The 3 rd person in the Exam Room

(1)

Dr. Matt Rafalski FAAFP Dayspring Family Health

Center Jellico, Tn mrafalski@dayspringfhc.com

The 3

rd

person

in the Exam

Room

DISCLOSURE STATEMENT OF

FINANCIAL INTEREST

• I, Matthew Rafalski, MD, DO have a financial interest/arrangement

or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject

of this presentation, they are: Affiliation/Financial Interest: Name of Organization (s):

Grant/Research Support: Consultant:

Speaker's Bureau: eMDS

Major Stock/Shareholder :

(excluding mutual funds)

Advisory Board:

(2)

COMMUNICATING WITH (IN SPITE OF) THE EHR

“ That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner …”

TECHNOLOGY

John Forbes M.D.

Introduction to the translation of a book about the stethoscope - 1821

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Work Excellently • Know Intentionally • Speak Graciously • Love Extravagantly • Live Selflessly

INTENTION

Preserve Sanctity

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Advantages / Disadvantages of EHR in exam room

•

Communication Techniques

•

System/Organizational improvements

(3)

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Most cannot afford to change system

•

Most shouldn’t change systems

•

“Wherever you go – there you are.”

WORKING WITH WHAT YOU HAVE

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

What did the vendor intend?

•

What is our intention?

WHAT IS OUR INTENTION?

COMMUNICATING WITH (IN SPITE OF) THE EHR

Communication = Diagnostic Procedure

(4)

COMMUNICATING WITH EHR

Patient

Provider

EHR

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Communication Advantages

• Positive effects for provider/patients

• Allow patients to better direct visit/influence behavior

of providers

• Shown not to effect or even improve patient

satisfaction

(5)

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Problems

• Introduces additional complexity

• Provider cognitive model/ process may not line up with patient’s physical realities or their representation in EHR

• Shuts down psycho-social issues / deeper conversation

• Limits creation of patient physician relationship

• Decreases empathy

USE OF EHR

(6)

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COMMUNICATING WITH (IN SPITE OF) THE EHR

IMPROVING EHR / COMMUNICATION SKILLS

14 Saleem JJ, Patterson ES, Militello L, et al. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc 2005;12:438–47.

(7)

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Provider with good communication skills

incorporate the computer better into the visit

•

Providers with good

(BUT NOT GREAT)

computer

skills incorporate communications better into the

visit

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

The BIGGEST Patent Concern:

• fixation of the physicians eyes on the computer screen

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Provider Concerns:

• Loss of eye contact • Falling behind schedule • Computers too slow

• Inability to type quickly enough

• Feeling that using computer in front of patient is rude • Preferring to Write long prose notes

EHR / INTERFACE / PATIENT LEVEL

(8)

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Divide the Encounter into patient and computer focused stages

• Computer – patient –

computer “sandwich”

• Demarcate by changes in

body language and focus of gaze

• Start the sandwich out side

the room

EHR / INTERFACE / PATIENT LEVEL

Preparation – Patient Visit

• Review the chart •Insert reviewed data when possible •Labs •Histories •Care Plans

Use the tools of eMR

•Data insertion •Pulling data forward •Review and

document

•Familiarize yourself with the template

COMMUNICATING WITH (IN SPITE OF) THE EHR

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

(9)

•

Charts done on the fly TAKE LONGER, less well

organized, less satisfying to patient and provider

COMMUNICATING WITH (IN SPITE OF) THE EHR

Patient Interaction

•

Greet the patient

•

USE THEIR NAME

•

Shake their hand

•

Do this before turning to computer

COMMUNICATING WITH (IN SPITE OF) THE EHR

OPEN the interview

•

Introduce the EHR

•

Set agenda with patient

•

Help from care team – nurse / MA

(10)

COMMUNICATING WITH (IN SPITE OF) THE EHR

OPEN the interview

•

Start with a positive about the patient

BEFORE you look at the computer

COMMUNICATING WITH (IN SPITE OF) THE EHR

Preparation: Physical Space

•

Monitor Position

•

“Side Saddle”

•

Font and low

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Reading out loud as you type

• telling them what is ordered, what is

TASKMAN’ed

• Synchronize what you are working on – with what is

going on in the visit

(11)

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Sign - posting

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Echoing /

Reflecting

(12)

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Using Continuers (go on…

, tell me more)

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Explaining intermittent pauses while provider reads / types

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Minimizing screen gaze

(13)

