EHR Documentation and the Patient–Physician Visit

Sheree Starrett, MD, MS

IN 1999 AND 2001, the Institute of Medicine (IOM) issued reports that galvanized the medical community about healthcare quality. The 1999 report, To Err Is Human: Building a Safer Health System highlighted the negative role that medical errors play in healthcare quality.1 Extrapolating from reviews of adverse events in Colorado, Utah, and New York, the authors concluded that between 44,000 and 88,000 Americans die annually as a result of medical errors; the cost in dollars was likewise very high. The authors reported that “total national costs—lost income, lost household production, disability, and healthcare costs—were estimated to be between $17 billion and $29 billion, of which health care costs represented over one-half.”1

Stressing the need to adopt a culture of safety within the American healthcare system to improve its quality, the authors noted that blaming individuals for errors was not useful—the focus should be “on preventing future errors by designing safety into the system.” The report further emphasized the importance of information technology and the need for computerized patient records, which would benefit patient care.The following are key highlights from the IOM report:

• The ability to access patient data without delay at any time in any place (eg, in an emergency or when the patient is away from home)
• Ensure that services are obtained and track outcomes of treatment 
• Aggregate data from large numbers of patients, both to measure outcomes of treatment and to promptly recognize complications of new drugs, devices, and treatments

To achieve these results, systems would need to be “patient specific, allow population-based analyses, and have systems that manage the case process through reminder, decision support, and guidance grounded in evidence-based knowledge.”1

In 2001, the IOM published Crossing the Quality Chasm: A New Health System for the 21st Century, which furthered the concept that using information technology would greatly improve healthcare quality.2 The report stressed “the importance of a strong information infrastructure in supporting efforts to reengineer care processes; manage the burgeoning clinical knowledge base; coordinate patient care across clinicians, settings, and over time; support multidisciplinary team functioning; and facilitate performance and outcome measurements for improvement and accountability.”

Despite the IOM’s belief that greater use of information technology and computerized records would improve healthcare quality, adoption of electronic record keeping remained slow. In 2001, only 18% of medical practices in the United States were using some form of an electronic health record (EHR). The HITECH Act of 2009 greatly spurred EHR implementation by offering financial incentives for adoption and penalties for failure to comply. Consequently, 78% of community practices in the United States had started using some form of EHRs by 2013,3 with the prediction that 90% of practices would have EHRs by 2017.4

Unintended Consequences
Unfortunately, the significant increase in the amount of data to be collected has created 2 unplanned consequences. For many practices, physicians became responsible for collecting this explosion of required data during the patient visit. This has caused them to spend more time doing data entry and clerical tasks than clinical activities. One study showed that “for every hour a physician spent providing direct clinical care to patients, he or she spent nearly 2 hours on EHR and other desk work, plus another 1 to 2 hours each night.”5 Another study reported the actual effect on physician well-being when the time allotted for a visit did not meet the actual time required to accomplish all the required tasks. These time pressures increased the following: “stress, satisfaction, burnout and intent to leave practice.”6 The problem of increased risk of physician burnout with EHR usage was confirmed in a 2016 report.7

The other unintended consequence for patient care was how the physical task of using computers or other electronic devices during a patient visit could adversely affect the quality of patient–physician communication. In 2005, Ventres et al related that physicians using EHRs were more occupied with data gathering and clarifying clinical information than listening to patients’ own narratives. They were more prone to neglecting patients’ agendas” and less likely to “explore psychosocial and emotional issues or discuss how health problems affect patients’ lives.” Using the computer also created other problems, with physicians spending more time staring at the monitor or intensely keyboarding, rather than interacting with the patient.8

Nowhere in medicine is effective patient–physician communication more vital than in the relationship between oncologists and their patients. A cancer diagnosis creates great stress and uncertainty. Patients need to be able to understand complex information about their illness and its possible treatments, and they are often required to make life-altering decisions. Patients depend on their oncologists to help them in all these areas.

