Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: multi-channel video study

Pooling of primary care electronic health record (EHR) data on Huntington's disease (HD) and cancer: establishing comparability of two large UK databases

OBJECTIVES

To explore whether UK primary care databases arising from two different software systems can be feasibly combined, by comparing rates of Huntington's disease (HD, which is rare) and 14 common cancers in the two databases, as well as characteristics of people with these conditions.

DESIGN

Descriptive study.

SETTING

Primary care electronic health records from Clinical Practice Research Datalink (CPRD) GOLD and CPRD Aurum databases, with linked hospital admission and death registration data.

PARTICIPANTS

4986 patients with HD and 1 294 819 with an incident cancer between 1990 and 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Incidence and prevalence of HD by calendar period, age group and region, and annual age-standardised incidence of 14 common cancers in each database, and in a subset of 'overlapping' practices which contributed to both databases. Characteristics of patients with HD or incident cancer: medical history, recent prescribing, healthcare contacts and database follow-up.

RESULTS

Incidence and prevalence of HD were slightly higher in CPRD GOLD than CPRD Aurum, but with similar trends over time. Cancer incidence in the two databases differed between 1990 and 2000, but converged and was very similar thereafter. Participants in each database were most similar in terms of medical history (median standardised difference, MSD 0.03 (IQR 0.01-0.03)), recent prescribing (MSD 0.06 (0.03-0.10)) and demographics and general health variables (MSD 0.05 (0.01-0.09)). Larger differences were seen for healthcare contacts (MSD 0.27 (0.10-0.41)), and database follow-up (MSD 0.39 (0.19-0.56)).

CONCLUSIONS

Differences in cancer incidence trends between 1990 and 2000 may relate to use of a practice-level data quality filter (the 'up-to-standard' date) in CPRD GOLD only. As well as the impact of data curation methods, differences in underlying data models can make it more challenging to define exactly equivalent clinical concepts in each database. Researchers should be aware of these potential sources of variability when planning combined database studies and interpreting results.

An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse-patient interactions and communication

AIM

To explore how nurses' use of electronic health records impacts on the quality of nurse-patient interactions and communication.

DESIGN

An integrative review.

DATA SOURCES

MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022.

REVIEW METHODS

Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach.

RESULTS

One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face-to-face communication, promotes task-orientated and formulaic communication and impacts on types of communication patterns.

CONCLUSION

Research examining nurse-patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse-patient communications, reflecting a task-driven approach, were predominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient.

IMPACT

The move to electronic health records has taken place largely without consideration of the impact that this might have on nurse-patient interaction and communication. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse-patient interactions and communication.

PATIENT OR PUBLIC CONTRIBUTION

Studies examined within this review included patient participants that informed the analysis and interpretation of data.

Video-based observation research: A systematic review of studies in outpatient health care settings

OBJECTIVE

To examine the use of video-based observation research in outpatient health care encounter research.

METHODS

We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics.

RESULTS

175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies.

CONCLUSION

Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement.

PRACTICE IMPLICATIONS

Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

Barriers and Facilitators to the Initiation of Injectable Therapies for Type 2 Diabetes Mellitus: A Mixed Methods Study

INTRODUCTION

Initiation of injectable therapies in type 2 diabetes (T2D) is often delayed, however the reasons why are not fully understood.

METHODS

A mixed methods study performed in sequential phases. Phase 1: focus groups with people with T2D (injectable naïve [n = 12] and experienced [n = 5]) and healthcare professionals (HCPs; nurses [n = 5] and general practitioners (GPs) [n = 7]) to understand their perceptions of factors affecting initiation of injectables. Phase 2: video-captured GP consultations (n = 18) with actor-portrayed patient scenarios requiring T2D treatment escalation to observe the initiation in the clinical setting. Phase 3: HCP surveys (n = 87) to explore external validity of the themes identified in a larger sample.

RESULTS

Focus groups identified patients' barriers to initiation; fear, lack of knowledge and misconceptions about diabetes and treatment aims, concerns regarding lifestyle restrictions and social stigma, and feelings of failure. Facilitators included education, good communication, clinician support and competence. HCP barriers included concerns about weight gain and hypoglycaemia, and limited consultation time. In simulated consultations, GPs performed high-quality consultations and recognised the need for injectable initiation in 9/12 consultations where this was the expert recommended option but did not provide support for initiation themselves. Survey results demonstrated HCPs believe injectable initiation should be performed in primary care, although many practitioners reported inability to do so or difficulty in maintaining skills.

CONCLUSION

People with T2D have varied concerns and educational needs regarding injectables. GPs recognise the need to initiate injectables but lack practical skills and time to address patient concerns and provide education. Primary care nurses also report difficulties in maintaining these skills. Primary care HCPs initiating injectables require additional training to provide practical demonstrations, patient education and how to identify and address concerns. These skills should be concentrated in the hands of a small number of primary care providers to ensure they can maintain their skills.

Oncologist responses to advanced cancer patients' lived illness experiences and effects: an applied conversation analysis study

BACKGROUND

An advanced cancer patient's life is often disturbed by fear of cancer recurrence, cancer progress, approaching suffering, and fear of dying. Consequently, the role of the medical oncologist is not only to provide best quality anti-cancer treatment, but also to address the impact of disease and treatment on a patient's life, the lived illness experience. We aimed to gain insights into whether and how medical oncologists working at an outpatient clinic identify and explore lived illness experiences raised by patients with advanced cancer, and how this influences patients' responses.

METHODS

Conversation Analysis was applied to analyse 16 verbatim transcribed audio-recorded consultations.

