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Having Coffee with friends… Cheering on your team….

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Presentation on theme: "Having Coffee with friends… Cheering on your team…."— Presentation transcript:

1 Having Coffee with friends… Cheering on your team….
A day at the beach…. A visit to the art museum… Engagement? Mindful in the moment? Nonverbal Communication? Having a conversation with your BFF…. Out on a date….

2 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 Joyce Scarpinato,DNP,PNP-BC, FNP-C Clinical Assistant Professor

3 A day at the beach….

4 Having coffee with friends…

5 Couples communicating…

6 Cheering on your team….

7 Having a conversation with your BFF….

8 Are we missing nonverbal communication messages in our conversations when using technology…. in health care? Next slide: Define NV communication and the focus of presentation

9 The Communication Process
External Climate EHR Nonverbal NV communication is the focus Next slide discuss nonverbal communication The effect of EMRs in the PC exam room on NV Communication. Hypothesis: EMRs are more distracting then paper documentation and data loss. Both equally distracting and loss of data

10 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 Gaze: Gestures: Head nod: validation putting pointer finger to lips..message “shhh” holding hand out with open palm…message “stop” Facial Expressions: Universal phenomenon; however cultural difference when the expression is shown; difficult when more than one emotion is displayed,(affect blend) Researchers have identified six facial emotions: happy, sad, surprised, fear, anger,& disgust.

11 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 NP + EHR +A Familiar Patient ….

12 The Research Question Do computerized Electronic Medical Records (CEMR) effect the Nurse Practitioner’s and patient nonverbal communication in the primary care exam room?

13 Literature Findings Patient satisfaction in the use of EMRs during an encounter Patient Satisfaction ↑ : when provider expressed emotion through nonverbal behaviors. (DiMatteo ,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) eye contact, head nods, body posture, & facial expression

14 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) Beck: Positive: mutual gazing, head nod by provider, uncrossed arms and legs. Negative: ↑ mutual gazing, body position away from patient, backward lean, crossed arms & frequent touch.

15 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

16 Provider-Patient Communication in the Exam Room with CEMRs
Makoul: Background cognitive psychologist “ when two task are performed in parallel most people focus on one at a time. EMR Patient Patient Provider

17 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

18 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%

19 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.

20 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.

21 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.

22 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….

23 Historical Development of the Patient's Medical Record
Prior to 18th Century Verbal transfer of patient data Mid 19th Century- present Paper Medical Records (PMR) 1800-Present 20th-21st century Electronic Medical Record (EMR) Present 1793 apothecary prepared a monthly report of names, disease of the person, decease or discharged. Charted retrospectively after discharge Late 1800 Cases hx more elaborate with + neg findings. 1900 Forms document observations of pt info, Hx, PE, orders, sleep and enema results Siegler (2010)

24 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) Patient Quality & Safety Improvement /positive patient outcomes

25 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) Boonstra et al 2010, BMC Health Services Research; $36,000/provider ($10,000/ provider for software) plus ongoing cost…. The effect of EMRs in the PC exam room on NV Communication. Hypothesis: EMRs are more distracting then paper documentation and data loss. Both equally distracting and loss of data One cohort sequential event design study, NP-S, two different clinical exams (OSCE) one exam using paper and one computer. % time (sec/min) NP-S is looking toward the patient/screen.

26 Adoption of EMRs in the US

27 Adoption of EMRs in the US
Next Motivators…

28 Patient EMR Data Flow Primary Care Provider Diabetic Patient
Nephrology Cardiology Neurology Dermatology Periodontal Endocrine Diabetic Patient Ophthalmology Podiatry Dental

29 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 Considerations/Implications: Patients will have access to EHR without difficulty Patient may have a level of control over their record content however without the ability to modify data entered by health care provider

30 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. e.g. Bipolar student Considerations/Implications: Breach of Information may cause minor embarrassment, loss of insurance or employment to the patient damage provider- patient relationship Lack of full disclosure by patient in fear of breach of confidentiality

31 EHR: Ethical Issues Beneficence Issue: Considerations/Implications:
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 Who owns the patient’s medical data….

32 EHR: Ethical Issues Justice Issue Considerations/Implications:
Patient’s digital access to EMR, driven by socioeconomic conditions Considerations/Implications: Lack of technology, computer or skill

33 Hey ! Are you listening to me?
Hey ! Where did the EHR go? Makoul: Background cognitive psychologist “ when two task are performed in parallel most people focus on one at a time. Hey ! Are you listening to me?

34 “Could a greater miracle take place
than for us to look through each others’ eyes for an instant?” Henry David Thoreau

35 Thank You…. Questions / Comments? Enjoy your day!
References on Request

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