Build EMR functionality into the exam room

In 2003 our practice had a rare opportunity to build EMR functionality into the floor plan of our new office.  I thought I had the perfect design for the EMR-based exam room.

The spring-loaded, cantilevered arms used to hold monitors and keyboards in ICU rooms would be perfect.  Fitting a touch screen monitor to a standard PC would allow the provider to work without a mouse.  I could turn the screen toward me or toward the patient, depending on what I was doing.  Could see it all in my mind’s eye, plain as day.  Fortunately my partners had more sense than I did; the group limited the idea to 2 of 8 exam rooms.  Six months after we moved into our new space the idea had been tried and had died, and the 2 arms now sit unused.

Shortly thereafter, the other member practices in our network were preparing to implement EMR.  Everyone wanted to know what kind of computers to buy and where to put them.  We considered many combinations of computers (desktops, laptops, tablets) and possible locations (exam rooms, back office, physician office).  Where inside the exam room should the computer be placed?  And where should the printers be installed?  I began to realize that behind these seemingly simple hardware questions lurked a much more challenging issue.

The introduction of information technology to the patient care environment fundamentally changes the physician’s interpersonal approach to the patient – one’s bedside manner.  If this change is not actively managed, the doctor-patient relationship will be adversely affected.  The computer competes with the patient for the doctor’s attention and can easily take over.  We must ensure that the patient always prevails over the machine.

To that end, we have learned some things over the past 5 years:

The e-scribe. This is a very effective technique but is also the most expensive.  Because the physician almost never touches the computer, the patient has the doctor’s undivided attention.  But the scribe has a big pitfall — it’s very easy for the physician to avoid contact with the chart altogether.  This reduces the quality of documentation and raises the risk of medical errors.  Every chart note must have some documentation that came directly from the physician’s brain, even if it is just a sentence or two.

The tablet PC. This is my favorite if you can’t afford to hire a scribe.  With a tablet you can work side by side with the patient and show what you are doing.  This demystifies the IT presence and gives you more time to navigate screens and get the work done.  It also showcases to the patient all that work you put in to get EMR.  They will notice.

The handwriting recognition in Windows 7 works well and is much better than Windows XP.  Handwriting in the chart in front of the patient is much more culturally acceptable than using a keyboard.

I tried an iPad for about a month.  The wow factor was great but the touch screen was a little too sluggish for a button-dense EMR screen.  Handwriting recognition that works with Remote Desktop is not available for the iPad.  The patients loved it though.

Laptops are most commonly used just outside the exam room, either at a workstation or on a rolling unit placed just outside the exam room door.  Carrying the laptop into the exam room works well as long as there is a convenient, safe place to put it.

Desktop PCs. Unless you have a scribe, using a desktop PC in the exam room will likely force you to turn your back to the patient to use the EMR.  I was hoping to avoid that problem by using the ill-fated spring-loaded arms to hold the monitor and keyboard.  Desktop PCs in exam rooms logged on to your EMR also raise privacy / security issues.

Hybrid techniques. Currently my assistant accompanies me in the exam room and uses a small netbook to take notes.  At the same time I use my tablet mainly for workflow (prescriptions, handouts, test ordering etc.) but I may jot down notes as well.  One of my partners uses a laptop for himself and one for his assistant, both on rolling workstations just outside the exam room.  They both work in the same chart at the same time – the MD on workflow, the assistant on documentation.

Speech recognition. I love it and use it every day.  But not in the exam room.  From a cultural standpoint it is too awkward.  Any extraneous noise wrecks the speech engine, and you will waste time deleting “word salad” from your chart note.  The patient must be totally silent during your dictation.  But it is not easy to be quiet when someone is talking about you as if you aren’t even there.

Remember the basics. Eye contact.   Listening.   Empathy.  Be sure you spend some time connected only to your patient.  Close the laptop, put the tablet down, and pretend you’re back in the good old paper chart days.

Think carefully about your exam room layout. The computer is yet another item that must be wedged into that tiny room.  Make some room by cleaning out anything that doesn’t really need to be there.  Think about wall-mounted document racks and folding work surfaces.

You won’t be able to guess what is going to work best for you ahead of time.  Pick an option, try it for a while, and then try something else.  If you have 2 exam rooms, set them up differently and see which is better.  As you gain experience your preferences may change.

Software and hardware aren’t there yet.  We still need products that operate based on how we practice medicine.

As technology changes so will our best practices.  We do our best to roll with the punches and keeping up as best we can.

Mike Koriwchak is an otolaryngologist who blogs at the Wired EMR Practice.

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  • pcp

    “Software and hardware aren’t there yet. We still need products that operate based on how we practice medicine.”

    Hate to harp on the obvious, but, if that is true, what’s the rush?

