Using the Computer In the Consulting Room Dr. Ramesh Mehay Programme Director Bradford VTS

Most of the stuff in this PowerPoint has been derived from a super CD resource called “Using the computer in the Consulting Room” by Dr. Paul Robinson when he worked with SCHIN www.schin.ncl.ac.uk . Go and get a copy, it will change the way you consult forever…. really! Another resource that’s really good is “Skills for Communicating With Patients” by Silverman, Kurtz, Draper. Essential resources

What You Will Learn: (aims) The position of the computer in the consulting room Entering Information in the consultation Learning from the computer Sharing electronic information with patients

You will learn how to: Integrating the computer into the consultation Reading from the screen Typing in clinical findings Relaying information from screen to the patient Sharing information on the screen with the patient Maintaining rapport without disrupting the doctor-patient relationship (maintaining rapport)

The Position of the Computer in the consulting room

The layout of the consulting room 2 1 Here are three possible layouts. Which do you think is the best? 3

1 Room layout 1 Allows the patient to see the screen clearly But means that the doctor has to turn away from the patient in order to read the screen. This might be interpreted as the doctor cutting the patient off BUT it can be helpful to the doctor in that (s)he has to turn to use the computer hence non-verbally signposting it to the patient (reducing reliance on verbal signposting – see later) Means that right-handed use of the mouse, and use of the keyboard, may lead the GP into hunching over the desk, isolating the patient OVERALL:  1

2 Room layout 2 Easy to glance from patient to screen Screen is not angled away from patient The patient may have to lean forwards to see the screen unless a flat-screen is used However, if a flat screen is used and it is slightly tilted towards the patient: the patient won’t have to lean and you can both truly “share” the computer OVERALL  2

Room layout 3 Doctor can divert gaze to the screen without turning head away from patient Right handed mouse usage may still cut the patient off Doctor’s reaction to screen content is clearly seen by the patient Patient is unable to read the screen without moving The screen is next to the patient’s head Layout may be physically oppressive if the screen is bulky OVERALL  3

Room layout: summary Sit back: the yellow triangle should be equilateral Maintain an open posture to enhance patient rapport and only turn to the computer when you need to use it; then back to the patient Use mouse with either hand Flat LCD screens do not dominate the desk and are easy to move when showing patient things If you’re not good at typing, now’s the time to learn… get a programme like “Mavis Beacon teaches typing” (you can become good over just a week)

Using the computer to enter info in the consultation

Using the computer: entering info Do one thing at a time: don’t input data if the patient is talking, otherwise you’ll miss important verbal cues Type stuff in only when there is a natural pause in the discussion And signpost this using the following 2 skills: 1. verbally: “That really helpful – thanks. Do you mind if I just jot some of that important information down?” 2. non-verbally: move your body and gaze to the screen If the patient starts to talk while you type, stop typing and turn your posture back to the patient to show you are listening. The other reason for doing this is not to miss important information; interruptions often contain important information. Then go back to the computer when another natural pause occurs. When you have finished with the computer, do the reciprocal movements (2. and 1. above) to indicate that you’re back with the patient

Using the computer: entering info You might want to consider involving the patient eg “that’s very helpful. Can you give me a moment just to capture all of that. In fact, it would be helpful if you could read what I type to make sure I’ve understood you properly and correct anything which you don’t think is quite right. Is that okay?” (doctor then verbally signposts by turning the screen slightly towards the patient and checks to ensure they can read the screen)

Using the computer: entering info Don’t treat the computer as belonging to you Share it with the patient The patient may need to get their glasses out… give them time to do so Check that they can read the screen okay Check with them that what you have written is okay But don’t forget to make sure a previous health care professional has not typed in something that might be upsetting or harmful for the patient to know If the patient comes in with a friend, colleague, relative or spouse, be careful as there may be info on the screen they don’t want others to see

Adding information to computer templates Get the patient involved to make the task more collaborative rather than doctor centred Eg “would you mind helping me to fill out some of this important information that we need from you. So, here it says (doctor points to screen) we need to know how many epileptic attacks you’ve had in the last year… can you remember?”

Learning from the computer during the consultation

Learning from the computer Both doctor and patient can learn from the computer (eg the patient can learn more about their condition and the doctor can look up what to do) Again, don’t treat it as it belonging to you; share it! Do one thing at a time: don’t read stuff off the screen if the patient is talking, otherwise you’ll miss important verbal cues If you look up something on the web, it might be helpful to share it with the patient – engages them in the process and with you! Get used to reading off a computer screen. Many people prefer paper but that’s only because they are used to it. The more you read from a screen, the more comfortable you will become. Once you get used to reading from a screen, the more likely it is you will be able to skim read something much faster than the patient and thus be able to highlight significant areas with your finger or mouse (and it make you look very professional and knowledgeable)

Learning from the computer Signpost what you are doing Verbally “thanks for telling me that. Would you give me a moment just to look up something on the computer that I think will be very helpful?” “That’s interesting. I don’t know much about black cohosh (used in HRT) and the effects on the liver. However, I do know where we might find that information. Shall we take a look on the computer together?” “There is some information about this on the computer, I just need a moment to find it” Non-Verbally  Move computer screen so it faces patient too

Sharing electronic information with patients in the consulting room

When sharing information: For example, an online patient information leaflet say something like “would it be helpful to go through the important points using a patient information leaflet on the computer together? And then I could print it off for you?” Turn the screen so the patient can see it too; check they can read from the screen Allow the patient to get their glasses out if needs be Highlight important key sentences/areas either with your finger (pointing to the screen) or with your mouse Read out the area you are referring to (so they can both read and hear the information) Chunk & Check: You may want to explain the “chunks” you point out and check they have understood before moving onto the next important “chunk”

Looking at the screen together Don’t forget these four important principles Give patient time to read Check the patient’s understanding Don’t forget to give the patient a chance to ask further questions You may wish to support the information given or any decisions that have resulted with a print-out of the information viewed together

What to do if you’ve given advice but the latest advice on the web/guidelines is different ( = conflict) You can do one of two things: 1. Accept the new advice and recommend it “oh, that’s a surprise. I was under the impression bed rest was the ideal advice for people with back pain but this information (doctor points to computer screen) which is based on the latest evidence says you should keep active…” “oh, that’s a surprise. I was under the impression bed rest was the ideal advice for people with back pain. It looks like the guidance on this has recently changed. Look, it says here you should keep pottering about because you’ll get better quickly and that pain will soon settle. So, I’d suggest we go with that; what do you think?” 2. Seek corroboration (from other doctor colleagues or a further evidence based web search) before recommending the advice eg “would you mind if I look more into this and see what they’ve based that advice on and then get back to you so we can both decide on the best approach?”

Don’t forget When using a computer, continue to use communication skills to maintain rapport There are many ways of doing this Some GPs used to recommend (and still do) that the computer should only be used when a patient has left because they feel it negatively interferes with the dr-pt relationship. I hope this presentation helps you realise that this is not the case. It depends on how you use it and how good your communication skills are.