RESULTS

We identified 37 fragments in which patients expressed a lived experience from 11 of the 16 consultations. We found differing responses from different oncologists. Patients continued talking about their lived experiences if the listener produced a continuer such as humming or tried to capture the experience in their own words. In contrast, a response with optimistic talking or the presentation of medical evidence prevented patients from further unfolding the experience. In consultations in which the lived illness experience was most extensively unfolded, medical oncologists and patients could constantly see each other's facial expressions.

CONCLUSIONS

When a patient with advanced cancer spontaneously introduces a lived illness experience, it helps to identify and explore it when the medical oncologist produces a continuer or tries to capture this experience in their own words. Our findings can be implemented in training sessions, followed by frequent reinforcement in daily care.

Impact of the introduction of falls risk assessment toolkit on falls prevention and psychotropic medicines' utilisation in Walsall: an interrupted time series analysis

OBJECTIVE

To determine the impact of the introduction of a falls risk assessment toolkit (FRAT) in a UK medical centre on the number and cost of non-elective admissions for falls and psychotropic medication utilisation.

DESIGN

Interrupted time series analysis quantifying the number and cost of non-elective admissions for falls and primary care use data for Rushall Medical Centre before and after the implementation of FRAT at July 2017.

SETTING

Data on the monthly number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service were provided by Walsall Clinical Commissioning Group. Primary care prescribing cost and volume data for Rushall Medical Centre was derived from the Openprescribing.net website for prescriptions dispensed between April 2015 and November 2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service, and the volume of utilisation of psychotropic medicines.

RESULTS

Following the implementation of FRAT at Rushall Medical Centre in July 2017, the number of non-elective admissions for falls decreased at a rate of 0.414 admissions per month (p<0.033, 95% CI -0.796 to -0.032). The utilisation of psychotropic medications (alimemazine, citalopram, escitalopram, fluoxetine, mirtazapine, olanzapine and risperidone) decreased. The expenditure on psychotropic medications prescribed/used at Rushall Medical Centre decreased by at least £986 per month (p<0.001, 95% CI -2067 to -986).

CONCLUSIONS

The implementation of FRAT at Rushall Medical Centre was associated with a reduction in the number of non-elective admissions for falls. Assessment of these patients together with deprescribing of psychotropic medications resulted in a reduction in the number of non-elective admissions for falls and associated costs.

Efficient Clinical Counseling for Sickle Cell Disease

Sickle cell anemia (SCA) is a chronic illness that requires frequent health care visits for preventative management. Adherence to national guidelines such as the National Heart Lung and Blood Institute (NHLBI) Expert Panel Report on the Evidence-Based Management of Sickle Cell Disease can be challenging to both the clinician and the patient. Utilizing effective communication strategies with patients and their families can improve clinician/patient relationships, as well as adherence to national guidelines. Aims of this overview are to review challenges faced in outpatient subspecialty medicine and describe evidence-based techniques for more effective communication for patients with sickle cell anemia.

Improving the Management of Atrial Fibrillation in General Practice: Protocol for a Mixed Methods Study

BACKGROUND

Atrial fibrillation (AF) is one of the commonest arrhythmias observed in general practice. The thromboembolic complications of AF include transient ischemic attack, stroke, and pulmonary embolism. Early recognition of AF can lead to early intervention with managing the risks of these complications.

OBJECTIVE

The primary aim of this study is to investigate if patients are managed in general practice according to current national guidelines. In addition, the study will evaluate the impact of direct oral anticoagulant use with respect to AF complications in a real-world dataset. The secondary aims of the study are to develop a dashboard that will allow monitoring the management of AF in general practice and evaluate the usability of the dashboard.

METHODS

The study was conducted in 2 phases. The initial phase was a quantitative analysis of routinely collected primary care data from the Oxford Royal College of General Practitioners Research and Surveillance Center (RCGP RSC) sentinel network database. AF cases from 2009 to 2019 were identified. The study investigated the impact of the use of anticoagulants on complications of AF over this time period. We used this dataset to examine how AF was managed in primary care during the last decade. The second phase involved development of an online dashboard for monitoring management of AF in general practice. We conducted a usability evaluation for the dashboard to identify usability issues and performed enhancements to improve usability.

RESULTS

We received funding for both phases in January 2019 and received approval from the RCGP RSC research committee in March 2019. We completed data extraction for phase 1 in May 2019 and completed analysis in December 2019. We completed building the AF dashboard in May 2019. We started recruiting participants for phase 1 in May 2019 and concluded data collection in July 2019. We completed data analysis for phase 2 in October 2019. The results are expected to be published in the second half of 2020. As of October 2020, the publications reporting the results are under review.

CONCLUSIONS

Results of this study will provide an insight into the current trends in management of AF using real-world data from the Oxford RCGP RSC database. We anticipate that the outcomes of this study will be used to guide the development and implementation of an audit-based intervention tool to assist practitioners in identifying and managing AF in primary care.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/21259.

Approaches for combining primary care electronic health record data from multiple sources: a systematic review of observational studies

OBJECTIVE

To identify observational studies which used data from more than one primary care electronic health record (EHR) database, and summarise key characteristics including: objective and rationale for using multiple data sources; methods used to manage, analyse and (where applicable) combine data; and approaches used to assess and report heterogeneity between data sources.

DESIGN

A systematic review of published studies.

DATA SOURCES

Pubmed and Embase databases were searched using list of named primary care EHR databases; supplementary hand searches of reference list of studies were retained after initial screening.

