The doctor-patient-laptop relationship

When a new patient asked whether she used electronic medical records, Dr. Kathleen LaVorgna mentally prepared herself to offer a list of reasons why not.

But before LaVorgna, a Norwalk general surgeon in solo practice, could explain that the cost seemed prohibitive, the woman expressed relief.

“That’s great!” she told LaVorgna. The patient then explained that she was fed up with seeing doctors who stared at computer screens or typed into their laptops instead of paying attention to her.

A major push is underway, bolstered by billions of federal dollars, to give medical practices a technological makeover, replacing paper medical charts with electronic records that can share information more fluidly between a patient’s health care providers.

Electronic medical records have many upsides. They’re expected to help cut costs and reduce errors. Experts expect the move away from easily misplaced paperwork will bring fewer duplicate tests. Many doctors who have converted to electronic medical records say that after what can be a long and excruciating adjustment process, the electronic systems can seem indispensible.

But for some doctors and patients like LaVorgna’s, the shift also brings concerns about how technology will affect doctor-patient communication. Will doctors spend more time looking at the computer than the patient? Will having a screen between them change the depth of their conversations?

“It’s great to have all the information readily accessible in one spot about a patient,” said LaVorgna, past president of the Connecticut State Medical Society. “But how you get it there, and how it interacts with the face time you have with your patient is a whole different thing.”

LaVorgna wrote about her encounter with the patient in the journal Connecticut Medicine. In an interview, she noted that there was once a time when doctors saw patients from behind a desk. When she was in medical school, LaVorgna recalled, she was taught never to do that, because the desk would become a barrier. Medical students were taught to make sure they were on the same level as a patient. If a patient was in bed, for example, the doctor should sit in a chair.

Now there are computers to contend with.

“How do we ease it into the doctor-patient relationship without it being a barrier? That’s what I don’t think anyone’s teaching us,” LaVorgna said.

Although uncommon, that sort of training should be commonplace, said Gregory Makoul, chief academic officer at St. Francis Hospital and Medical Center and an expert on doctor-patient communication.

Even if the shift from paper to computers does not change a doctor’s behavior, typing in a computer can seem more disruptive than taking notes on paper, said Makoul, who has studied the effects of electronic medical records on doctor-patient interactions.

A comparison of doctors using paper charts and those who had recently begun using electronic records found that there was little difference in the amount they looked at or wrote in the chart, Makoul said.

“But it’s extremely, unbelievably different what it looks and feels like,” he said.

Writing on paper can appear seamless, Makoul said, while typing makes noise and, particularly for less-than-confident typists, requires more time looking at the screen or keyboard.

The fear of losing eye contact with patients is a barrier to some physicians using electronic medical records, research has found. So is a sense that it is rude to use a computer in front of patients. Studies have also identified patient concerns about computer-related distractions and about the potential for losing confidentiality with their records computerized.

But research also indicates that patients accept the use of electronic records, and see them as having benefits, such as helping doctors become more familiar with their histories.

And having a computer in the examining room can also give doctors a tool for communicating with patients. Health care providers can use computer screens to show a patient graphs of his or her weight or blood pressure over time, or images of a body part they are concerned about, or pictures of a bedbug. Some doctors who treat patients whose first language is not English use their computers to find translations to help explain concepts in their patients’ native language.

“Using it as a patient education tool is a really valuable piece of that puzzle as well,” Makoul said.

Douglas S. Arnold, executive director of Medical Professional Services, an independent physician association that includes more than 400 Connecticut doctors, said the concerns he hears from practices that use electronic medical records tend to be about issues other than interactions with patients.

“It’s an art that the physicians learn pretty rapidly, to keep eye contact and interface with the patients at the same time that they’re trying to enter data in the [electronic medical record],” Arnold said.

Although she has concerns about how it will affect doctor-patient interactions, and with how doctors in small practices will be able to afford to purchase the systems, LaVorgna also believes they will bring benefits.

If she is called to perform emergency surgery at a hospital for a patient she has not previously seen, having the patient records would be extremely useful, LaVorgna said. For larger practices, they can also make it easier for doctors to take care of patients who typically see other doctors in the practice.

“It’s truly a mixed blessing,” LaVorgna said. “You could come up with 10 things that are absolutely great about EMR and 10 things that stink.”

“But let’s face it, everything’s going to be electronic,” she added. “It would be foolish for medicine to say ‘no, we’re not moving forward with that.’”