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'''Doctor Patient interaction and the EHR'''

'''Introduction'''

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The physician-patient interaction is at the core of the therapeutic relationship between healers and the sick from time immemorial. Prior to the development of the scientific discipline of medicine, healing was often little more than a "laying on of hands" by a provider to someone with a disease or ailment. The tradition still lives on in the direct form of the use of placebos, but indirectly, the communication between a provider and a patient still lies at the core of the healing relationship. Over the last century, with the advent of scientific discipline, medical research, and other therapeutic developments, there are now an array of actual treatments that can work reliably. But the relationship that existed prior to that did not disappear despite the growth of modern evidence based medicine. Ultimately, the central core of this relationship is the act of communication.

'''Communication'''

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Communication is everything. It lies at the heart of every aspect of medical care. Communication between members of the care team are a critical aspect of providing safe and effective care. However it is the communication between a physician (provider) and a patient that underlies the therapeutic relationship and is at the heart of all medical care. The ability of a physician to listen to a patient and hear their issues and problems is a core requirement of diagnosing and treating a patient's ailment. However perhaps even just as critical is the patient's belief that they are being heard. While we tend to think of communication as being through the spoken word, this constitutes only a small part of communication.

Polak and Avtgis (2011) suggest that nonverbal communication can be as important or even more important than verbal communication. Their concept is that there are a number of myths regarding how communication occurs. The suggestion that verbal communication alone is sufficient is not accurate. Non-verbal communication, body language, and even mere facial expressions often communicated critical information that went unspoken during medical interactions. Even within verbal communications, words that were used often had different meanings to different people. When those words intend different messages from the messages that are received, the outcomes can have potentially difficult if not disastrous results. Thus, it bears repeating that communication, both verbal and nonverbal is an important, even necessary component of the healing relationship between a doctor and his or her patient. Anything that will augment or impede that communication needs to be carefully evaluated for the impact on that process.

'''The Physician Patient Relationship'''

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The physician- patient relationship has been a focus of discussion since the time of Hippocrates (Goold &Lipkin, 1999). More recently though, the Emanuels (1992) described four models of the physician-patient relationship. The "paternalistic" model was the longest standing model, and the implication was that the doctor knew best, and offered what was considered the best care for a patient's condition, who would then, in turn, be thankful for the care provided. Alternative models that have been developed include a deliberative model, where the physician, through discussions with the patient, may attempt to alter the patient's values and decisions in ways that the provider feels may augment the patient's healthcare decisions. The other two models which move the relationship into a more modern form include the informative and the interpretive models. In the interpretive model, the physician acts more as a counselor or advisor, where the provider attempts to help the patient decipher what their values and goals may be, and to help them to arrive at a decision. Closely related to this, but as more of an educational and advisory role, the deliberative model assumes that the patient already understands their own values and desires, and is merely there to provide the information that the patient might need to formulate a decision as to what care to pursue.  Aside from the paternalistic model, where a provider may be able to make a decision for a patient and essentially try to order them to accede, all the other three models require intense and in depth communication in order to divine what the patient is thinking and feeling and then to assist them in making the proper decision regarding their own medical management. 


'''The Introduction of Technology'''

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In recent years, there have been increasing technologies that have impacted medical care and the therapeutic relationship. On the medical side, new tests and treatments that are increasingly effective have revolutionized medical care. From the standpoint of medical interactions, new modes of communication have also been dramatically changing how patients seek and respond to care. Access to the internet has broadened that amount of medical information available to the average patient. While some of that information may be more accurate than other information available, the ability of patients to learn about their symptoms, possible diseases, and potential treatments has been revolutionized. Mobile communication technologies have also had an impact on communication. Cell phones, email, telemedicine have all made access to care closer and more facile. However one of the more dramatic developments in terms of the impact of technology on the patient physician relationship has been the rapid deployment of the electronic health record. As with all innovations, the potential exists to make things better as well as to make things worse. With the advent of Meaningful Use, and the necessity of completing the medical record by the end of a consultative visit, the Electronic Health Record has now been inserted directly into the mechanics of the doctor patient relationship. In an era where physicians are having greater concerns about the ability of the EHR to improve quality of care (Friedberg, et al., 2013), it is important to delineate the effects that may occur as a result of this intrusion into the therapeutic process. 