STUDY SELECTION

Observational studies published between January 2000 and May 2018 were selected, which included at least two different primary care EHR databases.

RESULTS

6054 studies were identified from database and hand searches, and 109 were included in the final review, the majority published between 2014 and 2018. Included studies used 38 different primary care EHR data sources. Forty-seven studies (44%) were descriptive or methodological. Of 62 analytical studies, 22 (36%) presented separate results from each database, with no attempt to combine them; 29 (48%) combined individual patient data in a one-stage meta-analysis and 21 (34%) combined estimates from each database using two-stage meta-analysis. Discussion and exploration of heterogeneity was inconsistent across studies.

CONCLUSIONS

Comparing patterns and trends in different populations, or in different primary care EHR databases from the same populations, is important and a common objective for multi-database studies. When combining results from several databases using meta-analysis, provision of separate results from each database is helpful for interpretation. We found that these were often missing, particularly for studies using one-stage approaches, which also often lacked details of any statistical adjustment for heterogeneity and/or clustering. For two-stage meta-analysis, a clear rationale should be provided for choice of fixed effect and/or random effects or other models.

Impacts of Operational Failures on Primary Care Physicians' Work: A Critical Interpretive Synthesis of the Literature

PURPOSE

Operational failures are system-level errors in the supply of information, equipment, and materials to health care personnel. We aimed to review and synthesize the research literature to determine how operational failures in primary care affect the work of primary care physicians.

METHODS

We conducted a critical interpretive synthesis. We searched 7 databases for papers published in English from database inception until October 2017 for primary research of any design that addressed problems interfering with primary care physicians' work. All potentially eligible titles/abstracts were screened by 1 reviewer; 30% were subject to second screening. We conducted an iterative critique, analysis, and synthesis of included studies.

RESULTS

Our search retrieved 8,544 unique citations. Though no paper explicitly referred to "operational failures," we identified 95 papers that conformed to our general definition. The included studies show a gap between what physicians perceived they should be doing and what they were doing, which was strongly linked to operational failures-including those relating to technology, information, and coordination-over which physicians often had limited control. Operational failures actively configured physicians' work by requiring significant compensatory labor to deliver the goals of care. This labor was typically unaccounted for in scheduling or reward systems and had adverse consequences for physician and patient experience.

CONCLUSIONS

Primary care physicians' efforts to compensate for suboptimal work systems are often concealed, risking an incomplete picture of the work they do and problems they routinely face. Future research must identify which operational failures are highest impact and tractable to improvement.

Provider Preference in Exam Room Layout Design and Computing

BACKGROUND

The introduction of the electronic health record (EHR) has had a significant impact on provider-patient interactions, particularly revolving around patient-centeredness. More research is needed to understand the provider perspective of this interaction.

OBJECTIVES

Our objective was to obtain provider feedback on a new exam room design compared with the one already in use with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning. An additional objective was to understand elements of exam room design and computing that were highly valued.

METHODS

Semistructured interviews were conducted with 28 providers from several health care organizations. Interviews were audio recorded and transcribed for analysis. We used an inductive coding approach to abstract recurrent themes from the data.

RESULTS

Our analysis revealed several themes organized around exam room layout, exam room computing, and provider workflow. We report frequency of occurrence of the coded data for computer accessories, computing usefulness, computer mobility, documentation habits, form factor, layout preference, patient interaction, screen sharing, and work habits.

CONCLUSION

Providers in our study preferred exam room design to promote flexibility, mobility, and body orientation directed toward the patient. Providers also expressed the need for exam room design to support varying work habits and preferences, including whether to share the computer screen or not.

Intensification to injectable therapy in type 2 diabetes: mixed methods study (protocol)

BACKGROUND

In the UK, type 2 diabetes mellitus (T2D) is largely managed in primary care. Delay in the intensification to injectable therapy, a form of clinical inertia, is associated with worse glycaemic control. UK general practice is highly computerised, with care being recorded on computerised medical record systems; this allows for quantitative analysis of clinical care but not of the underpinning decision-making process. The aim of this study is to investigate perceptions of patients and clinicians in primary care on the initiation of injectable therapies in T2D, and the context within which those decisions are made.

METHODS

This is a mixed methods study, taking a "realist evaluation" approach. The qualitative components comprise focus groups, interviews, and video recordings of simulated surgeries; the quantitative analysis: an overview of participating practices, elements of the video recording, and an online survey. We will recruit primary care clinicians (general practitioners and nurses) and patients from a representative sample of practices within the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network. Participants will be patients with T2D, and primary care clinicians. Focus groups and semi-structured interviews will be recorded, transcribed verbatim and analysed using Framework Analysis. The simulated surgeries will include cases that might be escalated to injectable therapy. The consultation will be reviewed using the Calgary-Cambridge model to assess communication and determination of adherence to national prescribing guidelines. We will conduct multi-channel video recording including screen capture, clinician and patient facial expressions, wide angle view of the consultation, and the computerised medical record screen. This allows annotation and qualitative analysis of the video recordings, and statistical analyses for the quantitative data. We will also conduct an online survey of primary care clinicians' attitudes to, and perceptions of, initiation of injectable therapies, which will be analysed using summary statistics.

DISCUSSION

Results aim to provide a detailed insight into the dynamic two-way decision-making process underpinning use of injectable therapy for T2D. The study will provide insights into clinical practice and enable the development of training, interventions and guidelines that may facilitate, where appropriate, the intensification to injectable therapy.

