by: Ron Jimenez, MD, FAAP
It’s time we consider moving the computer out of the exam room. Let’s admit it, having the EHR in the exam room is impacting the patient-doctor relationship.
As a practicing pediatrician, I have even seen the computer become a distraction for children who are naturally curious, not to mention the potential
infectious disease implications of pediatric patients playing with the keyboard and mouse.
Now, this is not to say that information technology can’t be made to serve the doctor patient relationship. If fact, that is exactly what is needed. Rather
than have the physician attend to the needs of the information technology in the room, let’s enable the physician to attend to the needs of the patient.
How can this happen given the significant investment already made and all the changes that have come as part of this investment? The first step is to think
about what we really need the computer to do for us as providers and for the patient. In general, the computer does little for the patient in the exam
room. It is at home, when patients are using a patient portal, that the value of the interaction can be realized. Patients now have a powerful channel
of secure communication with their physicians. Physicians now have a way to hear from patients in meaningful ways between visits. Patients continue
learning the value of portal technology. Physicians have another tool to help promote wellness and empower patients around their health and well-being.
Making the Computer Invisible
For the physician, the computer serves many needs in supporting the care of the patient and performing tasks needed to accomplish this care. Ordering medications,
reviewing laboratory and x-ray results, locating relevant historical information and supporting decision making are among a few. These are all very
useful and necessary but do not have to take place in the exam room. Creating reasonable workflows that take advantage of all of the roles interacting
with the patient can make the patient experience and physician experience more positive.
Gathering data such as vital signs, filling out questionnaires and assessing current health care maintenance need not be solely the work of the physician.
Medical Assistants can play a key role in supporting workflows that maximize clinician time with the patient. Physicians can not only delegate tasks
as appropriate to licensed staff but can re-order their own work to make the patient’s time in the office short and pleasant. The shift from SOAP to
APSO has direct impact.
It’s important to arrange the office space in such a way that clinicians can easily access the computer from the exam room, allowing them to document without
taking precious face-to-face time away from the patient. Another option is to place laptops on carts so physician workstations are within a short walk.
In time, as Don Norman pointed out in his 1998 book, The Invisible Computer, the device itself should become invisible to both the patient and the physician.
In his preface, Dr. Norman described his vision as follows:
“The personal computer is perhaps the most frustrating technology ever. The computer should be thought of infrastructure. It should be quiet, invisible,
unobtrusive, but it is too visible, too demanding. It controls our destiny…Now is the time for The Invisible Computer, because that is the end
result, hiding the computer, hiding the technology so that it disappears from sight, disappears from consciousness, letting us concentrate on our activities,
upon learning, doing our jobs…”
Tips for Using Technology to Benefit Patient and Provider Experience
First, I’d propose that physicians leave the exam room for all computer related tasks, creating an exam room free of avoidable distractions. Next, take
advantage of technologies like speech recognition, natural language processing, telemedicine, augmented reality, and virtual reality to let information
technology do the heavy lifting of creating clinically useful information. By using the technology judiciously, you will improve both the patient and
physician experience of using the EHR.
Next, demand that users’ interactions with the EMR are designed to be intuitive for physicians. Advocate for using physician language, expressions,
and conceptual/mental models that make sense to physicians rather than express the specifications of the underlying technology. In time, ambient speech
recognition, natural language processing and true natural language understanding will begin to be woven into the everyday work of physicians with patients.
As the focus of care widens to include population health and value based care, we should pursue all the ways in which data and information technology can
positively impact patient care. This can be viewed from three perspectives: proactively, concurrently and retrospectively. Proactively, health maintenance
reminders for both patients and providers, make sense. Evidence has proven that primary prevention of disease is effective and such reminders contribute
to this approach. Concurrent to the doctor patient visit, providing clinical information relevant to both the provider and the patient in the exam
room (e.g. patient education, study exam results, references) can enhance the interaction, not dominate it. Retrospectively, the value of data analytics
and population health data can support new and powerful ways of caring for patients using clinical experience and powerful insights gained from data,
About Ron Jimenez, MD, FAAP, Principal Consultant
Dr. Ron Jimenez holds dual board certifications in clinical Informatics and pediatrics, and is an Epic Certified Physician Builder. During his tenure as
Medical Informatics Director, IT Epic Outreach at Stanford Hospital and Clinics, Dr. Jimenez implemented the EHR in multiple settings including oncology-hematology,
primary care, cardiology and multi-specialty practice settings. He has experience with implementation and support of EHRs and clinical systems in the
context of public hospital, IDN and academic settings.
Dr. Jimenez holds a clinical appointment in the Stanford School of Medicine as a Clinical Assistant Professor (Affiliated), Pediatrics. As a board member
of both CalRHO and Cal eConnect, he has been on the forefront of Health Information Exchange (HIE) in California and has been a key contributor to
the California Immunization Registry (CAIR) over the years.