Implementing EMR in P&#038;O

The Digital Revolution The British computer scientist who is credited with inventing the World Wide Web, Sir Timothy "Tim" Berners-Lee, made a surprise appearance at the end of a dance segment during the London 2012 Olympic Games opening ceremony. The segment told the love story of two teenagers who reconnected after a chance encounter through a social networking website. In addition to paying tribute to Berners-Lee, the dance number was designed to communicate how digital technology, computers, and the Internet have impacted everyday life. Another, unscripted scene demonstrated the same point in a very different manner. During the torch lighting ceremony, countless spectators held their cellular phones above their heads to record the event. No doubt a good number of those images and videos were later posted to various social networking websites. It was, perhaps, one of the most spectacular celebrations in the sporting world, but many spectators could not simply enjoy the moment-they had to record it. Not only has the digital revolution drastically increased our capacity to capture data efficiently, it has also greatly simplified the dissemination of that data to specific or general audiences. It could be argued that our propensity to digitally capture and share our experiences could actually detract from the full benefit of the experiences themselves. Using digital technology during clinical encounters can result in a similar dichotomy. While computers allow clinical information to be recorded, stored, and shared very efficiently, their presence and use during a patient care experience may impact the encounter in undesirable ways. Changes in Clinical Documentation Software programs for clinical documentation and record-keeping offer alternatives to handwritten notes and notes that are dictated, typed, and printed, as well as the filing systems required to store those notes. The use of electronic medical record (EMR) systems by office-based physicians is growing. According to a Centers for Disease Control and Prevention (CDC) report, "[i]n 2012, 72 percent of office-based physicians used EMR/EHR (electronic health record) systems, up from 48 percent in 2009." 1 While the use of such systems in O&P is likely much lower, the adoption curve is likely to take a similar upward swing in the near future. EHR vs. EMR The term electronic health record (EHR) refers to a patient record that is available to a broad network of practitioners and facilities. These records extend beyond the practice that collects the information to facilitate sharing of information with other healthcare providers. An electronic medical record (EMR) contains information from one provider or practice involved in a patient's care. An EMR is essentially a digital version of a patient's paper chart and contains the medical and treatment history of a patient at one practice. While current P&O EMR systems allow practitioners to include information about central fabrication facilities and suppliers used and enable linking within multi-facility practices, the clinical record is limited to information related to the P&O care provided by one individual or practice. Before a P&O practice adopts an EMR system, the impact of the technology on the practitioner/patient interaction should be considered. Does the computer affect the quality of the interaction? Do patients perceive a healthcare encounter differently when a computer is used? Are there negative consequences to using computers in an encounter? And, most importantly, are there best practices that will help practitioners to implement this technology in a way that improves the level of patient communication and care? Implementing EMRs To facilitate a successful transition to EMRs and use them effectively as part of everyday clinical encounters, practitioners and financial decision makers should consider the practitioners' attitudes toward the technology, the arrangement of physical office space, verbal and nonverbal communication styles, and data-entry methods. Attitude Toward Technology In 1957, sociologists at Iowa State University, Ames, reported on the rates of new technology adoption among farmers. 2 Today, this model is known as the technology adoption lifecycle (Figure 1). It identifies various levels at which individuals embrace technology, ranging from those who readily adopt new technologies (innovators) to those who adopt new technologies grudgingly or only partially (laggards). 3 The technology adoption lifecycle is useful for predicting responses to the implementation of EMR systems in P&O. Facility owners and practice managers can use the model to help them anticipate an individual practitioner's resistance to EMR implementation based on his or her attitude toward new technology. This understanding can go a long way toward helping facility owners and their staffs to overcome barriers to integrating EMRs into everyday practice. Clinical Impact of Technology Adoption Lifecycle Integrating EMRs into a P&O patient care facility has organizational implications, but it may also affect the quality of the clinical encounter. A group of Canadian researchers surveyed 300 patients to determine "whether computer use by physicians during the patient-physician encounter influenced patient satisfaction...." They evaluated the effect that 13 personal characteristics (such as gender, age, and whether the patients used a computer at home and work) had on whether the patient preferred the use of a computer or not. 4 The researchers concluded that "perception of the doctor's attitude toward the computer was the one category that influenced patient preference." 