Home Forums #ProjectedEHR

I am wondering if any fellow users have had a chance to try the dual monitor concept projecting the chart to the patient during the exam/office encounter while managing AC on your device of choice.
If so, what has been your take on the process?
I realize with all the other demands we face on a daily basis, changing the process of the patient encounter a bit is not high on the priority list, but if you are willing to try and give me feedback it would be greatly appreciated!
If you are curious about my experience, I have blathered on endlessly, so as not to detract from the user board, on my twitter site.

I figure 5/8 of my partners may adopt the projected EHR approach or a modification there of over time.
3 will likely not use an electronic device at point of contact, so unlikely to.
One has plugged a VGA cord between his desktop and 24 inch TV in one exam room, and has had very positive results.
The partner with the chromebook and e-clinical may give it a go, but will let you know the response, if he does. He is still in the ruminating phase.

I will say the patient response has been nothing short of extreme gratitude for being involved in this manner.

Hey Jim,

Hoping to have a set up like you here sometime this year. We talked about it when I got back from San Diego. We'll probably just set up one room for this. Can't wait.

Marty,
I will be very interested in your response and your patients'.
I bet it will help, and I agree start up with one room and if it doesn't pan out you have a chromebook to play with and an extra TV for use at home.

My experience however, was that once I got one room outfitted with the wall mounted TV, I couldn't get the other room fixed up quick enough.

This is a much bigger issue than only being AC related but has to do with MOC point acquisition.
I think most have UpToDate embedded in AC under the education tab. I have used UpToDate this way for a couple of years and find accessing information (both patient and doc level) extremely handy, and teach constantly, and with the information projected on the TV with AC as I go through the chart very motivational for patients.
However, there should be a way to obtain MOC points and not only CME credit for the work we do day in and out not only educating our patients but ourselves with great resources. Does this sound reasonable to lean on the ABIM to work on this issue, so we can get credit for the work we do on a daily basis?
Any thoughts would be much appreciated.

I thank Dr Wen for this article and insight!!!

http://www.npr.org/blogs/health/2014/08/14/340351393/when-patients-read-what-their-doctors-write

The #ProjectedEHR thread I started is much bigger than Amazing Charts and all of us. I have spent a significant amount of time and energy in the twitter sphere of late because of a passion to help our profession. Nearly every throw away, blog, article, patient or doc I run into keep running with the same thread of anger, contempt, frustration, disillusionment which is demoralizing.
Very few if any talk of a solution or how to change the course we seem to be on in our profession, and that is a chasm between doc and patient with the EHR in the midst.
IMHO the EHR is part of the solution but if used in an educational therapeutic way by changing the conduit of delivery.
It is how we use the EHR at the point of care. If projected on a large TV the record becomes instructive and the documentation improves because two people are working on one thing together.
I am reminded on a daily basis, just how darn lucky I am to have AC because it not only is easy to use (for me) but it is easy to understand on a visual level when shared on a large TV with your patient.
I never realized in 21 years of internal medicine work how important the visual is for learning and teaching.
I have seen a significant improvement in the satisfaction and appreciation by my patients since employing this change in how I integrate the EHR at the visit.
So, my point, AC if projected on a large screen mirrored to whatever device you see fit, shared with the patient at the time of visit, can be part of a cultural shift or change on how the EHR is used on a daily basis. No longer part of the problem but part of the solution to help mend the chasm between the doc and his patient.
I hope this approach will not only benefit AC users, but others using different EHR's as well, but that is the unknown for me. But what I do know, AC with all its frailties in nothing short of incredible when used in this fashion.

I have used dual monitors for three years now. For the most part, I keep the working portion of the chart on my screen and share labs, imaging (Dr web ambassador), graphs, instructional videos (gives me time to keyboard my note) and cartoons.

Most love it, some don't. I keep Epocrates and up to date on my screen.

Good luck.

I have not tried epocrates on the screen but use on my phone. That is a great idea.

If you don't mind commenting more on the instructional videos and Dr web ambassador, I would be interested in hearing more.

I think you are way ahead of the curve, but I think and hope this will be the standard of care, sharing the EHR at the visit as you do.

Thanks Frank!!!

Jimmie,

I will always start Epocrates on my monitor, usually pulling up adverse effects, then drag and drop the screen, if helpful to demo the list.

I handle Dr. Web the same way and will show the patient the area of concern and the report.

I will also show reports from consultants, review med lists, , letters from insurance carrier or pharmacy and graphs to see how we have progressed. I use the prescribing area to show when we used meds (or not) and refills. This helps clear up misconceptions or misinformation, especially from previous physicians (no one ever told me I had dm).

I keep the intake forms to show the patient that they had or had not notified us of information.

