I recall a patient who was drinking heavily, who I was unable to meaningfully convince to reduce his alcohol consumption. He felt that his drinking was no different than his work colleagues and that he did not need to make any changes. When his labs returned, not surprisingly, his GGT and AST were elevated. I turned the screen and showed him the results as well as the upward trending of the result’s graph. He didn’t say much but was clearly taking it all in. When we met next, he reported he had cut back significantly on his drinking. After acknowledging his accomplishment, I asked him what had changed. His response was that he was an engineer and that seeing the evidence, the real data on the screen was extremely impactful for him.
In their Ideas and Opinions piece in the Annals of Internal Medicine the authors explore what they refer to as a “counterintuitive tool for connected care”. The tool they are referring to is no other than the much-maligned EHR. They describe a workflow that incorporates and includes the EHR in preparation for, and as an integral part of the clinical encounter in ways that foster connection and patient engagement.
The first step in this workflow calls for the review of the patients’ records prior to stepping into the room. This avoids the inevitable, silent, distracted moments in the room when the provider is refreshing her familiarity with the patient’s history, recent lab results and consult notes. By attending to this task prior to entering the room the first moments of the visit can be spent making a warm, personal, unencumbered connection.
The authors recommend that the patient be positioned in a way that allows them to see the screen along with the physician, avoiding the “I am going to have my back to you while I look at this screen that you cannot possibly see”. The computer can then be used to educate the patients about themselves by sharing relevant EHR information with the patient. This could include reviewing lab result trends and graphs, or x-ray images or specialist consult notes, similar to what I did with the patient I described.
The authors even go as far as suggesting that the patient and provider spend the next phase of the visit charting together. They assert that this collaboration clarifies priorities, improves accuracy and builds confidence.
As a final step in the visit workflow, they suggest a phase of the encounter in which the clinician disengages from the computer faces the patient directly and spends the last few minutes of the visit addressing any remaining concerns and summarizing the conclusions of the visit and the recommended plan of action.
I found the workflow described very compelling, it certainly might not fit every encounter and every patient, but it provides a framework that amplifies the strengths of the EHR. It clearly requires providers are knowledgeable users of an optimized latest version EHR which is so important for the overall success of any EHR implementation.
There are other EHR workflows that support more meaningful patient engagement during the clinical encounter. Some clinicians will take advantage of voice-to-text capabilities offered by advanced mobile platforms to generate the clinical documentation of the visit with the patient during or at the end of the encounter. Patients are then able to listen to the physician’s summary of the visit and offer comments or points of emphasis if needed.
In the OpenNote movement, clinicians provide patients portal access to a full copy of the EHR note pertaining to their visit. Patients are able to review the note and comment on information that they feel is not accurate as well as gaining a better understanding of the diagnostic and therapeutic considerations made by their physician. The common thread among these workflows is that they all are made possible by the EHR technology and have been extremely well received by patients and clinicians alike.
The authors of the Annals of Internal Medicine article called the EHR a counterintuitive tool for connected care.
In the future, as these workflows evolve and proliferate, we may begin to intuitively refer to them simply as the tools for connected health.
About Dr. Betty Rabinowitz
Dr. Betty Rabinowitz is Chief Medical Officer at NextGen Healthcare, is a leading provider of ambulatory-focused technology solutions. Dr. Rabinowitz brings more than 25 years of extensive clinical experience and expansive knowledge of population health and value-based practice transformation.
1. Czernik Z, Chang R, Chopra V. A Counterintuitive Tool for Connected Care. Ann Intern Med. [Epub ahead of print 16 July 2019]171:283–284. doi: 10.7326/M19-0589