Exploring the Effects of Clinical Exam Room Design on Communication, Technology Interaction, and Satisfaction

OBJECTIVE

This article evaluates the effects of technology integration and design features in clinical exam rooms on examination experiences, communication, and satisfaction.

BACKGROUND

Exam room features can affect the delivery of patient-centered care and enhance the level of communication, which has been shown to directly impact clinical outcomes. Although there has been an increasing body of literature examining design and patient-centered care, little research has evaluated the extent to which information sharing and electronic health record (EHR) interaction are impacted.

METHOD

The research randomly allocated 22 patients, 28 caregivers, and 59 clinicians to simulated clinical encounters in four exam room mock-ups with semi-inclusive, exclusive, and inclusive layouts (128 sessions in 32 scenarios). Video recordings of the simulations were coded for clinician gazing, talking, and EHR-interaction behaviors. Participants also completed surveys and answered open-ended questions after experiencing each scenario (N = 362).

RESULTS

Semi-inclusive rooms with a triangular arrangement of consultation table, sharable screens, exam table, and caregiver chair were highly preferred as they supported conversation, gazing, and information sharing. The inclusive layout had higher durations of EHR interactions and enhanced viewing and sharing of EHR information. However, this layout was criticized for the lack of clinician-shared information. The exclusive layouts impeded information sharing, eye contact, and constrained simultaneous data entry and eye contact for clinicians. The distance and orientation between chair, exam table, curtain, and door were important for protecting patient and family comfort and privacy.

CONCLUSION

Characteristics and configurations of design qualities and strategies have a key role on examination experiences, communication, and satisfaction.

Impact of a brief faculty training to improve patient-centered communication while using electronic health records

OBJECTIVE

Despite rapid EHR adoption, few faculty receive training in how to implement patient-centered communication skills while using computers in exam rooms. We piloted a patient-centered EHR use training to address this issue.

METHODS

Faculty received four hours of training at Cleveland Clinic and a condensed 90-minute version at the University of Chicago. Both included a lecture and a Group-Objective Structured Clinical Exam (GOSCE) experience. Direct observations of 10 faculty in their clinical practices were performed pre- and post-workshop.

RESULTS

Thirty participants (94%) completed a post-workshop evaluation assessing knowledge, attitude, and skills. Faculty reported that training was important, relevant, and should be required for all providers; no differences were found between longer versus shorter training. Participants in the longer training reported higher GOSCE efficacy, however shorter workshop participants agreed more with the statement that they had gained new knowledge. Faculty improved their patient-centered EHR use skills in clinical practice on post- versus pre-workshop ratings using a validated direct-observation rating tool.

CONCLUSION

A brief lecture and GOSCE can be effective in training busy faculty on patient-centered EHR use skills.

PRACTICE IMPLICATIONS

Faculty training on patient-centered EHR skills can enhance patient-doctor communication and promotes positive role modeling of these skills to learners.

Incidence and prevalence of cardiovascular disease in English primary care: a cross-sectional and follow-up study of the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC)

OBJECTIVES

To describe incidence and prevalence of cardiovascular disease (CVD), its risk factors, medication prescribed to treat CVD and predictors of CVD within a nationally representative dataset.

DESIGN

Cross-sectional study of adults with and without CVD.

SETTING

The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) is an English primary care sentinel network. RCGP RSC is over 50 years old and one of the oldest in Europe. Practices receive feedback about data quality. This database is primarily used to conduct surveillance and research into influenza, infections and vaccine effectiveness but is also a rich resource for the study of non-communicable disease (NCD). The RCGP RSC network comprised 164 practices at the time of study.

RESULTS

Data were extracted from the records of 1 275 174 adults. Approximately a fifth (21.3%; 95% CI 21.2% to 21.4%) had CVD (myocardial infarction (MI), angina, atrial fibrillation (AF), peripheral arterial disease, stroke/transient ischaemic attack (TIA), congestive cardiac failure) or hypertension. Smoking, unsafe alcohol consumption and obesity were more common among people with CVD. Angiotensin system modulating drugs, 3-hydroxy-3-methylglutaryl-coenzyme (HMG-CoA) reductase inhibitors (statins) and calcium channel blockers were the most commonly prescribed CVD medications. Age-adjusted and gender-adjusted annual incidence for AF was 28.2/10 000 (95% CI 27.8 to 28.7); stroke/TIA 17.1/10 000 (95% CI 16.8 to 17.5) and MI 9.8/10 000 (95% CI 9.5 to 10.0). Logistic regression analyses confirmed established CVD risk factors were associated with CVD in the RCGP RSC network dataset.

CONCLUSIONS

The RCGP RSC database provides comprehensive information on risk factors, medical diagnosis, physiological measurements and prescription history that could be used in CVD research or pharmacoepidemiology. With the exception of MI, the prevalence of CVDs was higher than in other national data, possibly reflecting data quality. RCGP RSC is an underused resource for research into NCDs and their management and welcomes collaborative opportunities.

Estimating the burden on general practitioner services in England from increases in respiratory disease associated with seasonal respiratory pathogen activity

Understanding the burden of respiratory pathogens on health care is key to improving public health emergency response and interventions. In temperate regions, there is a large seasonal rise in influenza and other respiratory pathogens. We have examined the associations between individual pathogens and reported respiratory tract infections to estimate attributable burden. We used multiple linear regression to model the relationship between doctor consultation data and laboratory samples from week 3 2011 until week 37 2015. We fitted separate models for consultation data with in-hours and out-of-hours doctor services, stratified by different age bands. The best fitting all ages models (R2 > 80%) for consultation data resulted in the greatest burden being associated with influenza followed by respiratory syncytial virus (RSV). For models of adult age bands, there were significant associations between consultation data and invasive Streptococcus pneumoniae. There were also smaller numbers of consultations significantly associated with rhinovirus, parainfluenza, and human metapneumovirus. We estimate that a general practice with 10 000 patients would have seen an additional 18 respiratory tract infection consultations per winter week of which six had influenza and four had RSV. Our results are important for the planning of health care services to minimise the impact of winter pressures. •Respiratory pathogen incidence explains over 80% of seasonal variation in respiratory consultation data.•Influenza and RSV are associated with the biggest seasonal rises in respiratory consultation counts.•A third of consultation counts associated with respiratory pathogens were due to influenza.

Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Laboratory Simulation Study

Background

Challenges persist regarding how to integrate computing effectively into the exam room, while maintaining patient-centered care.

Purpose

Our objective was to evaluate a new exam room design with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning.

Methods

In a lab-based experiment, 28 providers used prototypes of the new and older "legacy" outpatient exam room layouts in a within-subject comparison using simulated patient encounters. We measured efficiency, errors, workload, patient-centeredness (proportion of time the provider was focused on the patient), amount of screen sharing with the patient, workflow integration, and provider situation awareness.

Results

There were no statistically significant differences between the exam room layouts for efficiency, errors, or time spent focused on the patient. However, when using the new layout providers spent 75% more time in screen sharing activities with the patient, had 31% lower workload, and gave higher ratings for situation awareness (14%) and workflow integration (17%).

Conclusions

Providers seemed to be unwilling to compromise their focus on the patient when the computer was in a fixed position in the corner of the room and, as a result, experienced greater workload, lower situation awareness, and poorer workflow integration when using the old "legacy" layout. A thoughtful design of the exam room with respect to the computing may positively impact providers' workload, situation awareness, time spent in screen sharing activities, and workflow integration.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care

BACKGROUND

Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication.

OBJECTIVE

This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system.

METHODS

This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as "multitasking EHR use," "silent EHR use," "non-EHR multitasking," and "focused patient-clinician talk." Finally, we analyzed communication patterns to develop a conceptual framework.

RESULTS

We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation.

CONCLUSIONS

Safety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.

Electronic-clinical evaluation exercise (e-CEX): A new patient-centered EHR use tool

INTRODUCTION

Electronic Health Record (EHR) use can enhance or weaken patient-provider communication. Despite EHR adoption, no validated tool exists to assess EHR communication skills. We aimed to develop and validate such a tool.

METHODS

Electronic-Clinical Evaluation Exercise (e-CEX) is a 10-item-tool based on systematic literature review and pilot-testing. Second-year (MS2s) students participated in an EHR-use lecture and structured Clinical Examination (OSCE). Untrained third-year students (MS3s) participated in the same OSCE. OSCEs were scored with e-CEX compared to a standardized patient (SP) tool. Internal consistency, discriminant validity, and concurrent validity were analyzed.

RESULTS

Three investigators used e-CEX to rate 70 videos (20 MS2, 50 MS3). Reliability testing indicated high internal consistency (Cronbach's alpha=0.89). MS2s scored significantly higher than untrained MS3s on e-CEX [e-CEX 55(10.7) vs. 44.9 (12.7), P=0.003], providing evidence of discriminant validity. e-CEX and SP score correlation was high (Pearson correlation=0.74, P<0.001), providing concurrent validity evidence. Item reduction suggested a three-item tool had similar explanatory power (R-squared=0.85 vs 0.86).

CONCLUSION

e-CEX is a reliable, valid tool to assess medical student patient-centered EHR communication skills.

PRACTICE IMPLICATIONS

While validation is needed with other healthcare providers, e-CEX may help improve provider behaviors and enhance patients' overall experience of EHR use in their care.

The Impact of Physician EHR Usage on Patient Satisfaction

Background and Significance

The increased emphasis on patient satisfaction has coincided with the growing adoption of electronic health records (EHRs) throughout the U.S. The 2001 Institute of Medicine Report, “Crossing the Quality Chasm,” identified patient-centered care as a key element of quality health care.[1] In response to this call, the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was developed to assess patients' health care experiences in the inpatient setting. Simultaneously, financial incentives have facilitated the rapid adoption of EHR applications, with 84% of hospitals maintaining at least a basic EHR in 2015 (a ninefold increase since 2008).[2]

Despite the concurrent deployment of patient satisfaction surveys and EHRs, there is a poor understanding of the relationship that may exist between physician usage of the EHR and patient satisfaction. Most prior research into the impact of the EHR on physician–patient communication has been observational, describing the behaviors of physicians and patients when the clinician accesses an EHR in the exam room. Past research has shown that encounters where physicians access the EHR are often filled with long pauses,[3] and that few clinicians attempt to engage patients by sharing what they are looking at on the screen.[4] A recent meta-analysis reviewing 53 papers found that only 7 studies attempted to correlate objective observations of physician communication behaviors with patient perceptions by eliciting feedback from the patients.[5] No study used a standardized assessment tool of patient satisfaction. The authors conclude that additional work is necessary to better understand the patient perspective of the presence of an EHR during a clinical encounter.

Additionally, increasing EHR adoption and emphasis on patient satisfaction have also corresponded with rising physician burnout rates.[6] [7] Prior work suggests that EHR adoption may be contributing to this trend.[8] Burnout from the EHR may be due in part to the significant amount of time physicians spend logged into systems, documenting long after clinic has ended in effort to avoid disrupting the patient–physician relationship.[9]

We used existing data sources to describe the relationship between the amount of time physicians spend logged in to the EHR—both during daytime hours as well after clinic hours—and performance on a validated patient satisfaction survey. Our null hypothesis is that there is no relationship between increased time logged in to the EHR and patient satisfaction.

