Provider interaction with the electronic health record: The effects on patient-centered communication in medical encounters

Abstract

Objective The computer with the electronic health record (EHR) is an additional ‘interactant’ in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit. Methods Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via video-recording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient satisfaction measures. Trained coders independently viewed videos of the interactions and rated the degree to which PCPs were patient-centered (informative, supportive, partnering) and patients were involved in the consultation. Conversational control was measured as the proportion of time the PCP held the floor compared to the patient. Results The final sample included 125 consultations. PCPs who spent more time in the consultation gazing at the computer and whose visits had more conversational silence were rated lower inpatient-centeredness. PCPs controlled more of the talk time in the visits that also had longer periods of mutual silence. Conclusions PCPs were rated as having less effective communication when they spent more time looking at the computer and when there was more periods of silence in the consultation. Because PCPs increasingly are using the EHR in their consultations, more research is needed to determine effective ways that they can verbally engage patients while simultaneously managing data in the EHR. Practice implications EHR activity consumes an increasing proportion of clinicians' time during consultations. To ensure effective communication with their patients, clinicians may benefit from using communication strategies that maintain the flow of conversation when working with the computer, as well as from learning EHR management skills that prevent extended periods of gaze at computer and long periods of silence. Next-generation EHR design must address better usability and clinical workflow integration, including facilitating patient-clinician communication.

Impact of Electronic Medical Record Use on the Patient–Doctor Relationship and Communication: A Systematic Review

“…Seven studies examined both patient perceptions and observed behaviors. 30,31,43,44,48,49,55 Only two studies were interventional in nature. 61,70 Forty-seven of the 53 studies were published after the year 2000, and 19 (35.8 %) were published since 2011.…”

“…While 11 studies [29][30][31]34,37,38,43,44,48,49,55 attempted to correlate objective observations of communication behaviors with patient perceptions of care, only seven of these studies elicited patient perspectives directly. 30,31,43,44,48,49,55 The remaining studies used researcher perceptions of the patient perspective as a proxy.…”

“…30,31,43,44,48,49,55 The remaining studies used researcher perceptions of the patient perspective as a proxy. Studies noted mixed patient perceptions.…”

“…An increase in provider screen gaze, keyboarding, silence and closed body posturing negatively impacted communication. 43,55 However, certain behaviors enabled more successful integration of the EMR into the visit, such as screen sharing that did not obstruct the visual field between doctor and patient. 30 Three studies directly examined patient perceptions of change in overall patient-doctor relationship and quality of care or satisfaction overall, and found no significant change as a result of EMR use.…”

Patient Perceptions of Electronic Medical Record Use by Faculty and Resident Physicians: A Mixed Methods Study

“…7 While most demonstrated a lack of change in the patient-provider relationship and high satisfaction with EMR use, concerns such as provider distraction by the computer and changes in non-verbal aspects of communication such as eye contact and long periods of silence were raised. [17][18][19][20][21][22][23] In addition, most studies were conducted prior to the 2013 Meaningful Use ACA mandates and rapid EMR adoption. 7 As more patients encounter their physicians using EMRs in the exam room after ACA implementation, they may be better primed to share their experiences on this timely issue.…”