Promoting Mindful Clinical Interaction While Using Electronic Technologies: A Group Training to Improve Patient Experience Colleen T. Fogarty, MD, MSc. Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session # October __, 2014

Faculty Disclosure Please include ONE of the following statements: I/We have not had any relevant financial relationships during the past 12 months.

Learning Objectives At the conclusion of this session, the participant will be able to: To describe the communication challenges and opportunities while using the Electronic Health Record (E.H.R.) in clinical practice. To develop a list of behaviors that help the E.H.R. use become more patient-centered. To learn and practice brief mindfulness activities and reflective writing to assist with the challenges of E.H.R. use.

This is Progress? Click, click, scroll, type, select, search: error. Repeat. Blah, blah,blah goes the background din of the patient’s HPI. Click, click, type, click…[pause]. Frozen. Reboot. The distracting din continues. Open, login, click, type, click…[pause] …I wish this patient would pause. Doesn’t she realize I am trying to provide state-of-the-art care? By Sean C. Lucan, MD, MPH, MS Families, Systems, and Health 2011

The Cost of Technology

Reflection and sharing experience Find a partner Focus on a recent patient care encounter using E.H.R. this could be a  --particularly helpful time  --particularly annoying situation  --OR when you particularly noticed the E.H.R. as a player in the visit. Jot down a few key elements of the story before telling it to your partner Option—write a 55-word story

Debriefing: Discuss your reactions to the exchange Now discuss your personal reactions to telling and hearing the story  Thoughts  Feelings  Bodily sensations What questions were helpful and why? How did you react to the exercise and to each other?

Take 10 minutes For the storyteller, address:  What happened?  What helpful qualities did you bring to that moment?  Who else was involved, and how did they contribute?  What aspects of the context made a difference?  What lessons from this story are useful to you? For the listener:  Be attentive, don’t interrupt  Ask questions to help your partner clarify and provide details  Don’t talk about your own ideas or experiences  Use reflective questions and empathy when appropriate If you get done sooner, just be silent. We’ll let you know when it is time to switch.

Video demonstration / /

Electronic interfaces & clinical care Divided attention or diffused focus Effects on communication Information overload Quality of information  Bringing irrelevant things to our attention (minimal drug interactions)  Difficulty entering/retrieving information

A Focus on Focus When you have a computer in the room, how do you parse your attention? When does the screen draw your attention? When does the patient draw your attention? How can you maintain dual attention; that is, integrate your attention to both the computer and the patient?

The literature Physicians with EHR’s structure interviews around data-gathering rather than the patients’ narratives. Several personal habits may help improve this dynamic.  Adjust the ‘geography’  Bring the EHR into the relationship  Use the computer to teach

Adjust the “Geography” Sit facing the patient Sit at eye-level when practical Adjust the computer screen to allow patient to see it Move close to the patient so s/he can see screen

Triad: Bring computer into the relationship Introduce yourself to the patient FIRST Introduce the computer to the patient Share information from the screen with the patient Maintain eye contact with the patient Let the patient know when there is need to focus only on computer

Using the computer as a tool with the patient Offer the patient a copy of something in the record (e.g. lab result, etc.) Access online patient information materials

Summary-- 10 Tips Position monitor so patient can see Learn to type Know when to stop typing/integrate with pt need Don’t let templates direct information gathering Don’t let the E.H.R. set the agenda

Summary-- 10 Tips Start with patient concerns Tell the patient what you are doing Point to the screen/show your patients data Involve patient in documentation Look at your patient

Use computer to teach & enhance quality of care Show patient her/his vital signs As appropriate, consider:  Showing flowsheets or other data trends  Offer patient copy of visit, vitals, or other data  Provide online patient education  Reconcile medication list with the patient  Indicate if you have seen patient entries in patient portal

Formal practice

Home practice Each day, notice your interactions with technology both in patient care and in learning and academic pursuit. Then take a few moments to explore your own reactions.  In what ways were you present to your patient?  What was most troubling to you about the technology?  What gave the most meaning?  What did you learn about your own way of responding to electronic stimuli and stresses?

References Ventres W, Kooienga S, Vuckovic N, Marlin R, Nygren P, Stewart V. Physicians, patients, and the electronic health record: An ethnographic analysis. Ann Fam Med Mar-Apr;4(2): Verghese A. Culture shock--patient as icon, icon as patient. N Engl J Med Dec 25;359(26): Hartzband P, Groopman J. Off the record--avoiding the pitfalls of going electronic. N Engl J Med Apr 17;358(16): Frankel R, Altschuler A, George S, Kinsman J, Jimison H, Robertson NR, et al. Effects of exam-room computing on clinician-patient communication: A longitudinal qualitative study. J Gen Intern Med Aug;20(8):

Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!