Inserting computers into heart and soul of medicine, the doctor-patient relationship

INDIANAPOLIS -- The latest technological innovation to affect the doctor-patient relationship is the examination room computer with its promise of supporting safer, more efficient and more effective patient care. But exam room computing is challenging and there is growing evidence that it can be a threat to patient safety and detrimental to good relationships and health outcomes.

In a commentary published in the Nov. 30 issue of JAMA Internal Medicine, Regenstrief Institute Investigator and Indiana University School of Medicine Professor of Medicine Richard Frankel, Ph.D., writes that the medical profession can ill afford not to develop and implement patient-centric, exam room computer-use best practices. He presents POISED, a model he has devised for developing and reinforcing good exam room computer-use by physicians.

• Prepare -- review electronic medical record before seeing patient
• Orient -- spend 1 to 2 minutes in dialogue with the patient explaining how computer will be used during the appointment
• Information gathering -- don't put off data entry as patients may question how seriously their concerns are being taken if physician does not enter information gleaned from patient into computer from time to time
• Share -- turn the computer screen so patients can see what has been typed signaling partnership and also serving as a way to check that what is being entered is what was said or meant
• Educate -- show a graphic representation on the computer screen of information over time, such as patient's weight, blood pressure or blood glucose, so it can become basis for conversation reinforcing good health habits or talking about how to improve them
• Debrief -- Exam room computers provide ideal opportunity to use 'teach back' or 'talk back' format for doctor to assess the degree to which recommendations are understood by the patient and correct as necessary

"Being POISED for examination room computer-use need not cost additional visit time. Used well, just the opposite is true," Dr Frankel's commentary concludes. "Medicine is fundamentally a human enterprise that is still practiced one conversation at a time. Our challenge is to find the best ways to incorporate computers [as care process partners] in the examination room without losing the heart and soul of medicine, the physician-patient relationship."

Over the past decade Dr. Frankel, a medical sociologist and health services researcher who is also a Department of Veterans Affairs research scientist, has conducted a series of studies based on direct observation and videotaping of use of computer in the exam room and conducted extensive interviews with physicians. He and colleagues have found wide variation in examination room computer use: some physicians spend more than 80 percent of the visit time interacting directly with the patient, while others spend more than 80 percent of the visit time interacting with the computer screen.

In these studies Dr. Frankel and colleagues have reported that accuracy of the information gleaned from the patient and entered into the electronic medical record is highest when it occurs closest to receipt of the information versus at the end of the patient's appointment or physician's shift. Studying the patient's perspective, they have found patients have a preference for doctors who they believed to be paying attention to them. In that study he found that patients who were extremely satisfied with their physician believed that the doctor had spent more time with them than actually was spent.

Analyzing exam room computer-use, Dr. Frankel has identified gender differences. Female physicians typically look up from the screen approximately every 30 seconds or so, making eye contact with the patient to signal that they are still actively engaged in the relationship, and return to typing. Male physicians tend to lock on to the computer screen and rarely look up to signal engagement.

The physicians' need to document must be balanced against the need to build and maintain a relationship with the patient. "Computers in the exam room are here to stay. We need to integrate them into the physician-patient relationship in a patient-centered way. POISED provides a framework for us to do so," Dr. Frankel said.

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