'''The Effects of the EHR on the Physician Patient Relationship'''

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Shahak and Reis (2009) reviewed the literature regarding the effects of EHR use on patient doctor communication at an earlier stage of deployment of EHR's and noted both benefits as well as negative effects. Although the positive effects of improved availability of prior records, laboratory and x-ray test results, and communications from other providers, the actual use of a computer for the EHR in the consultation room had significant distracting effects. Eye gaze at the computer screen, typing on a keyboard for data entry,  and even the time taken to evaluate other medical information all take time away and distract from the communication and interaction. There were also effects noted in terms of physician behavior as well as the patient's perception of that behavior. One of the studies, by Ventres and his team (2006)found three behavioral styles that were adopted by physicians during their office interactions with patients while using their EHR, and represented a full spectrum from focusing on the computer through focusing on the patient. The "interpersonal style" physician focused on the patient. There was little to no computer use during the encounter, and little time devoted to entering  patient information during the interview. The "informational-ignoring style" had the physician where there was little interaction with the patient, and the provider often lost their rapport with the patient while they observed the computer screen or entered data. The "controlling managerial style" resulted in alternating attention to the patient  or the computer screen. Both with verbal communication as well as by body language, the physician would move back and forth during the encounter between focusing on the patient or on the computer. 

This excessive attention directed towards the computer has been noted as a consistent hazard in the maintenance of the physician patient relationship during an office encounter. (Bailey,2011; Kazmi, 2013;Ventres,2007) Montague and Asan (2014) compared eye-gaze interactions between patients and their doctors and found significant differences when the encounter involved a paper chart versus a computer record. In a study directly observing interactions in a primary care office environment, the same authors (2012) found behavior patterns similar to what Ventres had described. They defined these as "technology-centered," "human-centered" and "mixed." These different behaviors, however might not necessarily alter the relationship between doctors and their patients unless the doctors or the patients perceive a negative difference in the relationship as well. Lovett (2014) and Bendix (2013) both related studies that suggested that physicians believed that EHR use significantly impaired their relationship and interactions with their patients.

One systematic review of the literature, however, (Irani, et al. 2009) found that of seven papers that were satisfactory for evaluation, only one found that physicians believed there was a negative effect on patient satisfaction. The other six papers suggested either a positive or neutral effect on patient satisfaction. Although these studies utilized a questionnaire sent out after the office encounter (which they describe as a methodology which has inherent limitations), the overall results did not suggest that patient's perceptions and their satisfaction was significantly worsened. In fact, another study by Danis and White (2013) found that "properly used," the EHR can enhance the physician patient interaction. When physicians involve their patients while entering or viewing information on the computer, patients who are involved in their own care may perceive that as a means of increasing their involvement in the diagnostic and decision-making process. They caution that entering some information, especially things that could be socially stigmatizing, must be done carefully, however otherwise the potential is there to make the process more transparent. Other aspects of improved communication and education have also been pointed out which include the ability to use decision modeling, obtain enhanced medical information, as well as the mere ability to access one's own medical record that all add to the potential for patient satisfaction.


'''Physician Behavior and its Effects on Patient Interaction'''

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In light of the information regarding different interaction patterns of various providers during EHR use in a patient encounter, it is possible that the variation may be part of what makes doctors different. It is possible that some of the differences noted are the result of pre-existing behaviors that are now only augmented by the intrusion of the EHR. One article by Schwartzstein (2015) regarding the compassion and communication skills of medical students (who obviously will become doctors) suggests that there is a complex relationship between "nature" and "nurture." While there is a selection process in who will be accepted to medical school, it will not always be possible to select the most nurturing or compassionate students. Furthermore, the educational opportunities and mentoring of young students does not always encourage the most humanistic tendencies and abilities. So deficits in communication while using an EHR in an encounter may be more complex than merely the introduction of the EHR.


'''How to Improve the Physician Patient Interaction with the Introduction of the EHR'''

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Whether nature, nurture, or merely technology, a number of strategies have been noted that can mitigate or even enhance the physician patient interaction during a consultative encounter (Shachak & Reis, 2009; Fried, 2013). Suggestions common to most of the papers that have made them include:
	▪	Positioning the computer monitor between the provider and the patient- this allows the provider to make eye  contact throughout the encounter.
	▪	Having a mobile monitor that can be turned around to demonstrate things to the patient during the encounter.
	▪	Minimize typing by having a scribe, using dictation software, or merely by waiting until appropriate moments to enter information-determined by the flow of the communication with the patient.
	▪	Ignore the computer when you enter the room, and look at your patients- not only at the start, but throughout the encounter.
	▪	Explain what you are doing as you do it, so that the patient stays engaged in the process.
	▪	Anticipate the visit- review patient history, problems, and other medical information prior to entering the room so as to minimize that time when sitting with the patient.
	▪	Stay with the flow of the interaction with the patient. Allow them to dictate to some degree their history and the description of their complaints.
	▪	Remember to question them about their prior history as well to ensure that their information remains up to date, and that you have not missed something.
	▪	If additional information is available, either in their chart, or online, either show them the information or tell them how to access it.

