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 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)
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