WASHINGTON -- Feeling disconnected during an office visit as you type on your computer with your patient sitting there watching you? There are easy ways to solve that problem, according to .
"You've got to recognize that there are three entities in the room, not just two," Sands, an internist at Beth Israel Deaconess Medical Center in Boston and co-founder of the Society for Participatory Medicine, said at the annual meeting of the American College of Physicians. "The computer should be part of the conversation ... the patient can look on and learn at the same time."
Sands urged doctors to arrange a setup in which the patient can look at the computer with the physician while he or she is typing. He noted that before he moved into his current practice, the hospital had installed the "network drops" for plugging in the computer "in all the wrong places -- we made them move all of them before we moved in."
Contrary to popular belief, using a computer during an office visit doesn't impede physicians' ability to communicate with patients, Sands said. He referred to showing that physicians who were good communicators before an electronic health record was installed in their office remained good communicators afterward, and those that weren't good communicators also retained that status.
However, he added, there are steps doctors can take to make sure that the computer isn't an unnecessary barrier during the visit, and they can be remembered with the acronym :
- Honor the "golden minute" -- those first few minutes of the visit -- by staying "tech free." "Look the patient in the eye and find out what's going on with them," Sands said.
- Use the equilateral "triangle of trust," meaning that your back is not turned to the patient while you're typing.
- Maximize patient interaction, including having the patient look at the screen as you type.
- Acquaint yourself with the patient record -- ideally, before the visit so you don't need to spend time doing that during the visit itself.
- Nix the technology and keep eye contact -- with hands off the keyboard -- when the patient discusses a sensitive topic. "Don't talk about the patient's cancer prognosis while typing away at the keyboard," Sands said.
- Let the patient look on while you are typing.
- Eye contact -- maintain it with the patient.
- Value the computer as a tool.
- Explain what you're doing on the computer as you do it.
- Log off, and tell the patient you have done so.
What patients want is good communication with their physicians, and email should be part of that, he continued. Although many doctors are concerned that emailing with patients might be a violation of the privacy and security rules in the Health Insurance Portability and Accountability Act (HIPAA), in actuality emailing does not violate HIPAA, nor is it a liability issue, Sands said. "Ideally, you would use secure messaging," but if that's not possible, regular email is OK once you have discussed any security risks, he added.
He gave a "top 10" list of reasons emailing is a good idea:
- 10. It can help physicians attain their Meaningful Use level 2 and 3 goals.
- 9. It can offset phone call volume.
- 8. It provides automatic documentation of patient communications.
- 7. It reduces malpractice liability -- "There is no evidence it increases it," he noted.
- 6. It helps doctors keep patients healthier and improves outcomes.
- 5. It increases patient and physician satisfaction.
- 4. Physicians can respond to email more quickly than a phone call.
- 3. Responses can be sent from anywhere -- "You can take care of patients in your PJs!" Sands said.
- 2. Doctors can respond at whatever time of day is convenient for them.
- 1. It frees physicians up to see in the office only those patients who need face-to-face care.
One physician told Sands he wasn't interested in using email with patients because he billed on a fee-for-service basis and emailing wasn't being compensated. Sands said he responded by asking: "Would you rather see a level 4 or 5 patient, or a level 1 or 2?" E-mailing can take care of many level 1 or 2 patients, leaving the physician free to focus on the more complex cases with office visits.
Doctors also should not be afraid of patients wanting to go online to get health information, according to Sands. Although it hasn't always been true, "the majority of health information you find online is good, and studies have shown that patients are pretty good at distinguishing good information from bad information," he said.
In fact, the relationship between doctors and patients is shifting: "The current paradigm is one of asymmetry -- 'I know everything, and the patient knows nothing.' That gives me an unfair advantage," said Sands. "And if you have to maintain an appearance that we do [know everything], aren't we living a lie? That's probably contributing to some of the burnout we've been having."
Instead, "we need to move to information symmetry where physicians and patients are partners, and rather than being threatened by this, we can feel liberated," he said. "I'm sure that why we went into medicine wasn't to be know-it-alls -- we wanted to be healers. If we stop trying to remember absolutely everything -- just know where we can find the information -- we can go back to being healers again."