The 3 rd person in the Exam Room

Transcription

1 The 3 rd person in the Exam Room Dr. Matt Rafalski FAAFP Dayspring Family Health Center Jellico, Tn mrafalski@dayspringfhc.com DISCLOSURE STATEMENT OF FINANCIAL INTEREST I, Matthew Rafalski, MD, DO have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation, they are: Affiliation/Financial Interest: Name of Organization (s): Grant/Research Support: Consultant: Speaker's Bureau: Major Stock/Shareholder : (excluding mutual funds) Advisory Board: emds THE 3 RD PERSON IN THE EXAM ROOM 1

2 TECHNOLOGY That it will ever come into general use, notwithstanding its value, is extremely doubtful; because its beneficial application requires much time and gives a good bit of trouble both to the patient and the practitioner John Forbes M.D. Introduction to the translation of a book about the stethoscope INTENTION Work Excellently Know Intentionally Speak Graciously Love Extravagantly Live Selflessly Preserve Sanctity INTENTION Advantages / Disadvantages of EHR in exam room Communication Techniques System/Organizational improvements 2

3 WORKING WITH WHAT YOU HAVE Most cannot afford to change system Most shouldn t change systems Wherever you go there you are. WHAT IS OUR INTENTION? What did the vendor intend? What is our intention? WHAT IS OUR INTENTION? Communication = Diagnostic Procedure 3

4 COMMUNICATING WITH EHR Patient Provider EHR USE OF EHR Communication Advantages Positive effects for provider/patients Allow patients to better direct visit/influence behavior of providers Shown not to effect or even improve patient satisfaction Provide Clinical Decision Support 4

5 USE OF EHR Problems Introduces additional complexity Provider cognitive model/ process may not line up with patient s physical realities or their representation in EHR Shuts down psycho-social issues / deeper conversation Limits creation of patient physician relationship Decreases empathy IMPROVING EHR / COMMUNICATION SKILLS 5

6 VS: P 88 BP: 154/65 RR: 18 T: 98.7 Thyroid Normal TSH: 2.81 (4/20/2014_ Heart: RRR Occasional PVC ECG : Nl Axis/Int No ST-T change!!! ALERT!!!: Mole - 98% probability of melanoma Liver: Normal Size AST: 38 ALT: 32 (4/20/14) BC/BC 20$ Co-pay Deductable: Met IMPROVING EHR / COMMUNICATION SKILLS 14 Saleem JJ, Patterson ES, Militello L, et al. Exploring barriers and facilitators to the use of computerized clinical reminders. J Am Med Inform Assoc 2005;12:

7 Provider with good communication skills incorporate the computer better into the visit Providers with good (BUT NOT GREAT) computer skills incorporate communications better into the visit The BIGGEST Patent Concern: fixation of the physicians eyes on the computer screen Provider Concerns: Loss of eye contact Falling behind schedule Computers too slow Inability to type quickly enough Feeling that using computer in front of patient is rude Preferring to Write long prose notes Ref 1 7

8 Divide the Encounter into patient and computer focused stages Computer patient computer sandwich Demarcate by changes in body language and focus of gaze Start the sandwich out side the room Preparation Patient Visit Review the chart Insert reviewed data when possible Labs Histories Care Plans Use the tools of emr Data insertion Pulling data forward Review and document Familiarize yourself with the template 8

9 Charts done on the fly TAKE LONGER, less well organized, less satisfying to patient and provider Patient Interaction Greet the patient USE THEIR NAME Shake their hand Do this before turning to computer OPEN the interview Introduce the EHR Set agenda with patient Help from care team nurse / MA 9

10 OPEN the interview Start with a positive about the patient BEFORE you look at the computer Preparation: Physical Space Monitor Position Side Saddle Font and low Reading out loud as you type telling them what is ordered, what is TASKMAN ed Synchronize what you are working on with what is going on in the visit 10

11 Sign - posting Echoing / Reflecting 11

12 Using Continuers (go on, tell me more) Explaining intermittent pauses while provider reads / types Minimizing screen gaze 12