Time Requirements for Electronic Health Record Use in an Academic Ophthalmology Center

Importance

Electronic health record (EHR) systems have transformed the practice of medicine. However, physicians have raised concerns that EHR time requirements have negatively affected their productivity. Meanwhile, evolving approaches toward physician reimbursement will require additional documentation to measure quality and cost of care. To date, little quantitative analysis has rigorously studied these topics.

Objective

To examine ophthalmologist time requirements for EHR use.

Design, Setting, and Participants

A single-center cohort study was conducted between September 1, 2013, and December 31, 2016, among 27 stable departmental ophthalmologists (defined as attending ophthalmologists who worked at the study institution for ≥6 months before and after the study period). Ophthalmologists who did not have a standard clinical practice or who did not use the EHR were excluded.

Exposures

Time stamps from the medical record and EHR audit log were analyzed to measure the length of time required by ophthalmologists for EHR use. Ophthalmologists underwent manual time-motion observation to measure the length of time spent directly with patients on the following 3 activities: EHR use, conversation, and examination.

Main Outcomes and Measures

The study outcomes were time spent by ophthalmologists directly with patients on EHR use, conversation, and examination as well as total time required by ophthalmologists for EHR use.

Results

Among the 27 ophthalmologists in this study (10 women and 17 men; mean [SD] age, 47.3 [10.7] years [median, 44; range, 34-73 years]) the mean (SD) total ophthalmologist examination time was 11.2 (6.3) minutes per patient, of which 3.0 (1.8) minutes (27% of the examination time) were spent on EHR use, 4.7 (4.2) minutes (42%) on conversation, and 3.5 (2.3) minutes (31%) on examination. Mean (SD) total ophthalmologist time spent using the EHR was 10.8 (5.0) minutes per encounter (range, 5.8-28.6 minutes). The typical ophthalmologist spent 3.7 hours using the EHR for a full day of clinic: 2.1 hours during examinations and 1.6 hours outside the clinic session. Linear mixed effects models showed a positive association between EHR use and billing level and a negative association between EHR use per encounter and clinic volume. Each additional encounter per clinic was associated with a decrease of 1.7 minutes (95% CI, -4.3 to 1.0) of EHR use time per encounter for ophthalmologists with high mean billing levels (adjusted R2 = 0.42; P = .01).

Conclusions and Relevance

Ophthalmologists have limited time with patients during office visits, and EHR use requires a substantial portion of that time. There is variability in EHR use patterns among ophthalmologists.

Using Technology to Enhance Patient-Physician Interactions

The computer is an integral part of a clinical office examination room. How a physician simultaneously uses the computer and interacts with patients will either enhance or deter patient engagement in areas of health maintenance and rehabilitation. With the growing emphasis on patient-centered care and management of chronic health conditions, patient engagement plays an ever-increasing role in U.S. health care. This paper reviews and discusses the 4 broad factors that influence the traditional physician-patient examination room interaction: physician computer/technology skills and dexterity, verbal and nonverbal communication, design and spatial arrangement, and hardware considerations. If used effectively, in-room technology will both enhance patient care and engender a greater degree of patient trust in their provider.

Developing an evidence base of best practices for integrating computerized systems into the exam room: a systematic review

OBJECTIVE

The introduction of health information technology systems, electronic health records in particular, is changing the nature of how clinicians interact with patients. Lack of knowledge remains on how best to integrate such systems in the exam room. The purpose of this systematic review was to (1) distill "best" behavioral and communication practices recommended in the literature for clinicians when interacting with patients in the presence of computerized systems during a clinical encounter, (2) weigh the evidence of each recommendation, and (3) rank evidence-based recommendations for electronic health record communication training initiatives for clinicians.

METHODS

We conducted a literature search of 6 databases, resulting in 52 articles included in the analysis. We extracted information such as study setting, research design, sample, findings, and implications. Recommendations were distilled based on consistent support for behavioral and communication practices across studies.

RESULTS

Eight behavioral and communication practices received strong support of evidence in the literature and included specific aspects of using computerized systems to facilitate conversation and transparency in the exam room, such as spatial (re)organization of the exam room, maintaining nonverbal communication, and specific techniques that integrate the computerized system into the visit and engage the patient. Four practices, although patient-centered, have received insufficient evidence to date.

DISCUSSION AND CONCLUSION

We developed an evidence base of best practices for clinicians to maintain patient-centered communications in the presence of computerized systems in the exam room. Further work includes development and empirical evaluation of evidence-based guidelines to better integrate computerized systems into clinical care.

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

BACKGROUND

While concerns remain regarding Electronic Medical Records (EMR) use impeding doctor-patient communication, resident and faculty patient perspectives post-widespread EMR adoption remain largely unexplored.

OBJECTIVE

We aimed to describe patient perspectives of outpatient resident and faculty EMR use and identify positive and negative EMR use examples to promote optimal utilization.

DESIGN

This was a prospective mixed-methods study.

PARTICIPANTS

Internal medicine faculty and resident patients at the University of Chicago's primary care clinic participated in the study.

APPROACH

In 2013, one year after EMR implementation, telephone interviews were conducted with patients using open-ended and Likert style questions to elicit positive and negative perceptions of EMR use by physicians. Interview transcripts were analyzed qualitatively to develop a coding classification. Satisfaction with physician EMR use was examined using bivariate statistics.

