Integrating the computer display into the patient visit

Integrating the computer display into the patient visit

Douglas W. Blayney, MD, FASCO

Feb 16, 2009
We initially put desktop computers into our exam rooms about three years ago. Like a lot of new tools, my colleagues and I have been variously successful with integrating them into our patient care visits. Below are staged photos of one of my colleagues in a clinic room. She is illustrating integration of the computer display into her interaction with her patient. Notice how both the physician and the patient can see the screen -- there are no mysterious entries into the record. When the physician enters data, using the keyboard or the mouse, both she and the patient can view the information, and the patient can correct her if necessary. (Isn't this how you would want to be treated?). The radiologic images can also be shown to the patient with this arrangement.

I like to conceptualize this as an equilateral triangle, as shown at the top of the panel, where the doc, the patient, and the display occupy equal points. I use this placement of the display to review tumor size and lab results with the patients and their families in my clinic. (We try and use similar techniques to integrate the computer display in the hospital inpatient setting, as discussed here).

Since these photos were taken in 2006, we have placed printers in each exam room. The printers are cheap inkjet printers, and if they break we replace instead of repair them, which is a cost saver. They sit in the compartment above the physicians head.

Inkjets are slow, so I don't print large items like informed consents or patient education material using them. . I often print off a copy of my patient's laboratory values, or since we don't yet do ePrescribing, I use these printers to print a copy of their perscription for them. Since Medicaid perscriptions have to be printed on expensive, copy-proof paper, there is a folder with this paper in each room, and we feed an individual new sheet of paper into the inkjet to print each Medicaid perscription.

One of the worst practices, I think, is to turn your back on the patient when you enter data into the computer, lest you signal the patient that they're not important. Look how unfriendly the nurse appears in this photo, which is a view from one of our chemotherapy chairs, and think how much you would object to this part of the encounter. Not only does turning your back on a patient to look and enter data into the computer send the wrong message, it is just plain impolite. Being polite ("good manners") can go a long way.

Michael W. Kahn, writing in NEJM recently, noted, "Patients ideally deserve to have a compassionate doctor, but might they be satisfied with one who is simply well-behaved? When I hear patients complain about doctors, their criticism often has nothing to do with not feeling understood or empathized with. Instead, they object that "he just stared at his computer screen," "she never smiles," or "I had no idea who I was talking to." Placement of the computer screen so that both the patient and the doc can see it simultaneously lends itself to good patient care.

In their article "Healing Skills for Medical Pracitce," Churchill and Schenck describe eight practitioner skills that promote healing relationships. One of them is to "Remove Barriers." The patient-physician barrier removal is illustrated by the quotation from one of the skilled clinician-healers whom they interviewed: "I never have anything between me and the patient. I've always had my desk up against the wall". Placement of the computer display as illustrated in the first photos, rather than placing it so that the physician or other caregiver is forced to turn their back to the patient, adheres to this principle.

I haven't seen a lot written on this subject, but I would be happy to be corrected.


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David M. Urbanski, MD

Jun, 16 2009 10:45 AM

Hi, Dr. Blayney,

I looked at this, & thought it didn't reflect my patient encounters. In the interest of time, my patients are usually on an exam table, & there's typically (an)other person(s) (spouse, relative, friend) in the room, which adds another angle or so to your diagram. Also, the screen looks like a 17" or at best 19" display, which gets pretty tiny across an exam room, and because the system that backs it is usually bought in bulk, it's probably underpowered. I've been thinking about this quite a bit, & here's what I've come up with. I'd lose the mouse & keyboard, as touch (tablet) technology will be more efficient & compelling for the patient. I recently visited Boston & saw a surface computing demonstration similar to those we saw during the last presidential election. I think a wall hung 24 - 30" touch enabled display backed by a system with the horsepower to open PET CT files quickly would transform the way we practice oncology, & bring a patients medical information into the exam room in a way that would be more meaningful to them and their significant other(s). Think of it as a digital blackboard arranged for teaching a small group of people. Interestingly, there's a company that makes touch enabled displays in Ann Arbor, but I haven't had the chance to visit them yet. There's also a company that makes touch enabled overlays for 24" displays. I think the technology is out there, its just that we as physicians are tethered to a systems technology that is aimed at the lowest common denominator.

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