13 Involving the patient with computer and information Share the Screen Use the screen to Confirm information is correct Display Patient education Building the Relationship EHR has shown to negatively effect empathic components of the interview Gaze inversely related to gathering of psychosocial info Lack of gaze inhibited full patient disclosure of sensitive information 13

14 Building the Relationship Empathy Builds relationship builds trust Improves: sharing of information patient satisfaction adherence to therapy has intrinsic therapeutic effect Building the Relationship Empathic Component can be Improved by: moving head, torso, and eyes toward the patient removes hands from keyboard/mouse push monitor away Signaling that you are giving patient undivided attention Closing the visit Going back and clarifying data Sharing Data with Patient Inserting patient education Ordering tests / medications / follow up Finishing / polish the note 14

15 Closing the visit Tell your patients what you are doing while you are doing it Point to the screen Encourage patient s participation in building their charts Comments Avoid negative/ disparaging comments about computer Avoid expressing your frustrations Make sure patient dose not mistake concerns about computer function/ malfunction with concerns about them Avoid Uh-Oh Rats O my Darn 15

16 IN SUMMARY Improve our communication skills Improve out computer skills Divide the visit into phases - computer patient computer Invest in workflow/template/clinical decision point Training IN SUMMARY Use patient s name Increase eye gaze Share the screen Tell them what you are doing Use verbiage and gestures to improve empathy and disclosure mrafalski@dayspringfhc.com 16

17 DAYSPRING FAMILY HEALTH CENTER Dayspring Family Health Center is a not-for-profit community health center founded on the conviction that everyone should have access to affordable quality health care. We are committed to providing our patients comprehensive medical care in a fair and gentile manor. A healthy community is one in which its members begin life with hope, experience life with joy, and end life with dignity. We are convinced that many health problems have community causes and community solutions. Therefore, our ultimate purpose is to promote full health physical, spiritual, mental and economic of the communities that we serve. TEAM COORDINATION / WORKFLOW TEAM COORDINATION / WORKFLOW Workflow Simple Clearly define Designed to max info / save time 17

18 TEAM COORDINATION / WORKFLOW Team Assignments Everyone plays a part Well assigned responsibilities Accountability TEAM COORDINATION / WORKFLOW Template Development Structure Consistent use TEAM COORDINATION / WORKFLOW Clinical Decision Support Designed well / implemented well to enhance communications Singular To many items overwhelm ability to process Simple To simple ineffective, too complicated interferes with communication Specific Address a particular aspect of a problem (i.e mammo vs breast ca screening) 18

19 TEAM COORDINATION / WORKFLOW Successful Clinical Decision Support Automatic Provided at time and location of decision making Computer based Ref 1 ORANIZATION LEVEL ORANIZATION LEVEL Training New providers Refresher New workflows Workflow Development Accountability 19

20 ORGANIZATIONAL LEVEL Preparation: Physical Space Desk and Chair position Monitor size?? Learn to touch type??? DEVELOPER LEVEL Improve documenting thought process Think-do-document Touch screen Skins Improved patient display Improve workflow decrease clicks IN SUMMARY Improve our communication skills Improve out computer skills Divide the visit into phases - computer patient computer Invest in workflow/template/clinical decision point Training 20

21 IN SUMMARY Use patient s name Increase eye gaze Share the screen Tell them what you are doing Use verbiage and gestures to improve empathy and disclosure DELAYED GRATIFICATION Efficiency Accuracy Improved Patient Care mrafalski@dayspringfhc.com 21

22 DAYSPRING FAMILY HEALTH CENTER Dayspring Family Health Center is a not-for-profit community health center founded on the conviction that everyone should have access to affordable quality health care. We are committed to providing our patients comprehensive medical care in a fair and gentile manor. A healthy community is one in which its members begin life with hope, experience life with joy, and end life with dignity. We are convinced that many health problems have community causes and community solutions. Therefore, our ultimate purpose is to promote full health physical, spiritual, mental and economic of the communities that we serve. mrafalski@dayspringfhc.com 22