Several solutions to this problem have been proposed. One approach is to have a medical transcriber in the exam room, someone who could document the information provided by the patient. Although transcription would free up the physician to focus on the patient, this option is potentially costly and associated with its own ethical concerns. Having a transcriber in the room could be considered a violation of a patient’s privacy. It could also impede the physician–patient relationship by inhibiting patients from raising sensitive or embarrassing issues. Voice-activated recording devices would provide automatic transcription, but capturing every word spoken by the patient might lead to voluminous, difficult-to-read notes. Sharing the computer screen with the patient has the potential to transform the EHR into a tool that supports shared decision making by facilitating physician–patient communication. For this to occur, optimally, the computer must be on a mobile arm so the patient can see it (Ann Fam Med. 2006;4:124-131). Some physicians use a listen-now-type-or-dictate-later approach. This may be the solution associated with the fewest ethical concerns that best maintains the physician–patient relationship, but it comes at a cost, as “typing later” adds time to the physician’s day.
Explore this issue:November 2014
A variety of approaches to improving communication while using EHRs has been suggested, starting with informing the patient what you are doing, avoiding computer use when sensitive psychosocial issues are at hand, and involving patients in building their charts. Practical steps can also help, such as learning to type and pointing at the screen (Fam Pract Manag. 2006;13:45-47).
Somehow, we must learn how to retain the patient’s narrative, both in the elicitation of the history and its documentation through EHR (Acad Med. 2011;86:11-14). And we need to be available to interact with that narrative, or we risk becoming the equivalent of computers ourselves.
Back to the Patient
After pushing the keyboard aside, you explain what you’re typing on the computer and how electronic health records have the potential to improve care. She seems impressed that your computer can check for drug interactions, a point of particular interest to your patient because her medication list is long. After discussing her [dizziness] and available treatment options, she is reassured that “ending up in a wheelchair” is not likely. Your visit is a minute or two longer than you’d aimed for, but your relationship with this patient is back on track.
Elizabeth A. Kitsis, MD, MBE, is director of bioethics education and associate professor of clinical epidemiology and medicine at the Albert Einstein College of Medicine. She is a member of the ACR’s Committee on Ethics and Conflict of Interest.