Is the patient experience enhanced by modern technology?

Most physicians went into the practice of medicine motivated (at least in part) by the reward that comes from that human-to-human connection. The reward that comes from helping people. It was true of my generation of physicians, it was true of those before me, and is true of newer generations of physicians who grew up in a more interconnected, digitized world.

We are now at a time in medicine where an unprecedented layer of technology, including Electronic Health Records (EHRs), pervades the ethos of care. From the perspective of that essential, interpersonal kernel of the caring professions – is this a good thing, or does it get in the way? Can we truly have “high touch, high tech” health care?

There are multiple facets to this question. Three that come immediately to mind are as follows:

  1. When you use an EHR as part of a doctor-patient encounter, does the computer become the “third party in the room” and get in the way of the healing relationship?
  2. Is patient engagement in one’s own health enhanced by the new technologies now becoming available, or is the flood of on-line data overwhelming the search for meaning that we all want when coming to grips with our own health?
  3. As we shift the financial underpinnings of health care away from simple fee-for-service, and towards methods that reward performance and efficiency (e.g. bundled payments, medical homes and accountable organizations that are charged with managing the health of populations), can all of this be used to enhance, rather than detract from, the patient experience/satisfaction?

Each of these questions could take up its own full essay. Let’s touch briefly upon each of them here.

Is the EHR an elephant in the room during a doctor-patient visit?

It has long been shown that when a doctor enters an exam room, remains standing, keeps her/his nose in the chart, does not make eye contact, and spends 10 minutes in the encounter, the patient will state that “the doctor didn’t spend enough time with me.” But when the doctor comes in to the room, puts the chart down, sits down with hands in lap, engages eye-to-eye, and has a conversation, those same 10 minutes will be perceived as “enough time” during the visit.

The same is true with an EHR. If the doctor enters the room carrying a small laptop computer (or even an iPad) – something no larger than a traditional paper chart – and sets the computer down, sits down, and engages eye-to-eye, then the “healing connection” is made. At that point, then, the computer can be opened up and used as a resource – labs can be reviewed together, medications can be verified, and e-prescriptions can be generated. Messages can be sent to the front desk, and a clear treatment or action plan can be formulated.

This sort of interaction is best facilitated by small, portable computer hardware that the clinician can carry around from room to room. The older, fixed hardware sitting coldly in an exam room can certainly be “the beast in the room.” But portable, lightweight computer hardware is low cost and ubiquitous these days, and facilitates the “best practice” interactive method described. This also means that the EHR needs to be one that can be deployed on these portable devices, and does not rely on hard-wiring. We live in an age of web-based EHRs (even sophisticated, free ones), which makes such a setup accessible to every practitioner in every setting – large and small.

Patient engagement in the age of the Internet

One of the elements of modern EHRs is that many of them (especially web-based EHRs) have patient-facing portals (a connected EHR-PHR). In fact, giving patients access to their own information electronically is incentivized by several Meaningful Use criteria. The widespread deployment of patient-facing portals is still early in its maturation, where people can see via the Internet (at a minimum) their own problem lists, medication lists, allergies, lab test results, and upcoming appointments. And preliminary data shows what is intuitively obvious: that patients do better when engaged with their own care.

This is especially true for patients on multiple medications – the typical Internal Medicine situation. There is reduced confusion about medication, improved adherence to prescribed regimens, and better outcomes simply from paying attention to one’s own health data. A portal that is connected to what is in the treating physician’s chart, and is updated when some change results from an office visit, is now part of the healthcare landscape.

Of course, people don’t stop there. Two studies by the Center for Studying Health System Change showed that in 2008 there was a striking increase in the percentage of people seeking health information from all sources (56% of respondents), but that in 2011 a repeat of the survey showed that the percentage had dropped to 50%. However, most of the drop was in using printed resources, while Internet searches for health information continued to increase.

Those of us in clinical practice know this to be true. Internet searches for clinical information abound, and the whole spectrum found in society can be found on-line – good data, wrong data, fraudulent data, cutting-edge data, trusted resources, and charlatanism. The Internet, if anything, is the most democratizing force we have ever seen. So patients, when they come to the doctor seeking health care, aren’t necessarily looking for “raw data” – the have already looked it up on-line. Instead, they are looking for meaning. For interpretation. They are asking “what should I believe?” The physician becomes a trusted source, and a guide through the chaos. This is a new role for physicians.

Is the patient experience enhanced by modern technology?

If the “best practices” of doctor-patient interaction is followed, and the EHR is used as a resource on-the-side, rather than something in the way of the human-to-human connection, then patient experience (formerly called “patient satisfaction”) is improved.

If there is better patient engagement, which includes sharing a doctor’s summary chart information with patients via a web-accessible portal, as well as serving as a trusted source for interpreting and giving meaning to the chaotic array of overwhelming data on the Internet, then patient experience is improved. And outcomes are better – we have seen data from smaller closed systems showing this, and expect that as such technology becomes ubiquitous, these findings will be seen more broadly.

As health care changes (from a financial underpinnings and incentives standpoint), these kinds of effects are not mere altruism. They turn in to better performance, and in a pay-for-performance environment they turn in to more income.

