Avoiding The EMR Alienation Effect

Recently, I stumbled across a very interesting article talking about I call the “patient alienation effect” generated by EMRs.  The author, Charles Smith, who practices at the University of Arkansas, is an EMR old hand who has been using the Centricity ambulatory EMR for more than a decade.

The article, which appears in the Journal of Participatory Medicine, talks about the well-known offputting effect EMRs have on patients, and the frustration that they impose on doctors. And as readers know, we’re not talking about a minor impact here.

In the new EMR world, he notes, physicians have a list as long as your arm of EMR related tasks they must perform during the patient visit, including medication reconciliation, managing the problem list, e-prescribing, updating the patient’s history, review of systems, physical exam, entering the follow-up plan into the record, and printing “after the visit” summaries for the patient. And as he points out, this all has to happen for the patient is still sitting in the exam room.

The way he handles this problem is to treat the challenge is one for the patient and physician to solve things together:

*  At the outset, he and the patient have an open discussion of the EMR issue with new patients, discussing the advantages and challenges of the computer in the room.

*  Then, he asks the patient’s to allow him to move their chair beside him in the computer, noting that they will “all three” work together during the visit.

* He also tries to create a hybrid experience of completing some EMR tasks during the visit and others after (for example telling the patient, “hold on while I enter this order for you) before returning to face-to-face conversation.

* He finds that it works best to take notes here and there during the patient visit, then complete the past medical, surgical, family and social history and the review of systems together with the patient directly in the EMR.

Obviously, there’s no one right way to integrate patients into the process of documenting their visit in an EMR. But these ideas seem like good ones.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.


  • Great post! Like the solution of doctor bringing computer around to patient, establishing the illusion of a “three-way” partnership which ultimately will assist all of them if implemented more like this and less impersonally.

    One thing my classmates and I were wondering, HIT / CERT , physicians & nurses bringing technology from room to room – doesn’t this increase the patient’s risk of exposure to all kinds of germs etc.? Know off topic but we were talking out loud other day about this and your post just reminded me so thought I would ask a pro!

    Keep up great work!

  • Bonnie,
    It definitely can depending on how you use the technology. Some of the newer devices can actually be cleaned and sanitized because of this issue. Definitely something to consider in your implementation of the technology.

  • I was with a Cardiologist in Delaware last Friday, and I saw how he was using technology. Here is a synopsis of what I saw.

    Patient comes in, MA updates medical history, takes vitals, initial review of system including the reason why patient is here (Chief Complaint). All of this is done in the EMR.
    When Dr. is ready to see patient, with one click, he sees what MA has done, as well as prior visit notes ( if this is a repeat patient).
    In the Exam room, he has a computer with a dual screen. The second screen is a large monitor attached to the wall. As he is talking to the patient, he is pulling up relevant parts of the chart so that the Physician and Patient are seeing the same thing. So, the actual interaction was a mix of eye contact and both the provider and patient looking at the screen while talking. He said the entire objection of ‘doctor looks at the screen and not at me’ is gone because doctor is sharing the screen on which he is charting. This, according to him, had a side benefit of patients sometimes pointing out that they are no longer taking a medication that was on the chart, or pointing out something else and asking questions. Increase patient involvement makes them happier. Therefore, he is able to finish most of the charting accurately while in the exam room with patient.
    Once he was done with the patient in the exam room, he walked the patient out, gave instructions to his staff if any, and went to his office. Being that his was a ‘cloud’ system, the same patient chart was accessible in his office. So, he did something interesting. In his office, he clicks on the HPI area and starts talking to the computer (using Dragon Dictation) about the patient’s ‘story’. Then, another click and he dictated the plan for his assessment and diagnosis. This took 2 1/2 minutes only! He actually signed off the note right there.
    He goes to the next exam room for the next patient.
    Just 1/2 an hour after his last patient, he was done, and he leaves for home, all his notes for the day are done and signed.
    Because of this, his billers are able to submit claims the same day and helps with better billing efficiency.
    I have to say that for this scenario to happen, he worked with the vendor to get a well oiled machine in place. In his words, “You can’t get this efficiency with a free EMR”, work with your vendor as a partner.

  • Whether it’s scribbling onto a notepad or form, dictating into a voice recorder, typing and clicking on a laptop, or tapping away at a mobile device there will always be something in between the doctor and the patient that each doctor must find their own way to overcome. There are established techniques and etiquette for the former two examples because they are decades or more old and I believe it will only be a matter of time until a same sort of etiquette is formalized for the latter two examples.

    It is of note though that since mobile devices and notepads are so similar in their obstruction that the etiquette for older of the two can be easily translated to the other. Instead of finding a techniques to unobtrusively integrate desktop and laptop computers into the exam room, doctors may choose to adopt vendor solutions that fully utilize mobile devices. Unfortunately though there will be those that claim it, no vendor I’ve seen has been able to create an EHR that is truly as fully functional on a mobile device as it is on a desktop or laptop.

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