Presentation on theme: "Having Coffee with friends…Cheering on your team…. Out on a date…. A visit to the art museum… A day at the beach…. Having a conversation with your BFF…."— Presentation transcript:
Having Coffee with friends…Cheering on your team…. Out on a date…. A visit to the art museum… A day at the beach…. Having a conversation with your BFF….
Joyce Scarpinato,DNP,PNP-BC, FNP-C Clinical Assistant Professor A Shift in Communication Flow Related to Technology… The Impact on Patient-Provider Nonverbal Communication
Are we missing nonverbal communication messages in our conversations when using technology…. in health care?
The Communication Process Nonverbal External Climate EHR
Nonverbal Communication Kinesic: Body motion e.g. gaze, body position, gestures, facial expression Environment: e.g. structural design, sounds Proxemic: personal space e.g. intimate space, social boundary Paralinguistic: vocal sounds e.g. vocal quality, ”ah”, “un huh” Touch
A clinical story….that led to a research project…. One day in a primary care practice a NP running 15 minutes behind…. She enters the exam room, quickly greets the patient with a smile and a handshake…. The NP starts the patient hx with diligent furor entering the hx data into the EHR… The patient’s voice makes the NP stop entering data and look at her patient… The patient has silent tears running down her face… A “Point of Care” research question was realized!
The Research Question Do computerized Electronic Medical Records (CEMR) effect the Nurse Practitioner’s and patient nonverbal communication in the primary care exam room?
Literature Findings Patient satisfaction in the use of EMRs during an encounter –Patient Satisfaction ↑ : when provider expressed emotion through nonverbal behaviors. (DiMatteo et.al,1980 and Roter et al., 2006) –Patient Satisfaction: 85.4% liked computers in the exam room –Increase communication –Provider knew them better –More active in medical decision making. (Hsu et al, 2005 and Stewart et al.,2010)
Literature Findings Nonverbal Communication –Nonverbal Behaviors: Positive & Negative Systematic Review (Beck et al. 2002) –Broken eye contact and lack of face to face interaction are linked to ↓ in patient disclosure. (Makoul et al.,2001) –Average provider viewed screen 25-55% during a patient encounter (Shachak et al., 2009) –EMR engagement by the provider may cause missed verbal and nonverbal patient cues. (Margalit et al., 2006 and Stewart et al., 2010)
The Study Documentation Types –Comparison of Paper Medical Records (PMR) to Computerized Electronic Medical Records (CEMR) and the effects on nonverbal communication between the Nurse Practitioner and patient
Provider-Patient Communication in the Exam Room with CEMRs PatientProvider EMR Patient
Methodology One group sequential-event design Convenience sample N=34 FNP Students Two videotaped OSCES; Use of two documentation methods –Paper –CEMR Nonverbal Variables: Eyes toward patient Body position toward patient
Nurse Practitioner Students Demographics Mean –Age: 34.7 years –RN Experience: 10.3 years –Gender Male: 5.9% Female: 94.1% –Experience with CEMR: Yes: 76.5% No: 14.7%
Significant Results Paired t-test NP students’ spent a significantly longer period of time with their body facing the patient when using the paper documentation vs computer / EHR (p=0.0001) No difference was found when eyes were toward the patient by the type of documentation, paper versus computer/EHR (p=0.099) Repeated Measure ANOVA Body position toward the patient is significant (p=0.000) The older group's (40-53 yr) longer than the youngest group (22-29 yr) when using the EHR computer.
Anecdotal Findings When viewing the videos: –Patient body language changed when there was lack of either body or eyes toward patient by the NP student. –When the NP students took their hands off the keyboard and made eye contact the patients reengaged with the NP student. –The NP student apologizing for spending time focused on the CEMR seemed to assist in keeping the patient engaged with the NP student.
Implications for Practice This study provides information for the Nurse Practitioner to recognize the potential for a loss of nonverbal data created by the CEHR, impacting the patient's assessment, diagnosis, and treatment.
Electronic Health Records Are here to stay…. Supported by the evidence…. Some thoughts about how we got here and how we can effectively use EHRs….
Historical Development of the Patient's Medical Record Prior to 18 th Century Verbal transfer of patient data Mid 19 th Century- present Paper Medical Records (PMR) 1800-Present 20 th -21 st century Electronic Medical Record (EMR) 1990- Present
Motivators Moving Health Care Toward the Use of EMRs Legislation –American Recovery & Reinvestment Act (ARRA) 2009 E-prescribing incentive (2009) /penalty (2012) –Health Information Technology for Economic and Clinical Health Act (HITECH) Funding toward secure EMR 2014 CMS 3% reimbursement penalty (Stewart, Kroth, Shuyler, & Baily,2010)
Barriers in Moving Health Care Toward the Use of EMRs Implementation Cost Adaptation by PCP (skill set) Appropriate/ correct data entry Multiple software EMR programs Currently, the EMR fail to capture data reflecting social & behavioral determinants of health. (Glasgow & Emmons, 2011)
Primary Care Provider Ophthalmology Podiatry Dental Nephrology Cardiology Neurology Dermatology Periodontal Endocrine Diabetic Patient Patient EMR Data Flow
EHR: Ethical Issues Autonomy –Issue: Respect of patient autonomy and decisions about access, content and ownership to the EHR Outcome: –Potential for higher quality documentation. –Patients may proofread record and request needed corrections. –Patients may identify what part of the EHR is released
EHR: Ethical Issues Privacy and Confidentiality –Issue Intimate patient information Trusting provider patient relationship Patient’s control of amount of record shared Outcome: Patients control of EHR may hinder their medical care if appropriate data is not shared.
EHR: Ethical Issues Beneficence –Issue: Patient raw data that will provide biomedical and public health research to help society. –Considerations/Implications: The development of a research data base which may effect the health of society. Costly EHR systems to interface with patients research data however with a long term benefit to society. Solving legal issues of data sharing
EHR: Ethical Issues Justice –Issue Patient’s digital access to EMR, driven by socioeconomic conditions –Considerations/Implications: Lack of technology, computer or skill