How to Integrate the Electronic Health Record and Patient-Centered Communication Into the Medical Visit: A Skills-Based Approach

Abstract

Background: Implementation of the electronic health record (EHR) has changed the dynamics of doctor–patient communication. Physicians train to use EHRs from a technical standpoint, giving only minimal attention to integrating the human dimensions of the doctor–patient relationship into the computer-accompanied medical visit. Description: This article reviews the literature and proposes a model to help clinicians, residents, and students improve physician–patient communication while using the EHR. Evaluation: We conducted a literature search on use of communication skills when interfacing with the EHR. We observed an instructional gap and developed a model using evidence-based communication skills. Conclusion: This model integrates patient-centered interview skills and aims to empower physicians to remain patient centered while effectively using EHRs. It may also serve as a template for future educational and practice interventions for use of the EHR in the examination room.

Keywords:

• electronic health record
• patient-centered care
• relation- ship-centered care
• patient–doctor communication
• patient-doctor-computer communication
• electronic medical record

BACKGROUND

The use of computers during medical encounters is becoming ubiquitous worldwide. Perhaps most notable is the investment of the U.S. government in promoting use of electronic health records (EHRs). ¹ Whereas technological, quality, and safety issues occupy center stage in the literature, research on the impact of examination room computing on patient–physician communication is in its infancy. ² Patients and clinicians express serious reservations about the EHR and the unintended negative consequences that may emerge from examination room computing and computer use in other healthcare settings. ^{3 , 4} Efforts have barely begun to improve practice in this area. Integration of the EHR is not formally addressed in medical education, residency training, or continuing medical education. ^{5 , 6}

We provide a literature review and analysis as well as a framework for educating health professionals on how to incorporate the EHR into the medical interview while maintaining a patient-centered approach. In the final section we have attempted to fill a gap in the medical literature by incorporating the attributes of patient-centered care into a skills-based model that integrates use of the EHR in patient-centered manner. This model is reproducible and can be incorporated by other institutions with their skills checklists to aide clinicians and learners in objective measurements of their EHR-related medical interviewing skills.

PATIENT-CENTERED AND RELATIONSHIP-CENTERED CARE

Patient–doctor communication is perhaps the most significant component of the healthcare visit, with ramifications for patient satisfaction, ^{7 – 9} adherence to treatment, ¹⁰ conflict resolution, ¹¹ laboratory costs, ¹² and clinical outcomes. ^{13 –16} The literature linking patient–doctor communication to a host of important outcomes has led to an expanded definition of quality care that now includes physicians’ interpersonal and communication skills. ¹⁷ These skills have attracted increased attention as a likely source of variation in the quality of care, with great potential for improvement. ^{18 – 20} The U.S. Institute of Medicine endorsed effective clinician–patient communication as a central component of high-quality healthcare. The Committee on Quality of Health Care in America and other key organizations (Accreditation Council for Graduate Medical Education, American Board of Medical Specialties) have identified communication skills as an important competency required for physician graduation in the United States. ^{21 – 23} Growing evidence also suggests that strong provider–patient relationships can have intrinsic effects on healing. ^{24 , 25}

Patient-centered care and relationship-centered care, which focus on the reciprocal influences patients and providers have on one another, are now the leading paradigms of patient–doctor communication in healthcare. ^{26 , 27} Much has been written on this topic, and multiple reviews have explored the benefits and challenges of these models. ^{28 – 30} Models describing the essential tasks, skills, and stages of effective patient-centered communication include the Kalamazoo consensus statement, ³¹ the Smith model, ³² the three-function model, ³³ the Calgary–Cambridge model, ⁵ the four habits model, ³⁴ and the patient-centered clinical method. ³⁵ We use a modified version of Smith's patient-centered model, because it is supported by evidence from randomized, controlled studies; is widely recognized; and has recently been updated. ^{32 , 36 , 37}

EXAMINATION ROOM COMPUTING AND COMMUNICATION RESEARCH

One of the authors (SR) published a literature review of patient–doctor–computer communication, retrieving 167 papers up to April 17, 2007. ³⁸ For this article, we updated the literature review to April 1, 2012, using the same search and analysis strategy. ³⁸ This search yielded an additional 17 papers that we have included in this narrative analysis.

