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    EHRs distracting physicians from patient encounters, study says

    It is no secret that electronic health records (EHRs) have changed the way physicians focus on their patients, while capturing their medical information in exam rooms. A recent study confirms that because physicians spend so much time looking at EHRs, they miss out on nonverbal communication cues from patients.

    Overall, physicians with EHRs in their exam rooms spend one-third of their time looking at computer screens, compared with physicians who use paper charts who only spent about 9% of their time looking at them. The study, conducted by Northwestern University and published by the International Journal of Medical Informatics in January, measured eye-gaze patterns during 100 patient visits when EHRs were used. The authors of the study say that evaluating where physicians and patients look during visits can help with future training and technology development.

    “When doctors spend that much time looking at the computer, it can be difficult for patients to get their attention,” says Enid Montague, PhD, first author of the study. “It’s likely that the ability to listen, problem-solve and think creatively is not optimal when physicians’ eyes are glued to the screen.”

    The study also found that physicians are missing opportunities to engage patients using the EHR. Physicians don’t notice when patients are looking at EHRs, don’t see the value in inviting patients to interact with the EHR, and often block the patient’s view of the computer screen. Patients looked at EHRs only 11% of the visit. Montague suggests that EHRs could be designed with more interactive elements for patients to follow along with in the future.

    “Not only does the doctor spend less time looking at the patient, the patient also almost always looks at the computer screen, whether or not the patient can see or understand what is on the screen,” Montague says.