4 When a patient perceived that his or her physician had a "very negative" attitude toward the computer, none of the participants preferred that it be used in the clinical encounter. However, when the patient perceived his or her physician's attitude as being "very positive," the majority of participants preferred that the computer be used" (Table 1). 4 Most of us can identify a person's attitude in just a few moments through observing his or her facial expressions and body language. The longer a person is exposed to a physician's attitude—positive or negative—the greater the impact will be on the clinical encounter. The Canadian study indicates that the clinician's attitude toward a particular clinical tool can make more of a difference on the patient's perception of the use of technology than the specific features of the tool itself. When asked how they felt about their physician using a computer, one of the study participants had this to say: "It is the attitude of doctors to patients that affects overall satisfaction.... Would you ask if we were concerned about a doctor's attitude toward his stethoscope?" 4 Although there is likely to be some level of anxiety about technology adoption among P&O staff members, recent research suggests that such anxiety will most likely resolve as practitioners are trained and become skilled in its use. In February 2012, Doyle and Nang reported on a study that examined physicians' attitudes toward computer use before EHR implementation and eight months after implementation. 5 "Before computer installation and full EHR implementation, physicians expressed concerns about the impact of computer use on patient care," the researcher's wrote. "After installation and implementation, however, many concerns were mitigated. Using computers in the examination rooms to document and access patients' records along with online medical information and decision-making tools appears to contribute to improved physician-patient communication and collaboration." 5 The Arrangement of Physical Office Space When helping to facilitate the successful integration of EMRs into a P&O practice, another factor that practice owners should consider is the arrangement of the furniture and computers in their examination rooms. Researchers in Israel observed 25 primary care physicians and studied the cognitive elements involved in EMR use. Some physicians reported that a "patient-centered" arrangement of the physical space, as compared to a "standard" arrangement often led to greater information exchange between them and their patients. 6 The computer should be positioned in a way that encourages personal interaction between the practitioner, patients, and caregivers. In a 2006 study, Ventres et al. found that "the ability to rearrange the position of the monitor changed the dynamic of encounters. It offered physicians the opportunity to engage patients in their own medical records." 7 One physician in the study described "bringing the computer into the encounter," rather than letting the computer pull the clinician away from the interaction. 7 Kinesics: The interpretation of body language such as facial expressions and gestures, or, more formally, nonverbal behavior related to movement. Artifacts: Man-made objects. Proxemics: Cultural, behavioral, and sociological aspects of spatial distances between individuals. In a 2007 study, McGrath et al. studied nonverbal communication during 50 internal medicine encounters with six physicians. 8 They reported that kinesics, artifacts , and proxemics worked together to produce noticeable differences in nonverbal communication between the physician and the patient. The researchers identified three spatial arrangements used by the physicians. They found that most physicians who used the computer at a high level used an "open" arrangement, which allowed them to attend to the computer while keeping the patient in their field of vision (Figure 3). A prosthetic/orthotic encounter often requires the clinician and patient to sit, stand, and move around an examination room. Use of a portable computer, wireless connection, and movable furniture allows the practitioner to rearrange the physical space to maximize personal interaction during each portion of the encounter. Verbal and Nonverbal Communication Styles Compared to paper-based documentation, charting on a computer may increase the potential for distractions. Researchers in Norway observed 22 physicians in 80 simulated encounters while they accessed patient-related information from a paper chart, a personal digital assistant (PDA), and a laptop computer mounted on a trolley. They concluded that the user interface and the physical characteristics, or form factor, of the computing device can influence whether or not collaboration between physicians and patients is successful (Figure 4). 