The examination room computer promises safer, more efficient and more effective patient care. But exam room computing is challenging and there is growing evidence that it can be a threat to patient safety and detrimental to good relationships and health outcomes, according to a commentary in JAMA Internal Medicine.

Regenstrief Institute sociologist Richard Frankel, Ph.D. presents POISED, a model he has devised for developing and reinforcing good exam room computer-use by physicians.

Prepare -- review electronic medical record before seeing patient

Orient -- spend 1 to 2 minutes in dialogue with the patient explaining how computer will be used during the appointment

Information gathering -- don't put off data entry as patients may question how seriously their concerns are being taken if physician does not enter information gleaned from patient into computer from time to time

Share -- turn the computer screen so patients can see what has been typed signaling partnership and also serving as a way to check that what is being entered is what was said or meant

Educate -- show a graphic representation on the computer screen of information over time, such as patient's weight, blood pressure or blood glucose, so it can become basis for conversation reinforcing good health habits or talking about how to improve them

Debrief -- Exam room computers provide ideal opportunity to use 'teach back' or 'talk back' format for doctor to assess the degree to which recommendations are understood by the patient and correct as necessary

Frankel and colleagues believe that accuracy of the information gleaned from the patient and entered into the electronic medical record is highest when it occurs closest to receipt of the information versus at the end of the patient's appointment or physician's shift. Studying the patient's perspective, they have found patients have a preference for doctors who they believed to be paying attention to them. He says patients who were extremely satisfied with their physician believed that the doctor had spent more time with them than actually was spent.

There are gender differences in physician behavior, he notes. Female physicians typically look up from the screen approximately every 30 seconds or so, making eye contact with the patient to signal that they are still actively engaged in the relationship, and return to typing. Male physicians tend to lock on to the computer screen and rarely look up to signal engagement.

The physicians' need to document must be balanced against the need to build and maintain a relationship with the patient. "Computers in the exam room are here to stay. We need to integrate them into the physician-patient relationship in a patient-centered way. POISED provides a framework for us to do so," Frankel said.