RESULTS

In total, 108 interviews were completed and analyzed. Two major themes were noted: (1) Clinical Functions of EMR and (2) Communication Functions of EMR; as well as six subthemes: (1a) Clinical Care (i.e., clinical efficiency), (1b) Documentation (i.e., proper record keeping and access), (1c) Information Access, (1d) Educational Resource, (2a) Patient Engagement and (2b) Physical Focus (i.e., body positioning). Overall, 85 % (979/1154) of patient perceptions of EMR use were positive, with the majority within the "Clinical Care" subtheme (n = 218). Of negative perceptions, 66 % (115/175) related to the "Communication Functions" theme, and the majority of those related to the "Physical Focus" subtheme (n = 71). The majority of patients (90 %, 95/106) were satisfied with physician EMR use: 59 % (63/107) reported the computer had a positive effect on their relationship and only 7 % (8/108) reported the EMR made it harder to talk with their doctors.

CONCLUSIONS

Despite concerns regarding EMRs impeding doctor-patient communication, patients reported largely positive perceptions of the EMR with many patients reporting high levels of satisfaction. Future work should focus on improving doctors "physical focus" when using the EMR to redirect towards the patient.

Determinants of a successful problem list to support the implementation of the problem-oriented medical record according to recent literature

BACKGROUND

A problem-oriented approach is one of the possibilities to organize a medical record. The problem-oriented medical record (POMR) - a structured organization of patient information per presented medical problem- was introduced at the end of the sixties by Dr. Lawrence Weed to aid dealing with the multiplicity of patient problems. The problem list as a precondition is the centerpiece of the problem-oriented medical record (POMR) also called problem-oriented record (POR). Prior to the digital era, paper records presented a flat list of medical problems to the healthcare professional without the features that are possible with current technology. In modern EHRs a POMR based on a structured problem list can be used for clinical decision support, registries, order management, population health, and potentially other innovative functionality in the future, thereby providing a new incentive to the implementation and use of the POMR.

METHODS

On both 12 May 2014 and 1 June 2015 a systematic literature search was conducted. From the retrieved articles statements regarding the POMR and related to successful or non-successful implementation, were categorized. Generic determinants were extracted from these statements.

RESULTS

In this research 38 articles were included. The literature analysis led to 12 generic determinants: clinical practice/reasoning, complete and accurate problem list, data structure/content, efficiency, functionality, interoperability, multi-disciplinary, overview of patient information, quality of care, system support, training of staff, and usability.

CONCLUSIONS

Two main subjects can be distinguished in the determinants: the system that the problem list and POMR is integrated in and the organization using that system. The combination of the two requires a sociotechnical approach and both are equally important for successful implementation of a POMR. All the determinants have to be taken into account, but the weight given to each of the determinants depends on the organizationusing the problem list or POMR.

Does sharing the electronic health record in the consultation enhance patient involvement? A mixed-methods study using multichannel video recording and in-depth interviews in primary care

BACKGROUND

Sharing the electronic health-care record (EHR) during consultations has the potential to facilitate patient involvement in their health care, but research about this practice is limited.

METHODS

We used multichannel video recordings to identify examples and examine the practice of screen-sharing within 114 primary care consultations. A subset of 16 consultations was viewed by the general practitioner and/or patient in 26 reflexive interviews. Screen-sharing emerged as a significant theme and was explored further in seven additional patient interviews. Final analysis involved refining themes from interviews and observation of videos to understand how screen-sharing occurred, and its significance to patients and professionals.

RESULTS

Eighteen (16%) of 114 videoed consultations involved instances of screen-sharing. Screen-sharing occurred in six of the subset of 16 consultations with interviews and was a significant theme in 19 of 26 interviews. The screen was shared in three ways: 'convincing' the patient of a diagnosis or treatment; 'translating' between medical and lay understandings of disease/medication; and by patients 'verifying' the accuracy of the EHR. However, patients and most GPs perceived the screen as the doctor's domain, not to be routinely viewed by the patient.

CONCLUSIONS

Screen-sharing can facilitate patient involvement in the consultation, depending on the way in which sharing comes about, but the perception that the record belongs to the doctor is a barrier. To exploit the potential of sharing the screen to promote patient involvement, there is a need to reconceptualise and redesign the EHR.

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

BACKGROUND

While Electronic Medical Record (EMR) use has increased dramatically, the EMR's impact on the patient-doctor relationship remains unclear. This systematic literature review sought to understand the impact of EMR use on patient-doctor relationships and communication.

METHODS

Parallel searches in Ovid MEDLINE, PubMed, Scopus, PsycINFO, Cochrane Library, reference review of prior systematic reviews, meeting abstract reviews, and expert reviews from August 2013 to March 2015 were conducted. Medical Subject Heading terms related to EMR use were combined with keyword terms identifying face-to-face patient-doctor communication. English language observational or interventional studies (1995-2015) were included. Studies examining physician attitudes only were excluded. Structured data extraction compared study population, design, data collection method, and outcomes.

RESULTS

Fifty-three of 7445 studies reviewed met inclusion criteria. Included studies used behavioral analysis (28) to objectively measure communication behaviors using video or direct observation and pre-post or cross-sectional surveys to examine patient perceptions (25). Objective studies reported EMR communication behaviors that were both potentially negative (i.e., interrupted speech, low rates of screen sharing) and positive (i.e., facilitating questions). Studies examining overall patient perceptions of satisfaction, communication or the patient-doctor relationship (n = 22) reported no change with EMR use (16); a positive impact (5) or showed mixed results (1). Study quality was not assessable. Small sample sizes limited generalizability. Publication bias may limit findings.