With electronic record keeping, patients are finding themselves sharing the physician’s time and attention with the computer, turning what used to be a “dyadic” relationship between patient and physician to a triadic relationship of patient, physician, and computer.10 Investigators write that patients across the globe have a “major concern about computers in the office—the fixation of the physician’s eyes on the computer screen.” This fear was not unfounded, as a study by Margalit et al found that physicians spent an average of 24% to 55% of the time gazing at the screen during a patient’s visit.11

Research has confirmed that the use of the computer during the office visit takes away from the goal of patient-centered care. Even the simple task of introductions and starting a visit was affected by the presence of the computer: investigators found that after a short greeting, physicians walked straight to the computer, rather than interacting with the patient or discussing the patient’s agenda.12 What the physicians saw on the computer screen often prompted their opening statement, failing to ask the patient to share his or her concern(s).12

Street et al noted that using the computer during the visit led physicians to focus more on information-related tasks and less on psychosocial issues.13 They also found that physicians busy filling out check boxes in the EHR reduced the number of open-ended questions they asked patients and that multitasking caused physicians to lose focus and compromise effective communication.13

Interventions to Improve Patient–Physician Computer Interactions
While physicians can control, to a variable extent, their choice of hardware and software and their communication style, they have little to no control over the amount of data collection mandated by external stakeholders (payers, governmental organizations, external review organizations, vendors and suppliers, etc). Recognizing the burden of administrative tasks on physicians, the American College of Physicians’ Medical Practice and Quality Committee issued a white paper on the need for all external stakeholders to review the value and necessity for all the information being collected and whether some of the data can be eliminated or decreased. The paper emphasized that this needs to be an ongoing process, not simply a onetime effort.14

Unfortunately, physician choice of hardware and software is very much influenced by cost. Purchase of software updates and training on how to use the software are added practice expenses, over and above unforeseen expenses such as changes in computer equipment and exam room layout. computer equipment and exam room layout.

Physicians need to appreciate the effect that EHR charting and documenting has had on physician–patient communication—they need to understand that paying excessive attention to the computer and EHR may cause them to lose focus on their patients. Physicians must recognize that certain behaviors under their control are not acceptable. "Looking predominantly at the computer monitor during office visits, typing while patients are talking about intimate concerns, reading silently from the monitor while patients sit idly, using templates to lead interviewing rather than listening to patient narratives, and having their backs to patients” all work against relationship building.15

In their 2013 paper, How to Integrate the Electronic Health Record and Patient-Centered Communication Into the Medical Visit: A Skills-Based Approach, Duke et al presented 10 behaviors or interventions physicians should follow when using an EHR.10

• Changing the location of the EHR’s computer screen is a fairly easy intervention. Ideally, exam room screens should be located in a position that allows physicians to maintain patient eye contact and avoid having their backs to patients.
• Similarly, the ability to share the screen and its information with the patient is another positive for effective communication.16
• A crucial skill that is under physicians’ control is their ability to type and their familiarity with their own EHR. As less computer-savvy physicians retire, the problems of poor typing and slowness with mouse clicks will disappear. In the meantime, all physicians using EHRs should make every effort to become proficient at typing and using computer hardware and know the capabilities and functionalities of their own EHR program.
• Ideally, physicians should have reviewed their patient’s records before starting any encounter. Upon starting a visit, they should introduce themselves and their role in the patient’s care. It is also useful for the physician to introduce the patient to the electronic record and explain that he or she might be typing into the computer during the course of the visit.
• A major pitfall to avoid is allowing the EHR template to dictate the course of the visit. Physicians need to start with open-ended questions and collaborate with the patient on what is to be accomplished during the course of the visit. Statements such as “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,” and “Let me tell you what I am typing” are ways to involve patients in what one is doing when focused on the computer and not the patients.10 Physicians should explain to the patients when questions specific to templates or required data elements must be entered into the EHR.
• Physicians need to be able to follow patient cues and emotions and know when to interrupt typing and devote their complete attention to their patients. Research has shown that “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.”10 One of the major advantages of the computer for clinical practice and for oncology specialists is the ability to educate patients about their condition and to share information. The physician can point to the screen and offer to visually share test results, lab findings with trends, or x-ray tests. Additionally, information on treatments and possible clinical trials can be found and printed out for the patient. This ability to readily share the information in the EHR is a
major benefit and facilitator of patient engagement.

Conclusion
The transition from paper-based office records to documentation using electronic media has had several unplanned consequences. Physicians are finding themselves spending more time on data entry and looking at computer screens than on focusing on patients. While the EHR has greatly improved the ability to share information and educate patients, it has also had a negative impact on patient centeredness and emotional and psychological communication and the ability to establish a trusting relationship between physicians and patients. This article outlines practical ways to use the computer in a positive way. 
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