Computers in the exam room: Good and bad setups

Does your doctor use a computer in the exam room? Some people think that computers are a great way to keep track of patient information.   Others see some advantage, but problems in the implementation.  There are also a few Luddites who oppose this change simply on principle.   I’ve had good experiences, and bad experiences, and believe we have a long way to go before computers are as helpful as they could be.

There are two separate issues.  The first one is quite significant:  is there software that will do what doctors need it to do?  The other issue is how this affects the doctor-patient relationship – definitely another significant factor.

In every other field, the best way to buy software is to define what you need to do, then look for programs that will meet that need.  To date, it appears that the accountants are shopping for software to meet their billing needs, without consulting physicians to determine what doctors want or need.  Not being a doctor, I can’t really elaborate on that, but when doctors and nurses spend more time cursing the software than they do seeing patients and documenting the encounter, there’s obviously a problem.

As a patient, I’ve seen that computers in the exam room have an impact on the doctor-patient relationship.  The doctor’s behavior is important.  So is room setup.  Both of these issues need to be considered.

One doctor I saw had exam rooms set up like this:

Computers in the exam room: Good and bad setups

This is obviously a bad way to arrange a room.  There’s a huge desk acting as a barricade between the doctor and the patient.  When the patient is sitting in the chair, the doctor must look away from the patient in order to see the computer screen.  No matter how caring a doctor might be, the patient isn’t going to perceive it when the doctor steps into the room, nods and waves at the patient, sits behind a desk to face the computer, and focuses on data entry.  In this room configuration, the computer literally comes between the doctor and the patient.

In contrast, I’ve been in other exam rooms that handled the computer’s presence better:

Computers in the exam room: Good and bad setups

Both of these room configurations allow the doctor to sit with the patient.  No computer comes between them.  My preference is for the room on the right, where the doctor is still 45° to the patient when looking straight at the computer screen.

These illustrations aren’t the only types of rooms I’ve seen.  At Children’s Hospital, my daughter’s rheumatologist sits at the end of the exam table and talks with her.  The computer is clear across the room, and data entry is done by a scribe; at the end of the appointment, the doctor clicks a few buttons.  The computer seems to be a tool that helps provide prescriptions and information, not a deity to be worshipped by everyone in the building.

About eight years ago, I saw a doctor who carried a laptop from one room to the next.  At my first appointment, he grinned and said that he found it easier to keep his notes on computer instead of paper.  It didn’t affect the exam or our rapport.  Everything seemed normal, except that he typed his notes instead of handwriting them.  It worked well.  That would be ideal (and should be easier today, with tablet computers).

My favorite way of handling computers, however, is the doctor who keeps the computer in his office and out of the exam room entirely.  He obviously pulls my file up to refresh his mind before coming into the exam room.  We talk and he does an exam, then he returns to his desk to type his notes while I dress, and there’s a prescription waiting at the front desk by the time I check out.  It seems the most efficient, and the computer isn’t at all intrusive.

The worst computer setup I’ve ever experienced had the computer behind the doctor so that he had to turn his back to me.  Or maybe that was a good thing – I was able to read over his shoulder.  When he typed, “no pain on movement” I was able to ask, “Why would you say that?”  He was astonished (1) that I was looking over his shoulder, (2) that I questioned him, and (3) that he got it wrong.  He had asked if I could move my wrist, not if it hurt to move it.  Huge difference – and we never would have known if I hadn’t looked at what he was typing.  It would be incredibly easy for doctors to project their computer screen onto a wall so that the patient could see what’s being said.  Patients might not feel quite so ignored while doctors are typing, and we’d know that the information going into our chart is accurate.

As more doctors switch to electronic medical records, patients will insist on the computer being a tool to help, not an interference.  We will refuse to see people who make us feel like saying My Doctor is a Computer! 

“WarmSocks” blogs at ∞ itis.

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  • CL3579

    I agree that the people designing medical charting software should be getting input from the doctors, nurses and anyone else who uses the software. It would be nice if charting software could include a page that worked something like a spreadsheet so that data such as weight, blood pressure and blood test results from each visit could be displayed in a way that would clearly show changes and trends over time. Having to jump or flip from one page to another to compare the data from past visits is not the most effective way to get an overview of a patient’s progress.

    I also agree that it would be helpful to be able to see what the doctor is entering as it’s being done in order to catch any misunderstandings or mistakes. Or if that’s not practical for the doctor, then I’d like to be able to review the chart by internet after a visit and to submit a request to have corrections made if necessary. I request copies of my medical records from time to time and I have found a few errors, as well as omissions of information that I felt was important to have recorded in my chart. Another benefit of being able to review the chart by internet after the visit would be to make sure I didn’t misunderstand the doctor’s instructions to me and haven’t forgotten anything important that I was told during the visit.

    • WarmSocks

      I would assume that all EMRs show trends in weight, bp, and lab tests. It’s a pretty basic thing to display data in a useful format.
      Until we get to validate accurate data entry, periodic requests for chart notes is probably the best we can do. During an appointment, I find it helpful to take notes; at the end of the appt, I summarize my dr’s instructions back to him to make sure that I understood everything.

  • Lumi St. Claire

    At my previous hospital, all the input in the world from the faculty and staff didn’t change the fact that, because our physical plant was so old, we had serious restrictions in where we could (and more importantly couldn’t) put computers when our clinic made the transition to EMR. We ended up with an unfortunate number of rooms that force the physician to turn their backs on their patients in order to enter information into the computer, despite a ton of protest ahead of time. The technology was there, but our building ironically couldn’t handle it.

    • WarmSocks

      That’s truly a sad state of affairs, particularly since a tabletPC could have been used instead. I suspect tablets are the direction we’ll be headed.

  • David Voran, MD

    The penultimate paragraph highlights the reason why computers in the exam room are absolutely necessary and has everything to do with transparency. Unlike banks and other industries medicine has no system or culture of ensuring data validity. There is no mechanism for us to know for certain whether a note is accurate. Only the patient and the physician know this and in the overwhelming majority of systems the patient is privy to nor signs off on the note attesting to it’s validity.
    The easy way to start building a culture of data validity into medicine is to use technology to engage the patient at the point of care. We have implemented large 23″ touchscreen all-in-one PC’s in the exam room to do just this and it’s a struggle to get all of our staff and clinicians to encourage the patient during the visit with positioning them to look at the screen and ask them “is this correct?” or “do I have the facts straight?”
    The touch screens enable us to transfer many parts of the interviewing process directly to the patient to reach out and select appropriate answers to questions rather than having to ask them and then rekey them in (a potential for error).

    IMHO the ideal exam room is a large 47-60″ wall mounted touch sensitive computer that is used by the patient where work flows are built around this and the patient signs an attestation at the conclusion of the visit to the accuracy of the data and that they’ve received the appropriate education.

    Of course, we’d have to change our reimbursement systems from volume to quality in order for this to be pervasive but until the patient is one of the primary users of the system we’ll never really be able to trust the data nor get a solid return on our EHR investments.

    • WarmSocks

      Thank you for your thoughtful comments. Having patients verify that everything was understood correctly is a great idea. Lacking a touch-screen, a plain monitor hung on the wall could work: I can connect my laptop to the large-screen TV at home so that everyone in the room can see what’s on my tiny screen. It would be quite simple to do this in an exam room, too.

  • EmilyAnon

    I wonder how easy it will be to involve older people using computers in the exam room. It would never work with my grandmother who still struggles with the TV remote.

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