9 "Physicians configured awareness with the paper chart. The physicians invited patients to speak by tilting the chart slightly towards [ sic ] them (top left). This was not found for PDA usage (top right). They signaled that the encounter was ending by closing the paper chart (bottom left) or placing the pen back in the chest pocket. This was not possible with the PDA (bottom right)." 9 [caption id="" align="alignnone" width="536"] Practitioners can minimize the negative impact of computer use by consciously adopting strategies such as reading aloud while typing, consciously maintaining eye contact, using body language to show attention and empathy, incorporating humor, and turning away from the computer and toward the patient when discussing important or sensitive issues.[/caption] An effective strategy for overcoming the negative impact of computer use is to distinctly separate computer use from time spent communicating directly with the patient. "Physicians who...took breakpoints (short periods of no computer use [coupled with] sustained eye contact with patients) used more nonverbal cues than physicians who tended to talk with their patients while [simultaneously] working on the computer." This strategy "allowed physicians to use nonverbal cues such as eye contact, head nodding, gestures, and para-language...." The researchers also found that when the physician paused to attend to the computer, it gave the patient an opportunity to ask questions. In fact, patients asked significantly more questions in encounters in which a computer was used. 8 This phenomenon was reported in Ventres' 2006 study as well. 7 In 2005, Ventres et al. reported on observations involving encounters between 29 patients and six practitioners. They found that the practitioner's "practice style" had more of an effect on clinician-patient interactions than computer use did. 10 This suggests that practitioners can minimize the negative impact of computer use by consciously adopting strategies such as reading aloud while typing, consciously maintaining eye contact, using body language to show attention and empathy, incorporating humor, and turning away from the computer and toward the patient when discussing important or sensitive issues. Data Entry Methods Traditional documentation involves writing a narrative description after the encounter has concluded or using paper "encounter forms" that contain common phrases, and descriptions of conditions, problems, or procedures during the interaction. Transitioning to EMRs requires that practitioners make decisions regarding both the time and method of data entry. Data can be entered into an EMR using free text or structured text . Free text refers to information that is typed into the record using a narrative style. Structured text involves selecting standardized nomenclature and phrases similar to those used on a paper encounter form. While EMR documentation templates can be set up using a combination of these methods, it's important to understand the pros and cons. Structured text can be a more efficient way to obtain information and facilitates easier searching and sharing of data within the practice. Typing free text into the record allows for adding information that is more specific to that patient. Hartzband and Groopman warn that structured text fields (drop-down menus and discrete data fields) lead physicians "to ask restrictive questions rather than engaging in a narrative-based, open-ended dialogue." This restriction can interfere with making the correct diagnosis and "understanding which treatment best fits a patient's beliefs and needs." 11 Another risk of using structured text or templates is the duplication of wording in clinical documentation for different patients with similar diagnoses and treatments. This is referred to as "cloned" documentation. 12 Specifically, cloning refers to cutting-and-pasting information from one date of service to another 13 and is more likely to occur during routine physician office visits. P&O practitioners should be careful to include enough specific information from each individual encounter in their documentation so that the unique features of the patient and the care provided can be easily identified. For example, an EMR template might contain the structured text phrases "patient was not wearing the correct ply of socks," and "patient was given instructions regarding proper sock management," which can be added to any record using only two mouse clicks. However, it is advisable to add information regarding the exact number and type of socks the patient was wearing, as well as any specific recommendations made to the patient. This additional documentation is more meaningful and specific to that particular encounter. In the following example, the first and last sentences are structured text, and the remaining documentation is free text: "Patient was not wearing the correct ply of socks. Patient was wearing five ply of socks (one three-ply and two one-ply socks). Eight ply of socks were required to obtain an appropriate fit. Patient was given instructions regarding proper sock management." Data Entry Times Immediate access to information is one of the benefits of EMRs. However, not all documentation must occur during the encounter. Data can be entered before, during, and after an encounter. Information that remains consistent from one visit to the