by Ken Terry, iHealthBeat Contributing Reporter

The use of electronic health records in the exam room need not harm the doctor-patient relationship if physicians use EHRs properly, according to a recent report from the American Medical Association Board of Trustees. But observers raise some serious questions about how EHRs may be changing doctor-patient interaction and about whether physicians are trained well enough to know what they’re doing.

William Ventres — an Oregon family physician who coauthored a Family Practice Management piece on the subject — said that many physicians are too absorbed in their computers to pay adequate attention to their patients during office visits. A major reason for this, he said, is insufficient training.

“Most people starting out with EHRs get very little training on how to use them in terms of the doctor-patient relationship,” he noted. “The computer is put down in front of them and they’re told to ‘use it.’ And there are many different ways of using it, but people don’t get that education.”

Older physicians who have been used to working with paper charts are not the only clinicians for whom this is a problem, Ventres said. Younger physicians may be more oriented to the technology, but they have a lot to learn about the physician-patient relationship. “It’s hard to learn that relational part at the same time you’re tending to the computer,” he pointed out.

Some medical schools are beginning to teach students how to use EHRs during patient encounters, Ventres said.

One of these courses is offered at the University of Arizona College of Medicine-Phoenix. Howard Silverman — associate dean for information resources and educational technology and a professor of family and community medicine at the medical school — teaches the course.

“There’s a misconception that the current generation of medical students is computer-literate, so they really don’t need any [EHR] instruction,” Silverman said. “That’s totally wrong.”

Even though his students pick up the mechanics of navigating an EHR very quickly, he noted, “They may not be able to figure out best practices. For example, when is it appropriate to use a template for your history of present illness vs. free text? When do you need to capture something that is not going to be captured on a template?”

To teach his students how to use an EHR during a patient encounter, Silverman devised two 15-minute training sessions — which he has since boiled down to one — that imparted the basics to them. For one thing, the student doctors are taught to “introduce” the computer to the patient in a way that makes the patient feel that the computer is enhancing the quality of care. Also, Silverman said, it’s essential to position the computer in such a way that the patient can see the screen, at least during part of the encounter.

Silverman and his colleagues did an-as-of-yet unpublished study in which they trained half of the students using these techniques and half without. The two cohorts were asked to use the EHR during videotaped encounters with “standardized patients” who were actors. The “patients” filled out surveys and later watched the video with the students and their instructors. The results showed “huge differences” in the perceived quality of the interaction between doctors and patients in the study and control groups, he said.

After this study, Silverman was convinced that this kind of training would help his students when they went into practice. It can also aid established physicians who communicate poorly when they use an EHR, he said. Many of these doctors “look like they’re sitting behind a fence” during patient encounters, he noted.

While this may reflect flaws in their communications style, he doesn’t blame it entirely on the physicians. “When you look at how clinicians are trained to use EHRs, this is never addressed. Nobody comes in and says, ‘By the way, doctor, we’re going to show you some things that will really help with the patients’ acceptance of this technology, so it will enhance the relationship and they’ll tell you more stuff.'”

According to Silverman, it wouldn’t require much training to close this critical communications gap for most doctors. “Fifteen minutes is all it takes,” he said.

Not only are physicians not learning how to use EHRs in patient exams; they’re not getting much EHR training at all. The typical doctor receives about three hours of training on the EHR, according to Mark Anderson, a health IT consultant in Montgomery, Texas.

Rosemarie Nelson — a Medical Group Management Association consultant based in Syracuse, N.Y. — agrees that doctors receive fairly little training, partly because they don’t want to take the time out of their busy work schedules.

Even if physicians could easily document in their EHRs, there’s a danger that they might spend too much time entering data and not enough time listening to patients. A recent study found that the degree to which physicians focused on entering notes in an EHR was correlated with how they viewed uncertainty in medical decision making.

“Reductionists,” who believed that more information could reduce uncertainty, entered more structured data in the EHR during exams. In contrast, “absorbers” of uncertainty — who were less concerned about getting information into the EHR — focused more on conversing with patients and observing their physical signs. Some doctors used a hybrid of the two approaches.

According to the researchers, the study suggests that “standardized clinical documentation could be inadvertently driving physicians toward an uncertainty reduction mindset, and thus unwittingly orchestrating the loss of alternative clinical mindsets.”

Silverman agreed that this could happen if physicians don’t receive proper training on how to use the EHR to enhance their patient relationships. Even in the era of paper records, he noted, physicians had to decide whether to hunt down a lab result in a thick chart or wait until after the visit to do that. “The same kind of thing occurs with electronic records.”

Silverman teaches students when and when not to document in the EHR. “If there’s anything that requires interpersonal attention, you quit typing. And for certain things, you’re not going to chart while you’re in the room — typically, during the physical exam. You’re not going to listen to someone’s heart and go clickeddy-clickeddy. Those things can be taught. But the students aren’t going to figure it out on their own, necessarily.”

Another problem with focusing too much on the computer, Ventres said, is that what brought the patient to the doctor’s office can easily be lost. “In primary care, whether it’s internal medicine, family medicine or pediatrics, people present as people with problems. They don’t present as a clinical issue. We translate what they give to us, and the [EHR] templates frame that translation in a very narrowly defined area.”

He cited a hypothetical teenage girl who comes in complaining of abdominal pain. The type of pain and where it hurts can be recorded in an EHR template. So can her sexual history and whether or not she smokes. But the story behind her complaint may not be so easy to document. For example, the girl might feel physical pain because she’s being bullied or teased in school.

“The problem is really somatic, which doesn’t fit into the template,” he noted. “If I just focused on the clicks, I’d have missed the real reason she came in to see me.”

Of course, a doctor could type or dictate that observation into the EHR as free text, perhaps with the help of voice recognition software. But to do so during an exam might be counterproductive.

“The bottom line is that [EHR documentation] is still a work in process and may be for many years,” Ventres said. “Given that fact, we need to make it as patient friendly as possible. And we need to spend far more time training doctors on how to attend to patients in the exam room, especially in primary care.”


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