There is no doubt that with use of the EHR, many opportunities exist to improve patient care through greater information exchange and to improve coordination of chronic disease treatment. ³⁹ Some physicians now give electronic copies of care plans or patient health information directly to patients, as proposed by meaningful use measures and to improve safety, quality, and efficiency of care. ⁴⁰ However, our literature review focused on how the patient–physician relationship is affected by the physician's use of the EHR during the medical interview. We found that patients worldwide express one major concern about computers in the office—the fixation of the physician's eyes on the computer screen. ³⁸ Although it is a passive piece of technology, counterintuitively the computer is shown to be an active player that mobilizes both patient and physician. ^{38 , 41 – 43} Data show that the first few minutes of the patient–physician encounter have changed with the introduction of computers in the examination room. With the computer present, the first minute of the consultation is often taken up with the physician interacting with the computer rather than interacting with the patient or discussing the patient's agenda. ⁴⁴ Researchers found that physicians often walked straight to the computer after a short greeting, with the screen prompting their opening statement, rather than inviting the patient to share his or her concern(s). ⁴⁴ The dyadic relationship of patient and doctor has turned into a triadic patient–doctor–computer relationship. ^{45 , 46} In addition, physicians find it hard to divide their attention between the patient and the computer screen. The physicians in a study done by Margalit et al. ⁴⁷ spent an average of 24% to 55% of the visit time gazing at the screen, and this time was inversely related to the physician's engagement in psychosocial question asking and emotional responsiveness. ³⁸ The computer often caused physicians to lose rapport with patients; for example, physicians typed in data or gazed at the screen while talking to the patient or while the patient was talking.

Strategies have been suggested in the literature to help physicians improve their communication skills while using the EHR. ³⁸ The major strategy we identified is dividing the encounter into patient- and computer-focused stages that are clearly demarcated from one another and indicated by changes in body language and focus of gaze. Another is keeping patients engaged by sharing the screen with them or reading out loud while typing. ^{38 , 48} Ten tips for physicians on how to incorporate the computer into consultation were suggested by Ventres et al. ⁴⁹ and have recently been modified and are integrated into our proposed model ³⁸ (Table 1).

TABLE 1 Tips for effective use of electronic medical record

Tip No.	Original Tip	Modified Tip
1	Use mobile computer monitors	Use mobile computer monitors (no modification^a)
2	Learn to type	Learn to type; enhance your surfing skills for patient education, decision support and evidence resources and practice fast screen scanning
3	Integrate typing around your patients’ needs	Integrate typing around your patients’ needs (no modification)
4	Reserve templates for documentation	Reserve templates for documentation (no modification)
5	Separate some routine data entry and healthcare maintenance issues from your patient encounters	Separate some data entry from the encounter; review problem list and previous visit before you call patient in, use time of patient's undressing and putting clothes on (when contextually appropriate, not in the United States) for data entry
6	Start with your patients’ concerns	Start with your patients’ concerns, and make sure the encounter is driven by them. Data gathering is important, but secondary
7	Tell your patients what you are doing – as you're doing it	Tell your patients what you are doing as you're doing it. Verbalize shifts to the computer by apologizing or asking permission. If possible, keep the conversation going
8	Point to the screen	Point to the screen; highlight the discussed data; print out when appropriate
9	Encourage patients’ participation in building their charts	Encourage patients’ participation in building their charts. Promote future supplementary virtual communication. Create interface with on call, house calls
10	Look at your patients	Look at your patients. Make sure your full attention is in listening to the patient, especially in the encounter-beginning patient monologue and when sensitive issues are brought up. Indicate this by pushing monitor away, positioning yourself facing the patient with eye contact, and taking your hands off keyboard and mouse
Note. Reprinted from Shachak and Reis ^38 with permission from John Wiley & Sons. Ventres et al. ^49 originally suggested these 10 tips for physicians for effective patient–doctor communication in settings using electronic medical records. Shachak and Reis modified these to incorporate use of the computer in medical interviews.
^a“No modification” indicates that Shachak and Reis did not change this tip from the Ventres original formulation.

As of April 2012, we could find only four examples in the literature of educational modules for integrating communications skills with examination room computing. ^{50 – 53} Two of these examples, one from the United Kingdom and another from the United States, are not clearly linked to specific, researched, patient-centered care models but rather provide general advice or are proprietary. The third model (from Israel, developed by the third author), and the fourth, developed by the authors for American Academy on Communication in Healthcare courses, use the method outlined next. The model described uses clearly researched patient-centered skills and is reproducible so that in the future it can be used for teaching and assessment of medical students learning interviewing skills.

