Electronic Health Records

How I Practice Video Series
Tina Foster, MD, MPH, MS, FACOG

HIP: Electronic Health Records from ACOG on Vimeo.

Transcript:

It’s been about fifteen years since I first used an electronic health record and like many others, I have a bit of a love/hate relationship with it. I’ve worked with several different systems, and they all have a lot to offer and sometimes they are frustrating to us. One of the concerns many of us have is whether the computer will interfere with our interactions with our patients. And I believe that’s not necessary and that there are a number of ways in which it could actually help our visit. First thing that I do is to talk about it. I mention that I have the computer, that I’ll be using it throughout the visit, and make sure that the patient knows that I may be typing as we’re talking. If that’s clearly distracting to her or she requests that I not do it then I can set it aside and conduct the visit the way that I used to before we had the computer in the room with us. I think it’s important to acknowledge it and whenever possible pull the patient into the experience of using the computer. If I can, I like to set it up so that she can also see the screen and this is a great way to use the computer as a tool to review images, to look at lab or other test trends over time, and to review an operative note or consultation report from another provider. This is a wonderful way to increase transparency into the medical record and to help her gain more insight into her health and health care issues. But I do really try to pay attention to how the patient is interacting with the computer and with me throughout this time. The after visit summary is a new feature that many of us have in our records and it’s a great opportunity to not only reinforce what was done in the visit and what upcoming visits or other things that we might do, but also to add a brief personal note and to tell a patient how great it was to see her or remind her about an upcoming event or to call me if she has any questions. Those little personal touches can go a long way towards really making the electronic record seem less impersonal. Finally, I think it’s really important now when patients have access to their record through the many patient portals that exist to think about how we can write our notes in a way that will be intelligible and helpful to patients. I’ve had a patient come to me with a printed out note from another provider and areas highlighted that she thought were incorrect or needed to be amended. It was a little bit of an uncomfortable situation. I’d prefer not to be in that situation so I really want to be sure that what I write will be understandable to the patient. That means writing somewhat simple and more clear language than we often do in our medical record and not sounding a bit as though we don’t trust the patient which is I think sometimes a tendency we have in medicine. It’s a longstanding tradition, the patient states. I try to write what she tells me and try to document my discussion with her in an honest and open way. It can be challenging sometimes but I think it’s actually an excellent discipline and makes for a good foundation for our relationship to grow and develop. Which is what’s needed for healthcare to be truly effective. I believe that this transparency into our records and the acknowledgement that the medical record really belongs to the patient, not to us, not to clinics, not to hospitals, are really important and we need to recognize this going forward. For now, we can do our best to make that transition from paper to electrons as seamless as possible and to look for how it can really help us in our visits and help our patients in improving their own health and dealing with whatever problems they may face from a health standpoint. This is how I practice.

   

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