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Health
Systems
IMPLEMENTATION
Computers
in the Exam Room--Friend or Foe?
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By
Ward R Mann, MSN, FNP; Joanne Slaboch, MBA
At first, it might be hard to imagine how using an electronic medical
record in your practice and in the exam room could improve communication
with patients. In fact, it may be easier to see the computer as just another
thing that gets in the way of our having meaningful interactions with
patients--a third wheel, so to speak. Because patients view communication
as the most important factor in the clinician-patient relationship, we
certainly don't want to compromise it in any way.1 Does the
computer in the exam room assist or hinder good clinician-patient communication?
The Experience
Our experiences
in Kaiser Permanente's Northwest and Colorado Regions have shown that
patients give a positive rating to clinicians' use of computers in the
exam room. Initially, clinicians experienced a period of time in which
they were not as efficient as they were with the paper record. There might
be some discomfort with the new equipment, with necessary new computing
skills, with the changes in workflow and, importantly, discomfort in the
conversations with members related to the computer.
We learned
that this discomfort fades as confidence is gained in new skills, in a
sense of consistency and reliability about critical patient data, and
in satisfaction with the comprehensive level of care that the clinicians
are able to provide. The information available from computers helps to
demonstrate comprehensive knowledge of the patient. Additionally, exam
room computing helps involve patients in decisions about medical care,
something patients highly value. As reflected in the chart, A Synthesis
of Recent Evidence (Figure 1), shows ample evidence that exam room computing
can enhance the overall clinician-patient interaction in the exam room.
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Figure 1. A synthesis
of recent evidence--member satisfaction with exam room computers
KP
Results Model
Leadership/Mgmt Work environment
Member satisfaction Business results
Background
With
the introduction of KP HealthConnect programwide, use of computers
in the exam room could have a significant impact on the care experience.
The Care Experience Council has compiled information from four internal
research studies (based in the Northwest, Colorado and Hawaii Regions)
to serve as a foundation for building evidence about patient satisfaction
with exam-room computers and guide future implementation efforts
and research.
Key Findings
- Patients'
perceptions toward exam-room computers are for the most part positive,
and integration of computers into the delivery of care has resulted
in improvements in patient satisfaction.
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Effective use of the computer can support a positive clinician-patient
interaction.
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Key clinician behaviors promote the patient's involvement with
the computer during the visit and establish the clinician's familiarity
with the patient.
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The patient's and the clinician's attitudes toward the computer
can all affect overall satisfaction with the visit.
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A small portion of patients with low patient satisfaction scores
who also express concerns about privacy and security of medical
information.
Implications for
Improving Member Satisfaction with their Care Experience
In
order to enhance members' care experience with exam-room computers,
operational leaders should offer clinicians multi-faceted training
and implementation support programs that address clinician-patient
communication, organization and multi-tasking
skills as well as technical training. Based on the existing research,
programs would be more effective if they emphasize clinician behaviors
that
- Promote
patient involvement during the visit by:
Maintaining eye contact with the patient
Providing a verbal description of what is being entered
Showing information on the computer screen to the patient
- Demonstrate
clinician familiarity with patients by:
Reviewing the record before entering the exam room
Indicating knowledge of the purpose of the visit
Referring to previous history
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Demonstrate a positive attitude toward the computer
- Address
privacy and security issues
Sources
- Clinical
Systems Planning and Consultation: Northwest Exam Room Computing
Project--Final Report. Michael McNamara, MD; Kathy Poterah, RN;
Carl Serrato, PhD (July 2002).
-
Crossing the Digital Divide: Preliminary Findings from the INTERACTION
Study. John Hsu, MD, MBA, MSCE; Rich Frankel, PhD; Kathy Poteraj,
RN; Bob Tull, PhD; Care Experience Council (Nov 2002).
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Clinical Systems Planning and Consultation: CIS Integrations Project.
Robert J Miller, MD (July 2002).
- AMR
as a Relationship Tool Interview (KPCO, KPHI, KPNW), sponsored
by the Care Experience Council
(Feb 2003).
- Automated
Medical Records and Patient Satisfaction: A Summary of Key Finds
from Kaiser Permanente-Sponsored research, Technology-Enable Care
Work Group, Care Experience Council, March 2004.
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Personal Challenges
What about
you and your practice? How are you supposed to maintain good communication
with your patient and deal with this new "thing" in the exam
room? Will you be able to make eye contact and type your note? Will you
be able to keep the patient involved and not be distracted by the computer?
Will you remember to secure the screen? Sound a little overwhelming? We
believe that you will find the following suggestions helpful to make certain
that the computer becomes a solid friend of yours in the exam room, and
definitely not a foe.
Solutions
The Interregional
Clinician-Patient Communication (IRCPC) Leaders of Kaiser Permanente (Table
1) have pooled their collective experience and understanding about clinician-patient
communication
and exam room computing. As a result they have identified five key communication
behaviors to foster smooth integration of computers into practice:
Let
the patient look on
Eye
contact with the patient
Value
the computer as a tool
Explain
what you are doing
Log
off and say you are doing so
The accompanying
chart, Do Your LEVEL Best With the Computer in the Exam Room (Figure 2),
applies these five communication behaviors and details some recommended
actions to use and scripts to say to effectively integrate the computer
into your exam-room interaction with your patient. The IRCPC has developed
five courses to help clinicians and support staff integrate the computer
into the patient visit using these LEVEL skills (Table 2).
© 2004, The Permanente Federation LLC
By including
a few new communication behaviors into everyday practice, a computer in
the exam room will enhance the overall care experience for the patient.
Reference
- Worthlin
Group. Communication and the physician/patient relationship: a physician
and consumer communication survey. West Haven (CT): Bayer Institute
for Health Care Communication; 1995.
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