• Involving the patient with computer and information

• Share the Screen

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Use the screen to

Confirm information is correct

• Display Patient

education

EHR / INTERFACE / PATIENT LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

Building the Relationship

• EHR has shown to negatively effect empathic components of

the interview

• Gaze inversely related to gathering of psychosocial info

• Lack of gaze inhibited full patient disclosure of sensitive information

(14)

COMMUNICATING WITH (IN SPITE OF) THE EHR

Building the Relationship

• Empathy – Builds relationship – builds trust • Improves:

• sharing of information •patient satisfaction

•adherence to therapy

•has intrinsic therapeutic effect

COMMUNICATING WITH (IN SPITE OF) THE EHR

Building the Relationship

• Empathic Component can be Improved by:

• moving head, torso, and eyes toward the patient

• removes hands from keyboard/mouse

• push monitor away

• Signaling that you are giving patient undivided attention

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Closing the visit

• Going back and clarifying data • Sharing Data with Patient • Inserting patient education

• Ordering tests / medications / follow up

(15)

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Closing the visit

• Tell your patients what you are doing – while you are

doing it

• Point to the screen

• Encourage patient’s participation in building their

charts

COMMUNICATING WITH (IN SPITE OF) THE EHR

Comments

• Avoid negative/ disparaging comments about computer • Avoid expressing your frustrations

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Make sure patient dose not mistake concerns about computer

function/ malfunction with concerns about them

• Avoid

• Uh-Oh

• Rats

• O my

• Darn

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IN SUMMARY

• Improve our communication skills • Improve out computer skills

• Divide the visit into phases - computer – patient – computer

• Invest in workflow/template/clinical decision point • Training

• Use patient’s name

• Increase eye gaze • Share the screen

• Tell them what you are doing

• Use verbiage and gestures to improve empathy and

disclosure

IN SUMMARY

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DAYSPRING FAMILY HEALTH CENTER

Dayspring Family Health Center is a not-for-profit community health center founded on the conviction that everyone should have access to affordable quality health care. We are committed to providing our patients comprehensive medical care in a fair and gentile manor. A healthy community is one in which its members begin life with hope, experience life with joy, and end life with dignity. We are convinced that many health problems have community causes and community solutions. Therefore, our ultimate purpose is to promote full health – physical, spiritual, mental and economic – of the communities that we serve.

TEAM COORDINATION / WORKFLOW

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Workflow

•

Simple

•

Clearly define

•

Designed to max info / save time

TEAM COORDINATION / WORKFLOW

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COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Team Assignments

•

Everyone plays a part

•

Well assigned responsibilities

•

Accountability

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Template Development

•

Structure

•

Consistent use

TEAM COORDINATION / WORKFLOW

• Clinical Decision Support

• Designed well / implemented well to enhance communications

• Singular

• To many items overwhelm ability to process

• Simple

• To simple ineffective, too complicated interferes with communication

• Specific

(19)

•

Successful Clinical Decision Support

•

Automatic

•

Provided at time and location of decision

making

•

Computer based

Ref 1

ORANIZATION LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Training •New providers •Refresher •New workflows • Workflow Development • Accountability

ORANIZATION LEVEL

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COMMUNICATING WITH (IN SPITE OF) THE EHR

Preparation: Physical Space

•

Desk and Chair position

•

Monitor size

•

?? Learn to touch type ???

ORGANIZATIONAL LEVEL

COMMUNICATING WITH (IN SPITE OF) THE EHR

•

Improve documenting thought process

•

Think-do-document

•

Touch screen

•

Skins

•

Improved patient display

•

Improve workflow – decrease clicks

DEVELOPER LEVEL

IN SUMMARY

• Improve our communication skills

• Improve out computer skills

• Divide the visit into phases - computer – patient –

computer

• Invest in workflow/template/clinical decision point • Training

(21)

• Use patient’s name • Increase eye gaze • Share the screen

• Tell them what you are doing

• Use verbiage and gestures to improve empathy and

disclosure

IN SUMMARY

COMMUNICATING WITH (IN SPITE OF) THE EHR

• Efficiency

•

Accuracy

•

Improved Patient Care

DELAYED GRATIFICATION

(22)

DAYSPRING FAMILY HEALTH CENTER

Dayspring Family Health Center is a not-for-profit community health center founded on the conviction that everyone should have access to affordable quality health care. We are committed to providing our patients comprehensive medical care in a fair and gentile manor. A healthy community is one in which its members begin life with hope, experience life with joy, and end life with dignity. We are convinced that many health problems have community causes and community solutions. Therefore, our ultimate purpose is to promote full health – physical, spiritual, mental and economic – of the communities that we serve.