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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The DoD EHR: Taking the Plunge
Relationship Centered Care using the EHR
Undercharted Territory
Complexity
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Brian K. Crownover, Eglin AFB, Florida Residency Program Director HQ Air Armament Center
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On 21 Nov 2005, the Assistant Secretary of Defense for Health Affairs, Dr William Winkenwerder, held a press conference to introduce the electronic health record (AHLTA) to be used at all DoD facilities.(1)Intended to cover 9.2 MIL beneficiaries, 70 hospitals, and 411 medical clinics across the globe, AHLTA represents the most ambitious effort to date to electronically track health data in a single system. At our local facility, the AHLTA road team trainers have been introducing the software, as we stood up the system four weeks ago. Key lessons learned so far in our residency program (and applicable to any EHR) include: 1. Software must be modifiable by the user. Powerful prebuilt templates are available for new users, however, AHLTA does not allow individual physicians to edit the templates. The powerful autoneg function to check all the boxes for a normal exam loses utility, if the template does not exactly match the typical history/exam for a given physician. 2. Physicians need training on how to incorporate the software and monitor into the patient interview. The highly useful communication insights by Ventres et al, are more useful in my opinion than the training we received on how to find certain buttons in the program. The frustration cited in the article on disruption of practice style has been mirrored by staff and residents alike in our program. 3. Medical assistants should co-train with physicians to determine which portions of the note each should enter. Avoiding duplication of effort and maximizing MA utility can only occur with frequent communication and teamwork on template development. Our training schedules were grouped by provider type, eliminating opportunity to dialogue on creating efficiencies. Physicians inside and outside the DoD are facing similar issues with EHR implementation. I commend Dr Ventres and his team for extending our knowledge on how to more efficiently incorporate new systems and reach President Bush's goal of EHR use for all Americans by 2014. (1) Health Affairs, Office of Secretary of Defense. Available at: http://www.ha.osd.mil/AHLTA/ahlta_ceremony.cfm. Competing interests: None declared |
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Joseph E Scherger, San Diego, CA, USA Professor of Family Medicine, University of California, San Diego
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Bill Ventres, et al, are to be commended for doing important qualitative research on the impact of the EHR on the physician-patient relationship. Anyone with life experience knows that something new will have unintended consequences. With EHRs, there are both good and bad unintended consequences. Indeed, EHRs are a disruptive technology to the traditional clinical encounter. EHRs are here to stay, and should get better over time with Yankee ingenuity and a smarter world with taking advantage of IT tools. As one who started with an EHR in 1994, I have had much experience in making it work. Like all important parts of the process of care, there should be training to achieve proficiency and even excellence. For EHRs, let's call this: Relationship Centered Care meets the EHR. Here are a few pearls I have learned and teach students, residents, and struggling colleagues: 1. Never start an encounter with the computer. Always face the patient and interact before using the computer. 2. When attention goes to the computer, always adjust the screen so the patient can see their own record. 3. Express and demonstrate advantages of the EHR to the patient, such as the flowsheet of vital signs and lab work. 4. Show some of the "magic" of the EHR, such as "the prescription is already at the pharmacy, the requisistion is already at the lab, etc" 5. Leave the computer to connect personally with the patient, use touch when appropriate, and end the encounter without the computer. 6. Be sure the patient gets the printout of the visit including all the instructions and patient education you gave captured in print. Competing interests: None declared |
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Frank M Sullivan, Dundee, Scotland, UK Professor of General Practice
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Computers intrude into consultations in ways which remain poorly explored. Despite this uncertainty, these clinical tools are considered an essential technology to transform health care in developed countries: especially by improving preventive care and the management of long term conditions. In this edition of the Annals, Ventres and his colleagues have built on their earlier work by conducting a series of ethnographic studies which provide useful insights into the process. Their focus was on the factors influencing how physicians use the electronic health record today in order to effect future improvements. This is an impressive piece of work reporting participant observation, individual interviews, observation of videotaped material and focus groups in a manner they describe as ‘intense analysis’. The results are presented as 14 factors which influence EHR use in four thematic categories which are plausible to this reader; well described in the text and justified by their methodology. Many of the quotes provided by study subjects will be familiar to family doctors and researchers who have explored the subject. They acknowledge the potential limitations imposed by their access to study sites and subjects. This challenges other research groups and educationalists interested in the field to replicate their findings in other contexts and take some of the issues forward which they have identified. The authors helpfully map out a list of exemplar questions in their final table. The Oregon team will no doubt be following other leads they have identified and blazing a trail. Refs Protti D. What can the American electronic health record (EHR) pioneers tell us about what it takes to be successful? Healthc Manage Forum.2002;15:33-5. Sullivan F. Intruders in the consultation. Fam Pract. 1995;12:66-9. Competing interests: None declared |
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Cynthia L Haq, Madison, Wisconsin USA University of Wisconsin
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Thank you for this excellent article that begins to classify the complex interactions of electronic health systems on medical encounters. I have struggled for years to smoothly integrate the use of computers into patient encounters. Initially I felt that there was probably something wrong with me since I could not quickly adapt to all the changes. I frequently apologized to patients as they watched me struggle with befuddling systems requiring many passwords that often did not respond as I hoped. As the clinic staff and I have finally learned to use the system more smoothly, patients and I are often amazed at how quickly information can be gathered, and prescriptions can be refilled and faxed to the pharmacy. Perhaps the greatest challenge I face is to maintain my primary focus on listening to and being with the patient despite the presence of the computer in the room. Your article provides the means for us to carefully examine and reflect on the use of this technology. Competing interests: None declared |
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