It is now almost two years since I wrote a blog on the introduction of the electronic medical record (EMR) in our local health service.¹ It was the day before the new EMR system went ‘live’ and clinicians were nervous about how it would affect their daily lives and, most importantly, communication with patients and families. At the time one of the doctors shared with me that he had real concerns about giving patients adequate ‘face to face’ time while simultaneously meeting the needs of the new computer record keeping system. It was clear to all that it would take extra time to provide and document care with the new system and there was going to be a steep learning curve in ways that had not even been anticipated. Since then, I have seen this same doctor on numerous occasions, interacting with patients and families. He still sits at the bedside talking to patients and families face to face without a computer in sight. He has clearly developed strategies to maintain this precious personal communication with his patients, while still feeding the computer with the necessary information for documenting patient assessment and response to care.

I am often amazed at how quickly new forms of technology become the norm. I cannot imagine life without a smartphone and easy access to the internet 24 hours a day is no longer a sophisticated luxury. On the healthcare frontline it has very quickly become normal to see nurses dragging their WOWs (workstation on wheels) and COWs (computers on wheels) between and around patient rooms in health care facilities. It also feels quite normal to see primary care providers logging on to the computer system as they enter the consultation room, pausing briefly to shake hands and introduce themselves, as they prepare to simultaneously and seamlessly discuss and document the reason for your visit. However, even after two years I see clinicians struggling with the demands of the new and often updated digital repository, robotically filling in the blanks as they appear on screen, searching for the right place to put things, sometimes frustrated that the information they are trying to input does not fit the information category provided by the program. At times it even appears that they are putting square pegs into round holes and crossing fingers that the clinician following them will be able to find key pieces of information being shared.

In my observation, some clinicians are better than others at establishing rapport and communicating to their patients that they are actually listening actively to their narrative, even though more often than not their eyes are fixed to their screens. I have observed clinicians who are masters in the art of maintaining just enough eye contact to communicate that they are interested in the story yet still diligent in capturing the details in the digital system. Others still use pen and paper to jot down notes as they give full attention and face the patient, choosing to document their findings at the conclusion of the consultation, checking with the patient that what they have gathered is correct, making sure they are both on the same page for plans moving forward. Clinicians have adapted to new technology in different ways, and in some cases the technology itself – designed to improve information sharing – has become a barrier to effective communication.

As expected, the digital natives seem to struggle less with new technology, accepting that EMRs are here to stay. Rather than fighting the inevitable, they quickly learn how to maximize the benefits of the systems and build upon them. They constantly look for ways to refine the capabilities of the system, so that the technology is working for them, rather than the other way around. We have much to learn about making the most of the EMR and the information within it, and this is a priority for nursing and healthcare research. We need evidence about the ongoing impact of EMRs on patient care and patient outcomes.

Putting these ongoing transitional challenges aside, there are many exciting ways for us to communicate with patients and to enhance information exchange. The EMR is only part of the larger puzzle, but it is likely to be an ever increasing conduit of communication between patients, families and clinicians in future healthcare.

Global interest in mobile health (mHealth) strategies, where information exchange can be integrated within systems of healthcare, including the EMR, has exciting possibilities for the future.² There is great potential to expand our healthcare reach to populations where people have previously lived with an absence of high quality evidence-based information to promote their health. Now many more communities have access to mobile phone technology to access texting services, hotlines, telemedicine and new decision support ‘apps’. In particular, support of growth of mHealth in Lower and Middle Income Countries (LMICs) has been recognized as an important research priority with great potential for increasing use of evidence-based health strategies that make a real difference to population health.²

There is increasing excitement about the potential for interactive digital patient decision aids to be housed within or linked to the EMR. This will enable patients to receive the right information, at the right time, and for providers to communicate with patients as they interact with decision aids, clarifying values and preferences in preparation for shared decision making. Easy access to high quality evidence-based information is central to effective preparation for decision making. Health information technology provides greater capacity to engage patients, accommodate individual learning needs and bridge communication gaps than the more traditional paper-based tools (books, booklets, pamphlets etc.). We are still exploring questions about what can be achieved with digital modalities over paper-based tools but the field is promising.

With any innovation, it is important to have the necessary passion, vision, resources and evidence to overcome the barriers to achieving a change that is worthwhile and increases access to more effective models of care. We must keep one eye focused on the tipping point, to ensure that the technology we integrate into clinical practice does not create additional barriers to effective care and communication. We must never stop evaluating the care we provide and gathering evidence about the consequences to guide our decisions about which systems work best and how the best patient outcomes can be achieved.

Allison Shorten, RN RM PhD

Yale School of Nursing

References:

1. Shorten A. (2013, February). Patient centered care and the electronic medical record, Evidence Based Nursing Blog (BMJ Group Blogs). https://stg-blogs.bmj.com/ebn/2013/02/06/

2. Mehl, G., Labrique, A. (2014) Prioritizing integrated mHealth strategies for universal health coverage. Science. 345 (6202), pp. 1284-1287. http://www.sciencemag.org/content/345/6202/1284.full.pdf