“It should be in my chart.”

I’m sure we have all heard this statement uttered with a subtle (or not so subtle) edge of frustration from our patients after asking a question such as “what medications do you take?”  I find clinicians despise this comment because it is interpreted as (a) the patient is not making an attempt to recall his or her medical history, or (b) that the patient doesn’t know his or her medical history.

In my experience, each time the dreaded “it should be in my chart” comment comes up, I find myself without access to the electronic health record (EHR) at the bedside.  As a hospitalist, I usually enter a patient’s room without a computer and hope there will be one inside; if there isn’t, in retrospect, I nearly always wish there was one.

Of course, there has been much written of technology dissolving the patient-clinician bond.  Stories abound of patients opening up to a clinician with back turned, staring at a glowing screen and frantically typing and clicking.  However, when utilized the right way, I say a computer at the bedside helps the patient encounter in more ways than it hurts.

The following is a typical scenario that occurs when I perform a history and physical exam without a computer in the patient’s room.  First, depending upon the complexity of the patient, I spend anywhere from 5 to 15 minutes reviewing the EHR before entering the room; but I’m human, and patients are often complex, with dozens of hospitalizations, medications, and past medical problems – so of course, I can’t recall every detail.  Then, I walk into the room and initiate the discussion, working through the history of present illness, past histories, medications, and allergies, doing all of this while trying to commit to memory every detail.  When finished, I exit and scurry to the nearest computer or to our office area.  When I sit down and re-enter the patient’s chart, I invariably uncover something that wasn’t discussed.  “Oh, it says the patient is on clopidogrel, I forgot to ask if he is still taking that,” or, “the ER note says she fell and hit her head two days ago, she didn’t mention that to me.”  If I had a computer at the bedside, I could verify or dive deeper into these issues.  Instead, I have to return to the patient’s room, ask later, or not address them at all.

So here are some of the reasons why I believe a computer at the bedside should be common practice for many clinicians:

1. It allows you to verify instead of eliciting the medical history.  Which one of these sounds better: “What medications do you take?” or “I see the nurse has already gone over your home medications with you, to avoid you having to recite all 20 of them again, I’m going to verify your medications to ensure we have the correct list.”  I guarantee the latter approach will take less time, improve your workflow, be appreciated by the patient, and catch errors (anecdotally, I find medication reconciliation errors nearly 100 percent of the time when I perform a computer-assisted medication reconciliation).

2. It allows you to look things up in the EHR at the point of care.  For instance, the patient may mention a historical event that you did not chart review on.  With a computer at the bedside, you can look it up right there while talking with the patient.  “You’re right, I see you did undergo a stress test 6 months ago that was normal”.

3. I find patients like it when you show them things.  If patients admitted with pneumonia can actually see the infiltrate on the chest X-ray, not only does it help them understand what is happening to them, it demonstrates you have taken the time to personally review the image.

4. Finally, I can place orders right there in the patient’s room.  This is especially important for things I would probably forget to do after walking out of the room.

Now, of course, we don’t want a technological presence to dominate the encounter, so here are some strategies to mitigate this risk:

1. Don’t immediately interact with a computer when entering a patient’s room.  Instead, first make eye contact and introduce or reintroduce yourself to the patient and family.

2. Go through the history of present illness without interacting with the computer unless you need to record specific details.  Additionally, if possible, sitting down at this point always helps build rapport and makes the patient feel heard.

3. When you are ready to start interacting with the EHR, tell the patient you are going to verify the medical history and medications in order to make sure nothing is omitted.

4. As mentioned above, you can show the patient imaging testing, lab testing, etc. if relevant. 

By employing these simple strategies, I personally have never had a patient tell me they were upset by my use of a computer.  In contrast, I suspect hundreds of patient encounters without a computer have resulted in one or more of the following: patient frustration, needing to go back into the room after the encounter, or inadequate patient care.

Now, I’m not perfect about bringing a computer into the room and realize that every sometimes there just isn’t a computer available.  And of course, there are caveats: I don’t think every single patient encounter requires a computer (but I do find it to be crucial on initial encounters), and I don’t believe certain specialists or sub-specialists addressing one problem necessarily need a computer.  But I do believe that access to the EHR at the bedside improves my workflow, makes me a better doctor, and improves patients’ trust in me.  What do you think?

Scott Keeney is an internal medicine physician.

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