    13 Comments

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    • JAREDSELLIS
      I started using an EHR in my rural family medicine practice in 2002. After the typical learning curve, I found it a great tool, and my patients seemed to love it too. However, I changed jobs in 2011, and learned a new EHR which is much more "robust" and meets MU standards. This EHR is much more difficult to use, small buttons, has high "click" density, and takes much longer to document with. I don't doubt it all it has drawn my eyes more to the screen off the patient, compared to my first EHR. So I definitely think it is somewhat product, and hardware specific. I will consider that when weighing in on the next EHR purchase. Maybe scribes are the answer.
    • Anonymous
      I have been using EHR for 12 years. I started as a reult of a medicare audit by a retired pediatrician. (I'm an Ophthalmologist.) The pediatrician instructed me that I had to document in my notes, among other things, why I needed to take another disc photo on a glaucoma patient, since according to this pediatrician, one photo per glaucoma patient per lifetime should be sufficient. Now my electronic records are chock full of useless information, 4 pages of single spaced typing for a follow up exam, so that if I look really hard, I might find the one or two pieces of information that I actually care about. After twelve years of EHR, I see 30% less patients, spend at least that much less time actually looking at the patient, and have many more mistakes in the record than when my records were hand written. Also, the mistakes are carried forward from note to note until or unless I happen to catch a mistake. Then I or my tech may have to go back months or years looking for when the error was first generated, and then correcting the error note by note. But, now I'm considered a good Ophthalmologist (I think) because my records document, when my patient had his last bowel movement, and how his sex life has been lately. (I'm stretching a little, but the point is still the same.) I certainly don't have time to actually read all the garbage that is by necessity, copied and pasted by my techs from prior notes, and they certainly can't be blamed for moving inaccurate data forward. Every so often, when I look back at a prior note, I'll, to my horror, see something like: lenses - clear (That's the default setting), diagnosis - cataracts, plan - cataract surgery. My luck, I'll get audited on that chart and be accused of fraud. This NEVER happened with written charts, EVER. Thank God I also happen to be an excellent typist. I took typing in 10th grade. I think this was probably the most important course of my high school and college career. If I ever quit medicine, I'm sure I could work as a transcriptionist somewhere. In response to the other Ophthalmologist's comments, I totally agree that being able to show patients pictures of their eyes and the numerous other tests we do in our specialty is very useful. (Although I constantly have to remind myself to look back from the monitor to the patient when I am describing a picture or visual field.) I have two computer moniters in each exam room, one for photos, etc. and one for typing the note. But the computer for photos has nothing to do with EHR requirements. EHR is just another way for the government to gain control over us, compare us to our peers, and data mine. Patient care is unfortunately, no longer important. It's only what is in the chart that counts. That's our only defense. That's how we are bonused, and soon, that's how we will be penalized.
    • Dr. chas wreschner
      EMR's that we use as physicians especially in primary care are terrible They don't talk to each other they give you lots of things to look at lots of things to click My suggestion is look at what businesses have done with their stocks and bonds you can turn on Fidelity E*TRADE any organization SigFig you could find out anything within split-second easily found track Data I'm saying that if we had those kind of EMR's they would be no problem but what a joke we have stuff that is like when I had my first Apple Computer in 1985 that is what we are dealing with enough said
    • Anonymous
      EMR's that we use as physicians especially in primary care are terrible They don't talk to each other they give you lots of things to look at lots of things to click My suggestion is look at what businesses have done with their stocks and bonds you can turn on Fidelity E*TRADE any organization SigFig you could find out anything within split-second easily found track Data I'm saying that if we had those kind of EMR's they would be no problem but what a joke we have stuff that is like when I had my first Apple Computer in 1985 that is what we are dealing with enough said
    • Dr. Anish U. Shah
      While I agree with a majority of the comments above, as an Ophthalmologist in very busy practice with 6 others eye surgeons, The EHR we use (Eyeformatics.com) was written by an Ophthalmologist and beta tested for three years in our practice before it was offered for sale. It is nimble, infinitely customizable and more efficient than paper charts now. Have the CMS and other governmental requirements bogged it down a bit? Absolutely!! However, we have approached it in a different manner. We use the screens and the necessary reports that are generated for meaningful use to actually engage and educate the patients on their conditions and interventions. "There Mr. Smith, you have a new diagnosis of macular degenration. This OCT on the screen shows the damage that is occurred under the photoreceptor layer and the items highlighted in your summary report I just printed will help us help you retard progression" The user interface is not cluttered like everybody else's. It is intuitive and actually a time saver since it was created by a practicing Ophthalmoogist!! Its time the rest of us realize that instead of fighting for the status quo, help make the future better by dictating what our needs are and make the industry respond. As an example, our server's RAM died unexpectedly and we were without the EHR for a day and a half. I had my staff measure chair time per patient and it nearly double with paper charts as my only documentation. A good effective EHR makes you more efficient. thankfully, we have found one. Eyeformatics will be unveiling their practice management software later this year that seamlessly integrates with their EHR. If their PM is as good as their EHR, it will save our practice tens of thousands of dollars a year. In summary, a good EHR engages the patient, makes them more involved with their care and makes the physician more efficent.
    • Dr.
      Then the problem is the regulations, and not the technology. Do you want to flip through a wheelbarrow full of paper attestations that basically say I AM NOT A FRAUD I REALLY SAW THIS PATIENT and documenting a negative 10 point ROS tht nobody really took?? That's what needs to change, or any benefit we may have had in going electronic may be negated and the egregious copy and paste without editing that some of my residents are still guilty of will continue to be inappropriately rewarded. Don't tell me we need to go back to paper, tell me how to fix this mess of all of us being considered potential bilkers of the system, while people who are really bilking the system still manage to do it.
    • Dr.
      I was about to comment based on the title of the article and even the "study" page that this had to be the most asinine study ever done, because OF COURSE you'd spend more time on the computer if you weren't using paper...but once you look into more details, I think it highlights that the major issue is physician discomfort and overfocus on the medium rather than the mesage rather than anything inherent to an EHR. If you let a computer screen block your view of THE PATIENT, figuratively or literally, your behavior is a bigger problem than even a bad EHR. If you fixate on your smart phone during a romantic dinner, its the same thing. Cell phone is not bad, your inability to master it and set limits with it is. "The study also found that physicians are missing opportunities to engage patients using the EHR. Physicians don’t notice when patients are looking at EHRs, don’t see the value in inviting patients to interact with the EHR, and often block the patient’s view of the computer screen. Patients looked at EHRs only 11% of the visit. Montague suggests that EHRs could be designed with more interactive elements for patients to follow along with in the future." Reposition stuff so you and your patient can both see the screen and each other, and talk while you type or click. It's not rocket science. It can be very congenial if you do it well. You can do this, and learn to do it well, just as you learned to interact with patients before the requirements for excessive documentation became paramount as they are today. You were not an expert the first time you sat down with someone in an exam room, and you will need some time and experience before this is easy and second nature as well. And there is also nothing wrong with telling a patient you are still getting used to the EMR and chatting with them about the vagaries of technology a little while watching the little hourglass at times.
    • Dr. DR.WILLIAM MULLIS
      this what happens when big gov't shows you how to do it because you are too dumb to figure it out yourself
    • Dr. stef
      I do not oppose progress and technology but the common sense must not yield to greed, envy, political experiment etc. When I began medical practice, doctors were still using 3X5 index cards to record their obstetrical histories. Premature birth rate was then 11%, decades later ACOG invented and promoted 9-page prenatal record,Prematurity rate climbed to 12%, now that we have EHR, prematurity is above 12%. Yet, when it comes to saving the smallest and most disadvantaged of babies, we in US do better than anyone else. Why did prenatal care not produce better results, even with a coveted EHR? Because it does not pay. Like in any other business, doctors do what pays.
    • Dr. Eugene H. Eisman, MD
      EHR's are inherently bad. The software is so intent on fulfilling the requirements that please the Feds, and insure reimbursement, that they completely disregard physician and patient needs.
    • Anonymous
      I couldn't agree more. Most industries adopt computer technology because of an inherent benefit in efficiency or accuracy. The EHR vendors set up systems to meet government criteria, and they do that very well. Even if you ignore the physician-patient interaction, I have yet to see an EHR that succinctly gives me the information I want as a physician in the medical record. I have to sort through pages of gobbledeegook to find a meaningful sentence! It will be interesting to see whether the systems evolve into more useful tools when all the government incentives are gone and they must sell them based on what they actually do for a medical practice.
    • Anonymous
      It's not that EHR's are inherently bad. Just that many of the most "popular" EHR's ie those with the largest corporate penetration are built with such horrible user interfaces. 80% currently don't even have a tablet app which those "in the biz" know is the best and most natural format for documentation at the point of care (POC). And the reason is those companies don't really care about the user experience because they don't have to. They make their money in the service contract which is what they are selling and the larger corporations and institutions who are only looking at a very myopic calculation of the "bottom line" are buying. Until someone builds an EHR "for the rest of us" whose focus is the end user and not just capturing codes, little is likely to change. Most EHRs that dominate the market today are less useful than they were 10 years ago and are becoming a liability not an asset.
    • JAREDSELLIS
      Completly agree. Same experience. I am sure I will lose money on lost productivity more than the MU $ we have gained.

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