    • Nancy

      Some might feel the need to change their current work habit when introducing an EMR. But simply stated, you don’t need to change the way you interact with your patient. If you’re used to documenting by pen & paper but need to still get this into your EMR solution you need to simply digitize your pen & paper….check this out and you will see what I mean. http://www.scantron.com/downloads/paros_video/

      It works for docs, clinicians & patients…think intake forms, consents, health histories, clinical drawing, etc. No re-keying of data & a friendly tool you’re already used to.

      • horseshrink

        Intriguing. Would need to see it in action to know if it’s truly ready for prime time.

  • Beth

    Please don’t disregard a potentially huge drawback of hiring a scribe: From the patient’s perspective, you are thereby inviting a stranger into the room. I would feel much less comfortable speaking with my doctor if a third person were present. It is hard enough to discuss intimate medical issues with a doctor; please don’t discount how much harder it could be with a scribe in the room too, no matter how quiet and “faceless” they tried to be.

  • AnnR

    Or worse, the doctor talks to the scribe the whole time and the patient is just an afterthought.

  • horseshrink

    I believe the best catalyst for EHR evolution and cost reduction is standardization of data constructs.

    If docs can change products at will, without the pain of database migration, EHR developers that want to remain in the market will become very interested in what docs actually want.

    As it is, right now, buying an EHR marries vendor and client via the proprietary database.

    Data migration cost + new product cost = very painful divorce

  • Mark

    I used to scribe in an ED. We used the ‘hybrid’ model described above. The increased billing from more extensive documentation more than covered the cost of the scribe program.

    • pcp

      Buy EMR. Hire scribe to run EMR. Document more while doing same amount of work to increase revenue. Increase revenue to pay for EMR.

      Makes LOTS of sense to me.

  • pcp

    Doesn’t the fact that there is even a conversation about using scribes and “virtual assistants” (that post was a little confusing, and sounds like he means off-site assistants) indicate that there is a big, big flaw in EMRs as currently designed?

    • horseshrink

      Yea … the “virtual assistant” sounds like a euphemism for “off-site contract scribe.” Would rather have the scribe as an in-house trainable employee to assure record consistency/quality/integrity.

      But … you also state the obvious. I needed no extra person to write in a paper chart. I was able to hand write notes and conduct a decent interview … simultaneously. Appointment over? Note over. Next patient.

      Yup … an EHR allows instant access to patient information simultaneous with other users … SO LONG AS the power is on, the computer is functioning properly, the software is running correctly, and the network is up. Hopefully the hard drive hasn’t crashed, or malware hasn’t made it into the system, the last Windows or EHR update didn’t break something, and backups are occurring properly.

      An EHR is supposed to improve what I can do with the medical record’s information. Analyze, flag, alert, search, etc. That’s assuming the EHR is designed adequately to do these things.

      And expense … several years ago my geek bubble was burst by a former hospital administrator from a large hospital chain who enlightened me re: the prodigious cost of creating and maintaining an EHR. For my clinic’s medical record, I used H.S. educated people (or, during the summer, their kids who were still in H.S.) to assemble and file my paper records. No can do with an EHR. Gotta have more educated (=more expensive) tech savvy people to keep the thing going. Or me … and I’m even more expensive. And computers don’t last as long as paper records. Gotta keep replacing them.

      My skepticism is especially fueled by current daily experience with a bad product deployed at the state level. This product is an icon of all that should be avoided in an EHR product … clunky, non-user friendly work flow, blind loculation of all information, poor data input and data review interfaces, no data analysis (at all), no dashboarding, cobbling of unfriendly, competing products, sloooooow network, periodic crashes, infinite forced response, bureaucratic radio buttons ….

      Why don’t we change … other than usual bureaucratic juggernaut inertial reasons?

      Because the change would be too expensive. So … I shake my head … and shake my head … to see the state persistently pour good money after bad to maintain the current atrocity, because change would be too expensive. Why?

      A new product would be enormously expensive. Data migration to the new product would be tremendously expensive.

      Data migration cost + new product cost = prohibitive cost.

      Thus, I’ve come to realize that EHR consumers would benefit if the data migration expense was removed. This is possible if data constructs are standardized. Example = the WWW. Web page data constructs are sufficiently standardized to allow use of a slew of different browsers … IE, Firefox, Konqueror, Chrome, Lynx, Safari … I want to check out a different browser? No problem. Install and use. The whole internet doesn’t have to change its configuration because I decided to use a different browser.

      The same should apply to health record data.

      Then, vendors won’t be able to lock clients into a product via an idiosyncratic database (unless that’s what a client actually wants.) When it’s as easy to change EHR products as it is to change browsers, EHR companies will shift their entire development strategy to discover and target what docs ACTUALLY want to use while seeing patients. Also, you lubricate competition and what happens to price?

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