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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