EHR Report: One step at a time


The response to our request for readers to comment on their experiences with electronic health records continues to astonish us, with the quantity, depth, and intensity of responses. The majority of e-mails discuss concerns about the way EHRs have affected both patient care and office workflow, and we have made an effort to make sure that these voices are heard.

This month, we thought that we would emphasize a response from Dr. Don Weinshenker, a general internist in Denver who has worked in the VA system since 1992 and who describes himself as a "champion" of the EHR for over a decade. What we like about Dr. Weinshenker’s comments is that while he acknowledges the challenges inherent in adopting electronic records, he also offers some solutions based on a decade of experience. Some of his suggestions remind us of columns we published about a year ago on Humanism and EHRs, two words seldom used together, but which present what we feel is an important concept – discerning how to use our new tools to carry out, not distract us from, our core goals of connecting with other human beings to help safely alleviate suffering and improve health using an empathic manner that communicates caring and understanding. Dr. Weinshenker shares his thoughts as follows:

I feel it is quite possible and relatively easy to integrate the computer into an exam room while maintaining the excellent clinician/patient experience for which we all strive.

The first thing I do when I walk into a room is greet the patient and look the patient in the eye. I don’t look at the computer at first. I then acknowledge the "elephant in the room." I usually say something to the effect of, "As you likely know, we do almost everything on the computer. I will be using the computer today during this visit." I have not had a single patient object.

Next I do bring the patient’s chart up on the computer, if I hadn’t already preloaded it, and open a progress note with my simple template. I then turn to the patient, away from the computer, and start to take a history. At an appropriate pause I say, "Let me get that into your chart." I do turn to the computer at that time and start to type. I repeat what the patient told me as I type. By doing this, patients know what I am typing as well as experiencing a version of "reflective listening" so that they know that I truly did hear them. Also, I always clarify as I type. "The left foot pain has been going on for 2 weeks, or was it 3 weeks?" I write my primary care note in real time while talking with the patient. The majority of the content of my notes is in natural language, as opposed to clicking on little phrases.

Then, I talk about what I am doing in terms of ordering on the computer. "I am going to go ahead and order that podiatry consult now. You said that you would prefer to be seen after the 15th, right? I’ll order that x-ray we talked about as well."

I am sitting at a desk with the patient next to me facing me. It only takes a small turn of my head to face the patient. It is common for me to turn the computer screen a little so it faces the patient. I involve the patients with the computer. Very frequently, they can actually see what I am typing into the computer. In addition, for many of the computerized clinical reminders that we use, I will have the patient read the questions off the screen, e.g., for depression screening, so that they can answer the questions directly.

It appears that some of your readers have misconceptions about the role of computers. At least one mentioned that the computers are essentially going to replace doctors. Ideally, the use of computers is synergistic. The whole is more than the sum of the parts. Using cars as an analogy, no one complains about having power steering or brakes in a car. They make the car easier to drive. It is more common to have a lane change warning if there is a car in the next lane. Some of the fanciest cars, such as the top-end Mercedes, monitor what is in front of the car and will automatically put on the brakes if a pedestrian is present. I can’t afford that car but would be grateful if I had it and it saved the life of a pedestrian who stepped in front of me.

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