I have netti pot videos, cartoons of otoliths with shift, diverticulosis, cardiac caths, normal vs x-rays ( ie. Knee Oa). Pulling X-rays up can take sometime, but can be very helpful.

I hope this helps.

Frank,

Thanks very much, very helpful.

Thanks to Mr. Squire and the AC team for doing a great job in Chicago at the ACUC, and great to meet a lot of new folks and learned quite a bit in a short time.
I appreciate being given the opportunity to present #ProjectedEHR. Also dedicating my presentation to Dr Robin McGee, author and cancer survivor of the book The Cancer Olympics, was a very special moment for me, and I think we as AC users have a great opportunity to visually share the chart at the visit to enhance communication.
I hope others will get a chance to try this approach or a similar one, and very interested in feedback, positives and negatives.

Jim, I saw this article and I thought of you. It almost sounds like you wrote it...

Some relevant quotes:

"One of the biggest physician complaints about EHRs is that the technology places a barrier between them and their patients, which negatively impacts interaction and engagement. This gripe I don?t buy. I just don?t see this issue being inherent to the technology, but rather a prime example of user error. In my opinion, an EHR is no more a barrier between the physician and patient than a paper chart is. Even with paper records, most doctors are inclined to, at some point, bury their noses in the chart and scribble notes that patients never see. ?The barrier effect? of this activity is more pronounced with EHRs because of the increased data entry demands and the fact that many doctors aren?t experienced typists. That being said, I would argue that EHRs don?t have to be a barrier between physicians and patients, but instead could serve as the catalyst for engagement. What if, instead of turning their backs to patients to type notes into a laptop, physicians positioned the computer screen to face patients and invited them to review, or even take part in, the data entry process? I am a patient in a doctor?s office that uses this approach, and the impact has been transformative. In this particular ENT office, physicians display EHR screens on large 32-inch monitors affixed to the exam room walls. Rather than typing information into tiny desktop computers, laptops, or tablets that are for ?doctors? eyes only,? physicians record or update EHR data in full view of the patient ? and often with their input. Seeing my patient record in full HD glory was an eye-opening experience. I was prompted to ask my physician questions and even identified errors in the information contained in my chart that the physician immediately corrected. More doctors need to stop viewing patient records as their private property and start involving patients in the creation, evolution, and maintenance of their medical information. EHRs can make this easier than ever before, and the benefits to patient engagement and wellness can be profound."

I'm not criticizing this approach, just questioning:
-- My (limited) experience with this (in my office, not the exam room), is that this significantly increases the visit length, already adversely impacted by EHR use. How are regular users dealing with this?
-- Much like the old comment about watching the process of making sausages, some patients don't like the process of generating office notes. Some of them thinks its too superficial, don't like negative comments like weight or lifestyle, don't like the exam descriptions. Does this stay on the docs monitor, and they only view assessment & plan?
My opinion, like most EHR related issues, needs some work...

Jon, Thanks for sharing this article & his experience reflects my two and a half years of doing this approach. However, I do very little data entry at the point of care and my nurse has all the info Tee'd up B4 the visit & then if any gaps of info/data become apparent (usually by the patient ie where is my ER visit & CT scan report?), then my nurse can get that immediately ePDF'd with Updox so we can view together during their visit.

John,
This has been a learning experience,but I have found paradoxically the elderly, complex patients are most interested in this approach & easier to keep on task when they can not only see but listen as we efficiently go thru their graphed out labs & BP's, INR's, review Past History, allergies, social, med list, & with the decision support, especially with wellness medicare visit, can rifle thru the recommendations much quicker when they see these as well.
I do all my own med reconciliation and with followup patients, not terribly time consuming, but again easier when pts take part visually & actively in the process.
I do have a few pts that don't care to see their EHR but not many, most want to & again the complex medicare patients are the most interested. When I first started I thought the young healthy tech savvy would be, but in general they are not as complicated and less interest compared to the elderly.
I don't share the HPI with them generally nor dictate in a way to be offensive to them but rather in a way they may be reading what I dictate.
I do most of my data entry when I am done with them, immediately after the visit, use dragon to dictate the HPI & summary, templates for exams & ROS.
Thanks Jon & John !

Jon,
Not sure if you had seen this article from 2014, but Gabe Perna wrote this one up about #ProjectedEHR.

http://www.healthcare-informatics.com/article/montana-one-physician-brings-ehr-bigger-screen

Also, having a separate wall mounted pivoting screen connected via HDMI to the chromebook to share the EHR is preferable than trying to screen share only on the chromebook. Having the chromebook resting on a mobile computer desk typing on the keyboard navigating around the EHR is easier, when not worrying about tilting the screen just right so the patient can see also. I can move the wall mounted screen by tilting downward or side to side for best viewing to suite the patient.