Mary Val Palumbo DNP, APRN, GNP BC UVM College of Nursing & Health Sciences

Transcription

1 Mary Val Palumbo DNP, APRN, GNP BC Clarissa Drill, SN Clarissa Drill, SN UVM College of Nursing & Health Sciences

2 Marie Sandoval MD Funding from the Frymoyer Scholar s Grant UVM Nurse Practitioner Students UVM Honor s College

3 1. Identify common student issues in communication when the Electronic Health Record (EHR) is utilized during history taking. 2. Explore optimal position of the computer in relationship to the patient

4 This study attempts to establish the student nurse practitioners (novice) communication challenges during history taking when utilizing the electronic health record (EHR) for the first time. This analysis begins to identify promising practices for patient provider communication whentheehr is utilized

5 The provider s primary task kin a clinical i l visit iitis to actively listen and effectively communicate with the patient in order to produce an accurate history of present illness (Frankel & Stein, 1999).

6 The primary care office visit has office visit has changed from an interaction between patient and provider to one in which the computer can now be computer can now be consider part of a triad of communication in the i i i h examination room (Morrow et al., (Morrow et al., 2009).

7 The implications of this change of documentation ti are just now beginning i to become apparent (Frankel et al., 2005). The students and novice providers struggle with the necessary communication skills, (especially active listening) when using the EHR. The identification of EHR patient provider Best Practices for communications must be developed and tested.

8 A convenience sample of nurse practitioner students, recently instructed on EHR use, were videotaped during a common health condition visit with standardized patients during two encounters in February and May of 2012 (n=36). IRB approval was granted and permission for use of images was received from the student participants.

9 In this descriptive design study the following strategies for data collection were employed: 1) A 10 point checklist of communication skills was completed by the observers for each student/standardized patient videotaped first encounter (n=16).

10 2) Actual time spent typing and talking, typing only, and looking at computer without t talking were measured using the OD LOG software for both encounters (n=36). The total time of the history taking interview was also measured (mean and range). Times spent using the computer were then summed and a percent ofthe total interview was calculated

11

12

13

14

15 3) Position of the computer was recorded for the first encounter. The most frequent positions were noted. The observers assessment of positions computer so patient can see screen was also recorded for each position. Interrater reliability was 0.84 overall between observers.

16 100% of students introduced themselves and established tblihdrapport, 92.5% asked open ended questions 92.5% attended to modesty and comfort, 85% kept good eye contact 85% closed the visit appropriately

17 95% washed their hands after computer use and prior to patient contact, 77.5% educated patient about the EHR and computer use, 70% explained long periods of typing and 62.5% positioned the computer so the patient could see it.

18 On the first visit (formative) mean group (formative) mean group total interview time for obtaining history of present illness was 11.4 minutes. Of this time, a total of 3.5 minutes were spent: typing minutes were spent: typing and talking (45.9sec) typing only (125.1 sec) and looking at computer not talking (37.3sec) for a total 30.6% of this visit of this visit.

19 One the second visit (evaluative) mean total interview time was 12 4 interview time was 12.4 minutes of this time, a total of 2.95 minutes were f spent: typing and talking (31.9 sec),typing only (124 7 sec) and looking at (124.7 sec) and looking at computer not talking (20.9sec) for a total 26% of this visit.

20 Slight difference noted between mean group times( p = 0.361) between bt the visits. iit The percent of time spent by individuals changed over the two visits: Typing and talking ( 3.1%, p= 0.3); Typing only (+12.8%, p=0.038); Looking at computer ( 9.6% p= 0.039). (paired T test)

21 Students were instructed to let the patients see the computer and explain what tthey were doing. They entered the exam room with a laptop computer and a wheeled bedside table was available for their use.

22 Patient can see computer screen (n = 3) Most common computer placement by students (n = 8)

23

24

25

26 Have current providers received training on EHR communications skills? What should be the norm for computer time during the history? Are computers being utilized fully for patient education or to show patients t their health indicators? How will exam rooms be redesigned dto accommodate the EHR in the most patient friendly way?

27

28

29

30

31

32

33 Scribes in the exam room?

34 These NP students performed better on general communication skills than EHR skills on their formative visit Results reveal a significant ifi change in the individual student time spent engaged with the computer (increase typing only and decreased looking only) on the second visit (evaluative). Computer positioning was challenging for students on the first visit.

35 L. Let the patient look on E. Eye contact V. Value the computer E. Explain what htyou are doing L. Log out Developed by Kaiser Permanente Produced by Linda Adkins (2011)

36 Small sample size Convenience sample not generalizable Validity testing not done

37 With the introduction of the EHR into the primary care visit, attention must be paid to communication skills of all providers. This research is a beginning step to understanding di how to instruct a novice provider on mastery of this skill. Further research regarding experienced providers utilization of the EHR when precepting students is recommended.

38