Are EHRs Leading Us to Turn Our Backs on Our Patients?
Like it or not, electronic charting has become a reality of contemporary psychiatry. Since the Health Information Technology of Economic and Clinical Health (HITECH) Act of 2009 mandated that all health care providers billing Medicare adopt and demonstrate “meaningful use” of electronic medical records, psychiatrists have had to grapple with computers in the consulting room.
While psychiatrists in private practice have the option of opting out of Medicare and its rules, those in hospital settings—from residents to supervisors—must incorporate electronic health records (EHR) into their practice. The couch is optional; the computer is not.
The goal of an initial psychiatric encounter is to make a human connection, establish a diagnosis, and generate a treatment plan. The traditional office arrangement of comfortable chairs and couches naturally lends itself to making eye contact, observing body language, and noticing subtleties. A computer divides the psychiatrist’s attention, drawing focus away from the patient.
For psychiatrists trained before the era of the EHR, adapting to electronic charting can be a technological challenge. But for a new psychiatrist, there is a risk of paying more attention to the computer template than to the patient. Typing during an encounter with a patient may add to the early trainee’s natural defensiveness; rather than resonating with a patient in pain, the resident can look at the screen, check boxes, and believe that she has done her job.
Although a typing psychiatrist may not diminish the quality of the encounter for everyone, asking questions using a template can create an atmosphere in which the patient may not feel comfortable expressing his or her more shameful thoughts and feelings.
And so we are faced with a dilemma. How do we teach residents to attend to the patient when multiple forces—psychological, habitual, legal, and financial—divert them from patient to computer? Documentation takes time, and not typing notes in real time adds hours at the end of the day. For millennials, who took notes on a computer through college and medical school, constant attention to a screen is normative, but educational research suggests that using a computer may lead to less effective information processing.
After training, the realities of back-to-back patients, productivity requirements, and CPT coding set in. The ideal is not always possible, but during training, we should teach residents how to listen. This means encouraging them to follow the patient’s affect rather than relying on a checklist. There are several ways to help residents navigate computer use during a session with a patient:
Ensure that the room layout allows for the computer to be placed in a way that facilitates a face-to-face conversation between the psychiatrist and patient.
When framing the interview, acknowledge the unfortunate reality of needing to type; for example, “I’m sorry that I have to type during this interview, but I’ll do my best not to let it get in the way.”
Make time for open-ended questions; for example, “Help me understand what depression is like for you.”
When seeing a patient with a supervisor, use the time to hone psychiatric skills by observing an experienced clinician rather than finishing notes.
For training purposes, conduct some interviews without the computer. This enables residents to appreciate the value of face-to-face contact with their patients.
Residency programs should offer structured teaching about how to effectively connect with patients in the era of electronic medical records.
Electronic medical records make it possible for relevant data to be incorporated into written reports, but they sometimes do so at the expense of the human connection. Without a strong alliance, we compromise the relationship and the information—which can be elicited only in an atmosphere of trust. Notes typed during a psychiatric interview will be completed on time, but they may be incomplete or inaccurate.
Turning our backs on our patients is never acceptable. Our job is to listen, to observe, and to notice what others do not. Most importantly, our job is to create a safe and welcoming space in which patients can express their most private thoughts and feelings. Ultimately, only a face-to-face relationship will lead us to comprehensive and meaningful assessment. ■
This article was adapted from “Are We Turning Our Backs on Our Patients? Training Psychiatrists in the Era of the Electronic Health Record,” which can be accessed here.
