.

Given the intensity of data collection, maintaining good eye contact during the face to face encounter and sustaining a congenial, engaged and supportive atmosphere is a real challenge. Here are some things we try to do to keep the patient encounter a personal one:

* Get as much done as possible before you enter the exam room.

We work to utilize our support nursing staff to the highest level of their capability. After greeting the patient, the nurse can ascertain and document the patient's chief complaint and part of the HPI. Many templates have 10-20 yes/no questions which our nurse can complete. (One local physician actually goes into the waiting room as soon as the patient arrives and simply welcomes the patient, and tells him or her that a nurse will be along soon.)

* Whenever possible pre-populate data before going into the exam room. For physical exams or pre-operative evaluations, we have the nurse close the note ASAP, and then enter the HPI and ROS from the data sheet the patient has already handed to the nurse.

This allows us to stay focused looking at the patient, while we just review the answers and make additions and changes. We are then prepared for a symptom specific ROS (review of systems).

This way you enter the room with a lot of the history data already entered, including vaccine, colonoscopy, or mammography needs evaluated before going into the room.

* Your first encounter with the patient is more important than ever. Whatever your personal style, put the patient at ease and, if needed, stop and explain why and how you are using a computer during the visit. Explain the benefits for the patient.

* Some of us use a computer cart on wheels (COW) which offers some advantages. You stand and so you are at an eye-to-eye level and facing the patient directly.  The cart also lets you share screen views with the patient when you think it will help involve the patient in the visit and in his or her own care.

* Try to ‘batch’ your questions and observations and then make one comprehensive entry rather than break eye contact to make entries after each one.

* When ordering at the end of the visit, we talk out loud as we click and order what’s needed. First meds are ordered or renewed giving us an opportunity to confirm correct doses and where the Rx is being sent with e-prescribing. As we talk, the patient can hear the exact labs, imaging, referrals and vaccines that are being ordered or contemplated. This keeps the patient fully informed, and re-emphasizes what is being ordered or asked of the patient. The patient also knows that we, not the computer, are prescribing the care.

The good rules of a patient visit are still the same, but the inclusion of the EMR does require us to adapt to the new technology.