Keywords: EMR, physician-patient communication, patient-centered care.
Citation: Smith CW. Is the EMR enhancing or hindering patient-provider interactions? J Participat Med. 2013 Oct 23; 5:e39.
Published: October 23, 2013.
Competing Interests: The author has declared that no competing interests exist.
My institution, University of Arkansas, has been using Centricity ambulatory electronic medical record (EMR) for over a decade and, a few months ago, began implementing Epic, currently the most widely used EMR in America. This transition has been challenging on many levels. Great effort and skill is required to interact with any EMR system while the patient is in the room. Furthermore, implementation of EMRs has a significant, sometimes negative, impact on the patient’s experience.
How does the patient feel when the provider is focusing on the screen while addressing important health issues? Is the provider able to focus attention on the patient during discussion of health issues? How can the physician deal with the various EMR tasks such as medication reconciliation, active management of the problem list, electronically prescribing medications, entering lab, imaging, and referral orders, updating the patient’s history, review of systems, physical exam, entering the follow up plan into the record, and printing “after the visit” summaries for the patient — all while the patient is still sitting in the exam room? If this sounds like a distracting — even sometimes chaotic — scene, then you get the picture!
Sachak and Reis noted positive effects from EMR use on such issues as exchange of information, assuring completeness, and improving medication management. They also noted a negative effect on patient-centeredness and patient rapport. They suggested that refining certain computer skills and provider behavioral styles such as focusing on the patient’s problem before going to the computer screen, looking at the patient instead of focusing on the computer screen, learning to type efficiently, and separating routine data entry from those that needed to be entered during the encounter were helpful in overcoming these negative effects. Asan and Montague noted 3 styles of patient-doctor interaction in their video review of provider-patient interaction with the EMR: technology centered, human centered, and mixed. The technology group tended to focus more on the computer screen, the human centered on the patient, and the mixed group tended to move back and forth between computer and the patient. They noted positive features of each style and concluded that more research was needed.
In this era of digital technology, the physician and the patient must face the challenge together in order to keep our interactions humanized while meeting records requirements and staying compliant with regulations. One way is to have an open discussion of this issue with new patients, reviewing the advantages and challenges of practicing with the “computer in the room.” On the positive side, the EMR allows very helpful information exchange, such as viewing lab and imaging results through online patient portals. The portal also provides the patient with a method for asking the health care team questions between visits. Furthermore, the portal may allow patients to make their own appointments, eliminating phone calls and hassles. Prompts from an EMR also prevent both patient and provider from forgetting important health screening such as mammography, Pap smears, lipid tests, and others. It also reminds the physician about potentially harmful drug-drug interactions. Finally, many patients appreciate the opportunity to actually view their record “under construction” during the visit, ie, they can see what the doctor is documenting about their own care.
But, on the negative side, it is very difficult to conduct in-depth conversations with the patient while working with the EMR. Workstations in exam rooms often face the door, away from the patient, which further complicates patient interaction. So, I ask the patients to allow me to move their chair beside me and the computer, noting that we will “all three” work together during the visit. I also believe that a hybrid of completing some EMR tasks during the visit and others after usually allows continued high quality patient interaction. When I must, I tell the patient: “Hold on a minute while I enter this order for you” or “Just let me send your prescription electronically to your pharmacy,” before I return to face-to-face conversation. I may take notes here and there, for items in the EMR that need to be updated after the patient has left. This “after the visit” completion usually includes documentation of the physical examination. I also find that it works best for me to complete the items of the past medical, surgical, family and social history and the review of systems together with the patient directly in the EMR.
I would never advocate a return from EMR use to paper. On the other hand, the encounter between a provider and a patient, in the examination room, is drastically different now compared to “pre-EMR” days. By reviewing positive as well as challenging aspects with the patient, and by limiting the items that are completed in “real time,” the provider and patient can stay focused and engaged in the important task of effective communication about their health.
- Shachak A, Reis S. The impact of electronic medical records on patient-doctor communication during consultation: a narrative literature review. J Eval Clin Pract. 2009 Aug;15(4):641-9. doi: 10.1111/j.1365-2753.2008.01065.x. Epub 2009 Jun 10. ↩
- Asan A, Montague E. Physician interaction with electronic health records in primary care. Health Syst (Basingstoke). 2012 Dec 1;1(2):96-103. ↩
Copyright: © 2013 Charles W. Smith. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.