STEP-BY-STEP TEACHING MODEL FOR INTEGRATING THE EHR INTO THE PATIENT-CENTERED INTERVIEW

Ventres and Frankel ⁵⁴ noted that physicians with good communication skills tend to better integrate the computer into ambulatory visits. They postulated that the art of medical communication relies on the integration of patient- and relationship-centered communication skills with computer use. The goal of this proposed integrated approach is to enable the physician to optimize use of the EHR in the examination room while maintaining rapport with the patient and building the patient–provider relationship. ^{38 , 48 , 54}

The Smith model provides steps for teaching patient-centered interviewing and is thus easily amenable to embedding discrete EHR-related skills into phases of the encounter and in the future expanding on ways of teaching or evaluating these skills. The following paragraphs map computer use to a modified version of Smith's patient-centered encounter stages and skills (Figure 1).

FIG. 1 Teaching patient-centered interviewing and key communication skills. Note. EHR = electronic health record (Color figure available online).

I. Setting the Stage

1. Room Set Up

Before greeting the patient, it is important to ensure that the room is arranged to accommodate the triadic relationship of the patient, the computer, and the clinician. This step could include using a mobile computer or any type of movable screen (i.e., accordion arms, or computers on wheels [COWS]). It is helpful to arrange the room so as to allow both the patient and the provider to see the screen. This format demystifies the computer and encourages patient participation by allowing the patient to join in or initiate discussion while looking at, pointing at, or highlighting items on the computer screen. ³⁸ That being said, patients have different styles and may have differing levels of comfort with the computer; the physician must assess this and modulate the amount of screen sharing if needed. ⁵⁵

2. Previewing the Chart

Another component of setting the stage is to preview the EHR before entering or having the patient enter the room. ³⁸ Familiarity with the patient, his or her last visit, laboratory results, and medications is efficient and leads to less screen gazing at the beginning of the encounter. By prescanning and prepopulating components of the EHR, it is possible to update such items as medications and health maintenance information and then confirm the accuracy of the information by showing the patient or discussing it when the patient is in the room. Although time might seem to be the enemy of previewing the chart, visits done on the fly tend to take longer, are less well organized, and are less satisfying to both the patient and the physician. ⁵⁶ Another strategy is to have another member of the team, such as a medical assistant, nurse, or physician assistant, prepopulate certain components of the chart. ⁵⁷

II. Greeting the Patient

1. Greeting

On entering the room, it is always appropriate to extend a greeting to the patient. Greetings do not take long (15–20 seconds typically) but should be done before turning to the computer (Table 2).

TABLE 2 Greeting examples

“Our office uses an electronic medical record so I will be typing in information during today's visit.”

“I will be typing into the computer as we talk and looking up information during the visit today. If you want to look at any of the results or you want copies of any of the reports, let me know.”

2. Introducing the Computer

This task may become obsolete as patients become more comfortable with computers in the examining room, but presently this step allows the patient to understand the triadic relationship as well as the role the computer will play during the visit. Patients may have different levels of comfort with the computer that should be explored. Patients should also be assured that their digital information is secure and confidential. A positive attitude on the part of the physician instills confidence in the patient. ⁵⁸

III. Opening the Interview

1. Setting the Agenda

Having the patient and clinician decide on an agenda is most helpful in an outpatient general medical practice and may not be necessary in all types of encounters. ^{59 , 60} Indicating the time available can help the patient and clinician realize that not all possible issues can be addressed; some may need to be deferred to a later visit. Summarizing and briefly touch typing in the agenda may entail negotiating if there are too many agenda items. This step may seem awkward at first but can lead to improved satisfaction and time efficiency. ⁵⁹

2. Opening the History of the Present Illness

After creating an agenda, the first part of the interview is centered on the patient's concerns and his or her illness narrative. Discussing the history of the present illness is typically initiated using an open-ended statement that bridges from the agenda-setting portion of the visit. Studies have shown that a physician often interrupts a patient within the first 18 to 23 seconds of the encounter. ^{61 , 62} Marvel et al. ⁶² found that physicians who interrupted frequently did not discover the patient's reason for the visit. Provider fears that open-ended questioning will prolong the interview are not supported by the literature. On average, patients talk for 28 to 78 seconds when not interrupted. ^{62 , 63} By not interrupting, you are also telling the patient that you are listening and care about what he or she is saying.

Both verbal and nonverbal communication behaviors demonstrate attentive listening. These cues include nonverbal behaviors such as eye gaze and affirmative head nodding. Eye gaze is critical to observe emotion and distress in a patient. If the provider is gazing at the computer, he or she can miss this key aspect of relationship building. ⁶⁴

Verbal skills that demonstrate active listening include “continuers” such as “Uh-huh,” “Go on,” “I see”; echoing statements; short requests such as “Tell me more”; and short summarizing statements, all of which can accompany typing on the computer. Signposting (telling the patient what you are doing as you transition to the computer) will signal that you are making a shift but still attending to his or her needs. Reading back what you have written, and then looking at your patient, also demonstrates active listening (Table 3).

