Presentation on theme: "Having Coffee with friends… Cheering on your team…."— Presentation transcript:
1Having 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….
2Joyce Scarpinato,DNP,PNP-BC, FNP-C Clinical Assistant Professor A Shift in Communication Flow Related to Technology… The Impact on Patient-Provider Nonverbal CommunicationJoyce Scarpinato,DNP,PNP-BC, FNP-CClinical Assistant Professor
8Are we missing nonverbal communication messages in our conversations when using technology…. in health care?Next slide: Define NV communication and the focus of presentation
9The Communication Process External ClimateEHRNonverbalNV communication is the focusNext slide discuss nonverbal communicationThe 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
10Nonverbal Communication Kinesic: Body motion e.g. gaze, body position, gestures, facial expressionEnvironment: e.g. structural design, soundsProxemic: personal space e.g. intimate space, social boundaryParalinguistic: vocal sounds e.g. vocal quality, ”ah” , “un huh”TouchGaze:Gestures: Head nod: validationputting 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; difficultwhen more than one emotion is displayed,(affect blend) Researchers have identified six facial emotions: happy, sad, surprised, fear, anger,&disgust.
11A 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 ….
12The Research QuestionDo computerized Electronic Medical Records (CEMR) effect the Nurse Practitioner’s and patient nonverbal communication in the primary care exam room?
13Literature FindingsPatient satisfaction in the use of EMRs during an encounterPatient 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 roomIncrease communicationProvider knew them betterMore active in medical decision making.(Hsu et al, 2005 and Stewart et al.,2010)eye contact, head nods, body posture, & facial expression
14Literature 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.
15The 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
16Provider-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.EMRPatientPatientProvider
17Methodology One group sequential-event design Convenience sample N=34 FNP StudentsTwo videotaped OSCES;Use of two documentation methodsPaperCEMRNonverbal Variables:Eyes toward patientBody position toward patient
18Nurse Practitioner Students Demographics MeanAge: 34.7 yearsRN Experience: 10.3 yearsGenderMale: 5.9%Female: 94.1%Experience with CEMR:Yes: 76.5%No: 14.7%
19Significant 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 ANOVABody 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.
20Anecdotal 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.
21Implications 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.
22Electronic Health Records Are here to stay….Supported by the evidence….Some thoughts about how we got here and how we can effectively use EHRs….
23Historical Development of the Patient's Medical Record Prior to 18th CenturyVerbal transfer of patient dataMid 19th Century-presentPaper Medical Records (PMR)1800-Present20th-21stcenturyElectronic Medical Record (EMR) Present1793 apothecary prepared a monthly report of names, disease of the person, decease or discharged.Charted retrospectively after dischargeLate 1800 Cases hx more elaborate with + neg findings.1900 Forms document observations of pt info, Hx, PE, orders, sleep and enema resultsSiegler (2010)
24Motivators Moving Health Care Toward the Use of EMRs LegislationAmerican Recovery & Reinvestment Act (ARRA) 2009E-prescribing incentive (2009) /penalty (2012)Health Information Technology for Economic and Clinical Health Act (HITECH)Funding toward secure EMR2014 CMS 3% reimbursement penalty(Stewart, Kroth, Shuyler, & Baily,2010)Patient Quality & Safety Improvement /positive patient outcomes
25Barriers in Moving Health Care Toward the Use of EMRs Implementation CostAdaptation by PCP (skill set)Appropriate/ correct data entryMultiple software EMR programsCurrently, 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 dataOne 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.
28Patient EMR Data Flow Primary Care Provider Diabetic Patient NephrologyCardiologyNeurologyDermatologyPeriodontalEndocrineDiabetic PatientOphthalmologyPodiatryDental
29EHR: Ethical Issues Autonomy Issue: Respect of patient autonomy and decisions about access, content and ownership to the EHROutcome:Potential for higher quality documentation.Patients may proofread record and request needed corrections.Patients may identify what part of the EHR is releasedConsiderations/Implications:Patients will have access to EHR without difficultyPatient may have a level of control over their record content however without the ability to modify data entered by health care provider
30EHR: Ethical Issues Privacy and Confidentiality Issue Intimate patient informationTrusting provider patient relationshipPatient’s control of amount of record sharedOutcome:Patients control of EHR may hinder their medical care if appropriate data is not shared.e.g. Bipolar studentConsiderations/Implications:Breach of Informationmay cause minor embarrassment, loss of insurance or employment to the patientdamage provider- patient relationshipLack of full disclosure by patient in fear of breach of confidentiality
31EHR: 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 sharingWho owns the patient’s medical data….
32EHR: Ethical Issues Justice Issue Considerations/Implications: Patient’s digital access to EMR, driven by socioeconomic conditionsConsiderations/Implications:Lack of technology, computer or skill
33Hey ! 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
35Thank You…. Questions / Comments? Enjoy your day! References on Request