next, or unique information that is obtained through preliminary telephone conversations, can be entered into the record before the encounter. This process is called "preloading." Staff members who are not directly treating the patient can add this information, leaving more time for the practitioner to document other pertinent information during the patient visit. Documentation during the encounter should be reserved for information that results from direct physical examination and device fitting. Information can also be entered into the record after the encounter. Separating patient care time from documentation time can be a convenient way to limit the duration of an office visit. Entering information at the end of the day, even remotely, can be an effective way to manage the limited time available for patient care during a busy day. However, practitioners must be aware of the potential negative consequences of adopting this strategy, including increased potential to forget important information. It is also crucial to be aware of the requirements of accrediting bodies, state licensure boards, and the Centers for Medicare & Medicaid Services (CMS) regarding the time frames allowed for completion of a digital record. Conclusion Transitioning to an EMR system requires practitioners and business owners to make changes in how they practice. While there are barriers to accepting EMR technology into P&O offices, and computer use during a clinical encounter may have a negative impact on the patient experience, EMRs can improve the quality of a clinical encounter by improving documentation efficiency, facilitating record retrieval, and encouraging the collection of more detailed information. Practitioners can transition to EMRs with confidence if they understand how their own attitudes toward the technology, the use of physical space, verbal and nonverbal communication styles, and their data-entry methods affect the encounter. Adopting an effective implementation strategy will allow the technology to be integrated into the patient care experience, rather than allowing the technology to dominate it. John Brinkmann, MA, CPO, LPO, FAAOP, is the lead prosthetic instructor at the Northwestern University Prosthetics-Orthotics Center, Chicago, Illinois. He has more than 20 years of experience treating a wide variety of patients and is chair of the American Academy of Orthotists and Prosthetists Gait Society. References Chun-Ju, H., and E. Hing. 2012. NCHS Data Brief: Use and characteristics of electronic health record systems among office-based physician practices: United States 2001-2012. Centers for Disease Control and Prevention. www.cdc.gov/nchs/data/databriefs/db111.htm Bohlen, J. M., and G. M. Beal. 1957; 1981 Reprint. The diffusion process. Special Report No. 18, Cooperative Extension Service, Iowa State University of Science and Technology. www.soc.iastate.edu/extension/pub/comm/SP18.pdf Orr, G. 2003. Diffusion of Innovations , 4th ed., by Everett M. Rogers, 1995:265. www.stanford.edu/class/symbsys205/Diffusion%20of%20Innovations.htm Lelievre, S., and K. Schultz. 2010. Does computer use in patient-physician encounters influence patient satisfaction? Canadian Family Physician 56(1): e6-12. Doyle, R. J., N. N. Wang, D. D. Anthony, J. J. Borkan, R. R. Shield, and R. E. Goldman. 2012. Computers in the examination room and the electronic health record: Physicians' perceived impact on clinical encounters before and after full installation and implementation. Family Practice 29:5601-608. Shachak, A., M. Hadas-Dayagi, A. Ziv, and S. Reis. 2009. Primary care physicians' use of an electronic medical record system: A cognitive task analysis. Journal of General Internal Medicine 24(3): 341-8. Ventres, W., S. Kooienga, N. Vuckovic, R. Marlin, P. Nygren, and V. Stewart. 2006. Physicians, patients, and the electronic health record: An ethnographic analysis. Annals of Family Medicine 4(2): 124-31. McGrath, J. M., N. H. Arar, and J. A. Pugh. 2007. The influence of electronic medical record usage on nonverbal communication in the medical interview. Health Informatics Journal 13(2):105-18. Alsos, O. A., A. Das, and D. Svanaes. 2012. Mobile health IT: The effect of user interface and form factor on doctor-patient communication. International Journal of Medical Informatics 81(1):12-28. Ventres, W., S. Kooienga, R Marlin, N. Vuckovic and V. Stewart. 2005. Clinician style and examination room computers: A video ethnography. Family Medicine 37(4): 276-81. Benge, J., T. Beach, C. Gladding, and G.Maestas. 2008 Use of electronic health record structured text and its payoffs. Journal of Healthcare Information Management 22(1):14-9. www.himss.org/content/files/jhim/22-1/07.pdf Harzband, P., and J. Groopman. 2008. Off the record-avoiding the pitfalls of going electronic. New England Journal of Medicine 358(16):1656-8. Palmetto GBA Medicare. Jurisdiction 11 Part B: Medical Record Cloning. www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Part%20B~CERT~General%20Information~8MKQK88358?open&navmenu=CERT%7C%7C%7C%7C (accessed December 28, 2012). Priority Health. Use of cloning in electronic records. www.priorityhealth.com/provider/manual/office-mgmt/records/documentation-cloning (accessed December 28, 2012).

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