Most of the new ways of organizing health care, such as ACOs, include patient-experience questionnaires as part of measuring performance. There are well-studied satisfaction tools that are part of the NQF library of clinical quality measures which will become part of the fabric of performance-based health care in the coming years. And the best ways to maximize performance in these domains is to be cognizant of the “best practices” of doctor-patient interaction (while using EHRs) as well as to be pro-active in enabling and encouraging patient engagement.

Call me an optimist. But my belief is that it is possible to have both high-touch and high-tech health care. The tools we have at our disposal are powerful resources for high quality health care – however, they are not a substitute for the human-to-human connection that is at the core of the healthcare-giving professions.

Robert Rowley is a family physician and Medical Director of Practice Fusion.  He blogs at EHR Bloggers.

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  • Lumi St. Claire

    Thank you Robert for a really insightful post.  I am very glad you mentioned old, immoveable hardware as a real “beast in the room”.  In my clinical practice, I worked with a cultural minority that was very grounded in high context communication (strong emphasis placed on body language and non-verbal communication).  I also worked in a hospital that, for a variety of reasons, insisted on purchasing large, fixed EMR computers that were placed against the wall so that we were forced to turn our backs on our patients when we entered information.  It was a truly demoralizing experience.

    I also don’t feel it’s exactly an apples-to-apples comparison when you talk about putting aside paper charts and computers for 10 minutes to meaningfully engage with patients.  When our clinic was still using a paper chart system, I could really focus on communicating with my patients, and would simply jot down cues on the encounter form for the important stuff, which I was able to easily resurrect later when I was completing charts.  With our (admittedly Jurassic) EMR system, there were so many pages of mandatory boxes that had to be checked and forms that had to be printed out while the patient was there that I found it impossible to maintain the same level of engagement.  if I didn’t check the right boxes during the visit, I wouldn’t be able to complete the charts accurately at the end of the day.  This kind of “automation creep” into the patient encounter itself, in my opinion, does nothing to improve patient care or the care experience itself.  

    Thank you again for sharing a thoughtful post with us.

    Lumi St. Claire

    http://mywhitecoatisonfire.com

  • http://www.thehappymd.com/ Dike Drummond MD

    Great post Robert and I agree with all of your points. One of the challenges I see is that the heart of a healing encounter can only begin when the doctor puts the chart down (paper or tablet computer) and the patient does the same thing by putting down their web browsing cell phone. It is the person to person, empathetic, real time, in-the-same-physical-space connection that is most important IMHO.
    Yes the doctor will use their EHR of choice and become more of a curator for the patient’s online research AND there has to be time for everyone to put the devices down to connect and communicate for real.
    I see tech as an adjunct to that core connection. You?

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • Anonymous

    EHR use by a small laptop is just as cold as mostly perceived by patients. Personally, I tried two modes of encounters, with and without laptop with me when I see and examine my patients. I found out that patient satisfaction is far greater without the laptop in the room during my encounter.

  • http://www.facebook.com/clare.stride Clare Stride

    The perception of technology in health care (and indeed in life everywhere) is changing rapidly and younger generations will not see its use during consultations as intruding in the same way that older generations may.  Used as a tool for collecting, explaining and transferring data, EHR and the hardware they are stored on could be a great advantage as long as they fulfil their uses and are put away so not to replace one on one talking.  The challenge of using medical technologies to improve access to and quality of health care without de-personalising the care or breaching patient confidentiality is huge but one we have to face.  There is massive potential in e-health technologies, especially in reaching remote communities. 

  • http://twitter.com/CarisSevern Caris Severn

    Comparing paper record-keeping and EHR as a patient, I much prefer the latter.  My internist can now retrieve prescription- and condition-related data so much more quickly and efficiently without having to laboriously page through my previously voluminous folder.  As I take quite a few vitamins and other supplements and sometimes make changes to this assortment, EHR allows for reliably accurate, current listings.  It saves a great deal of the doctor’s time, too, in the process.

  • Anonymous

    I agree with you that patient’s experiences are enhanced by modern technology.  As you suggest, we as patients can benefit from the high touch- high tech.  What would be the price we would pay for such an experience?

  • Steve Wilkins

     Nice post!  A couple of thoughts.

    The strength (and theraputic potential) of the physician-patient relationship is about people not technology. A patient-centered communication style on the physician’s part is what distinguishes physicians with good patient communication skills from those with average (physician-directed) patient communications skills.

    To the extent that technology facilitates patient-centered commincations, it has the potential to enhance the patient experience – for a segment of the patient population.  To the extent that technology get’s between the physician and patient…then no so much.

    Secondly,  I contend that patients are already engaged by the time they walk through the front door of the physician’s office…jjust not in the way providers tend to define engagement.  Simply look at the conginitive efforts on the part of patients that precedes their showing up for their appointment.  Will technology foster the level of engegment patients have when they walk into the office or will it diminish or totally disengage the patient’s pre-existing level of engagement?  At this point, I suspect that adding technology to practices in which physicians don’t do a good job of talking with patients will not do much to improve the patient experience…at least for most people. .

    Steve Wilkins, MPH
    http://www.healthecommunications.wordpress.com