TABLE 3 Communication skills to integrate the computer into the medical history

• Signposting

• Echoing

• Explaining intermittent pauses as provider reads/types

• Involving patient with computer and text

• Pointing to screen when appropriate

• Minimizing screen gaze

IV. Building the Relationship

Empathy is a key component in building a relationship in which the patient trusts the provider and is encouraged to give information. ⁶⁵ Empathy has been demonstrated to improve patient satisfaction and adherence ⁶⁵ and to have an intrinsic therapeutic effect. ⁶⁶

The EHR has been shown to negatively affect these emotional components of the medical interview. In one study, screen gaze was inversely related to gathering of psychosocial information and inhibited full patient disclosure of sensitive information. ⁴⁷ Research has emphasized that the biopsychosocial and emotional aspects of the interview are best accomplished when the physician moves her head, eyes, and torso toward the patient; removes her hands from the keyboard or mouse; pushes the monitor away; and gives the patient her undivided attention. ^{43 , 47 , 48}

V. Middle of the Interview

The middle part of the interview is more “doctor centered” in that it uses more closed-ended questions. ³² A transition can be accomplished here by using a summary statement acknowledging what the patient has said and then signaling that you will be asking more specific questions (Table 4). It is estimated that at least 70% of the information needed for physicians to make a correct diagnosis comes from the patient-reported medical history. ⁶⁷ The medical history can be taken while building the relationship with the patient. ²⁷ The middle portion of the encounter uses all of the skills previously discussed: making transition statements when turning back to the computer, signposting, real-time typing, scanning, and use of “talk or read back” (where the clinician reads back what he or she has written to ensure it is accurate).

TABLE 4 Examination room computing transition skills

• Excuse me a second while I type this into the record.

• Just give me a minute while I look at the computer.

• I want to make sure I get this down correctly.

• Let me tell you what I am typing.

TABLE 5 Patient education examination room computing skills

• Verify patient literacy, primary language, vision.

• Point to screen to indicate relevant information.

• Give patient time to read text.

• Check for understanding and for questions.

• Print relevant handout (or send electronically).

VI. Patient Education and the End of the Interview

The computer is a powerful tool to provide educational support for the patient encounter. If the provider has not already done so, he or she should verify the patient's literacy, primary language, and visual acuity to optimize computer use. Examples of what the EHR can provide at this stage include links to online risk calculators, patient handouts, website references, and information about community support services, medication side effects, and follow-up appointments. Prepopulating the file using commercial and public sources will make this step more efficient. Repositioning the screen so that it is closer to the patient and pointing to relevant areas enhance the feeling of collaboration. The EHR allows providers to print out or share care plans, medication lists, and office notes, all of which are now linked to meaningful use criteria. Research has shown that patient involvement in treatment planning improves adherence and patient outcomes. ^{68 , 69} Collaboration with the patient is also linked to decreased unnecessary testing, increased patient satisfaction, and fewer malpractice claims ^{70 , 71} (Table 5).

VII. Closure

After completing the encounter, a defined closure is needed to indicate the end of the visit. There are three major goals in closure: checking understanding, arranging follow-up, and providing support. ⁷² Visit summaries, prescriptions, referrals, and other documents can be printed out and handed to the patient at this point (sometimes they are printed outside the examination room). Verbal closure can be a brief review of the agenda items agreed upon earlier and of action plans going forward. After the visit, the provider should take a moment to ensure that the medical record is complete and to note any “to do” tasks before seeing the next patient.

DISCUSSION AND CONCLUSION

This article reviews the literature on how computer use in the examination room affects the medical interview and proposes an integrated patient- and relationship-centered model for the triadic interaction between the clinician, the patient, and the computer. We believe this integration has the potential to unleash the power of the computer as an information tool and at the same time add to the healing potential of the encounter as a biopsychosocial event.

Much remains to be studied about this complex interaction, and in the future we hope to evaluate the effects of this model and the effects of use of EHRs on patient care. We base our recommendations on the best evidence to date, which in some cases rests on expert opinion and anecdote rather than being grounded in higher levels of evidence. Further inquiries in this domain are needed. The Society of Behavioral Medicine recently issued a policy brief recommending the standard collection of practical patient-reported measures in EHRs in order to provide higher quality, safer, and more patient-centered care. ⁷³ We endorse a recent statement outlining reporting criteria for observational studies of examination room computing. ⁷⁴ We are optimistic about the potential for meaningful integration of the complex technical and interpersonal challenges that EHRs have introduced to the patient–doctor relationship. We look forward to new and creative adaptations of computer use in the examination room with the goal to enhance the patient experience.