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 in patient-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.

Introduction

With the widespread implementation of electronic health records (EHR), clinicians increasingly are multitasking during medical encounters, as they have to simultaneously interact with both patient and computer to retrieve data, gather information, and make treatment plans. While conventional wisdom has held that use of the computer interferes with effective communication since a clinician's time and effort are taken away from directly interacting with the patient, the empirical evidence is mixed. Compared to paper records, the use of a computer during the visit does create different patterns of clinician–patient verbal and nonverbal communication [1] that may lead clinicians to focus more on information-related tasks and less on psychosocial issues in the encounter [2], [3]. Other studies have reported that EHR use can have both positive and negative impacts on physician–patient relationships [3], [4], depending in part on the physician's skills in using the computer [1], [5], [6], the positioning of the computer in the exam room [7], [8], how distracted physicians are when using the computer [9], and the structure and data processes of the EHR itself [10].

The goal of this study was to explore what features of primary care providers’ (PCP) interaction with the computer influence patients’ perceptions of the quality of provider–patient communication. First, eye contact is an important aspect of interpersonal communication in that it signals interest in one's conversational partner and engagement in the discussion [11]. When a clinician spends considerably more time looking at the computer than the patient, that patient may perceive the clinician as distracted or not fully engaged in the conversation. Second, clinicians physically interact with the computer through mouse clicks and key strokes. Patients may view the clinician's tactile ‘conversation’ with the computer as multitasking and not providing the patient with his or her undivided attention. Finally, the cognitive requirements of working with the EHR could take away from cognitive resources needed to carry on a conversation. If this creates a pattern where the clinician alternates between working on the computer and talking to the patient, it could result in more conversational dead space during which neither clinician nor patient is speaking, thus disrupting the flow of the interaction.

On the other hand, patients may perceive the use of EHR as part of the provider's responsibilities and an important source of information at the point of care [3]. Moreover, some clinicians may be quite skilled at multitasking, enabling them to more successfully integrate their interactions with the computer and the patient [12]. Thus, their use of the computer might have positive or at least neutral effects on their communication with patients. Within the context of a USA Veterans Administration (VA) primary care setting, we examined the effects of PCPs’ nonverbal interaction with the EHR—looking at the computer, rate of mouse click/scrolling activity, and silence while working on the computer—on observer ratings of the providers’ patient-centered communication, patient involvement in the consultation, and provider control of conversation.