So, for better or for worse, the EHR and technology is here to stay. The benefits still far outweigh the drawbacks. As we learn more about how the use of technology affects our own behaviors and the perceptions of both providers as well as patients, we can move forward to integrating that technology in better and more satisfactory ways.



'''References'''

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Bailey, J.E. (2011). Does Health Information Technology Dehumanize Health Care? American Medical Association Journal of Ethics March 2011, Volume 13, Number 3: 181-185.

Bendix, Jeffrey (December 10, 2013) Can the doctor-patient relationship survive? medical-economics [online journal].Retrieved from http://medicaleconomics.modernmedicine.com/medical-economics/content/tags/electronic-health-records/can-doctor-patient-relationship-survive?page=full

Denton,David M. (8/21/2014).EHR Must Fit Into Doctor-Patient Relationship. informationweek.com/healthcare. Retrieved from http://www.informationweek.com/healthcare/electronic-health-records/ehr-must-fit-into-doctor-patient-relationship/a/d-id/1298168

Emanuel EJ, Emanuel LL.(1992). Four models of the physician-patient relationship. JAMA. 1992 Apr 22-29;267(16):2221-6.

Fried, D. (January 22, 2013). 7 Ways to Maintain Patient Interaction in the Age of the EHR. profitable-practice.softwareadvice.com [online weblog]. Retrieved from http://profitable-practice.softwareadvice.com/7-ways-to-maintain-patient-interaction-ehr-0113/

Friedberg, Mark W., Peggy G. Chen, Kristin R. Van Busum, Frances Aunon, Chau Pham, John Caloyeras, Soeren Mattke, Emma Pitchforth, Denise D. Quigley, Robert H. Brook, F. Jay Crosson and Michael Tutty. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa Monica, CA: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR439.

Goold, S. D., & Lipkin, M. (1999). The Doctor–Patient Relationship: Challenges, Opportunities, and Strategies. Journal of General Internal Medicine, 14(Suppl 1), S26–S33. doi:10.1046/j.1525-1497.1999.00267.x Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496871/

Irani JS1, Middleton JL, Marfatia R, Omana ET, D'Amico F.(2009).The use of electronic health records in the exam room and patient satisfaction: a systematic review.J Am Board Fam Med. 2009 Sep-Oct;22(5):553-62. doi: 10.3122/jabfm.2009.05.080259.

Kazmi, Z.(2013).Effects of exam room EHR use on doctor-patient communication: a systematic literature review. Inform Prim Care. 2013;21(1):30-9. doi: 10.14236/jhi.v21i1.37. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24629654

Lovett, M. (Nov 14, 2014).Is your EHR damaging the patient-provider relationship?Healthcare IT News (http://www.healthcareitnews.com)

Montague E, Asan O (2012).Physician Interactions with Electronic Health Records in Primary Care. Health Syst (Basingstoke). 2012 December 1; 1(2): 96–103. doi:10.1057/hs.2012.11.

Montague E, Asan O (2014).Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention.Int J Med Inform. 2014 Mar;83(3):225-34. doi: 10.1016/j.ijmedinf.2013.11.003. Epub 2013 Nov 28.

Polack, E.P. & Avtgis, T.A. (2011). Medical Communication: Defining the Discipline. Kendall Hunt Publishing Co.: Dubuque, Iowa.

Schwartzstein, Richard M. (2015).Getting the Right Medical Students- Nature versus Nurture. N Engl J Med 2015; 372:1586-1587April 23, 2015DOI: 10.1056/NEJMp1501440

Shachak,A. and Reis,S. (2009) The impact of electronic medical records on patient–doctor communication during consultation: a narrative literature review. 41Journal of Evaluation in Clinical Practice 15 (2009) 641–649

Ventres, W., Kooienga, S., Vuckovic, N., Marlin, R., Nygren, P., & Stewart, V. (2006). Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis. Annals of Family Medicine, 4(2), 124–131. doi:10.1370/afm.425

Ventres W, Shah A. (2007). How do EHRs affect the physician-patient relationship?Am Fam Physician. 2007 May 1;75(9):1385, 1390.

White A, Danis M. (2013).Enhancing Patient-Centered Communication and Collaboration by Using the Electronic Health Record in the Examination Room. JAMA. 2013;309(22):2327-2328. doi:10.1001/jama.2013.6030.