DISCUSSION

Despite objective evidence that EMR use may negatively impact patient-doctor communication, studies examining patient perceptions found no change in patient satisfaction or patient-doctor communication. Therefore, our findings should encourage providers to adopt the EMR as a communication tool. Future research is needed to better understand how to enhance patient-doctor- EMR communication. This research should correlate observed physician behavior to patient satisfaction, focus on physician communication skills training, and explore inpatient experiences.

Computers in the clinical encounter: a scoping review and thematic analysis

OBJECTIVE

Patient-clinician communication has been associated with increased patient satisfaction, trust in the clinician, adherence to prescribed therapy, and various health outcomes. The impact of health information technology (HIT) on the clinical encounter in general and patient-clinician communication in particular is a growing concern. The purpose of this study was to review the current literature on HIT use during the clinical encounter to update best practices and inform the continuous development of HIT policies and educational interventions.

METHODS

We conducted a literature search of four databases. After removing duplicates, reviewing titles and abstracts, performing a full-text review, and snowballing from references and citations, 51 articles were included in the analysis. We employed a qualitative thematic analysis to compare and contrast the findings across studies.

RESULTS

Our analysis revealed that the use of HIT affects consultations in complex ways, impacting eye contact and gaze, information sharing, building relationships, and pauses in the conversation. Whether these impacts are positive or negative largely depends on the combination of consultation room layout, patient and clinician styles of interaction with HIT as well as each other, and the strategies and techniques employed by clinicians to integrate HIT into consultations.

DISCUSSION

The in-depth insights into the impact of HIT on the clinical encounter, especially the strategies and techniques employed by clinicians to adapt to using HIT in consultations, can inform policies, educational interventions, and research.

CONCLUSION

In contrast to the common negative views of HIT, it affects the clinical encounter in multiple ways. By applying identified strategies and best practices, HIT can support patient-clinician interactions rather than interfering with them.

Designing Patient-facing Health Information Technologies for the Outpatient Settings: A Literature Review

Introduction

The implementation of health information technologies (HITs) has changed the dynamics of doctor–patient communication in outpatient settings. Designing patient-facing HITs provides patients with easy access to healthcare information during the visit and has the potential to enhance the patient-centred care.

Objectives

The objectives of this study are to systematically review how the designs of patient-facing HITs have been suggested and evaluated, and how they may potentially affect the doctor–patient communication and patient-centred care.

Method

We conducted an online database search to identify articles published before December 2014 relevant to the objectives of this study. A total of nine papers have been identified and reviewed in this study.

Results

Designing patient-facing HITs is at an early stage. The current literature has been exploring the impact of HITs on doctor–patient communication dynamics. Based on the findings of these studies, there is an emergent need to design more patient-centred HITs. There are also some papers that focus on the usability evaluation of some preliminary prototypes of the patient-facing HITs. The design styles of patient-facing HITs included sharing the health information with the patients on: (1) a separate patient display, (2) a projector, (3) a portable tablet, (4) a touch-based screen and (5) a shared computer display that can be viewed by both doctors and patients. Each of them had the strengths and limitations to facilitate the patient-centred care, and it is worthwhile to make a comparison of them in order to identify future research directions.

Conclusion

The designs of patient-facing HITs in outpatient settings are promising in facilitating the doctor-patient communication and patient engagement. However, their effectiveness and usefulness need to be further evaluated and improved from a systems perspective.

Using video-based observation research methods in primary care health encounters to evaluate complex interactions

OBJECTIVE

The purpose of this paper is to describe the use of video-based observation research methods in primary care environment and highlight important methodological considerations and provide practical guidance for primary care and human factors researchers conducting video studies to understand patient-clinician interaction in primary care settings.

METHODS

We reviewed studies in the literature which used video methods in health care research, and we also used our own experience based on the video studies we conducted in primary care settings.

RESULTS

This paper highlighted the benefits of using video techniques, such as multi-channel recording and video coding, and compared "unmanned" video recording with the traditional observation method in primary care research. We proposed a list that can be followed step by step to conduct an effective video study in a primary care setting for a given problem. This paper also described obstacles, researchers should anticipate when using video recording methods in future studies.

CONCLUSION

With the new technological improvements, video-based observation research is becoming a promising method in primary care and HFE research. Video recording has been under-utilised as a data collection tool because of confidentiality and privacy issues. However, it has many benefits as opposed to traditional observations, and recent studies using video recording methods have introduced new research areas and approaches.

Computer use in primary care and patient-physician communication

OBJECTIVES

This study evaluated how physicians and patients perceive the impact of computer use on clinical communication, and how a patient-centered orientation can influence this impact.

METHODS

The study followed a descriptive cross-sectional design and included 106 family physicians and 392 patients. An original questionnaire assessed computer use, participants' perspective of its impact, and patient centered strategies.

RESULTS

Physicians reported spending 42% of consultation time in contact with the computer. A negative impact of computer in patient-physician communication regarding the consultation length, confidentiality, maintaining eye contact, active listening to the patient, and ability to understand the patient was reported by physicians, while patients reported a positive effect for all the items. Physicians considered that the usual computer placement in their consultation room was significantly unfavorable to patient-physician communication.

CONCLUSIONS

Physicians perceive the impact of computer use on patient-physician communication as negative, while patients have a positive perception of computer use on patient-physician communication.

PRACTICE IMPLICATIONS

Consultation support can represent a challenge to physicians who recognize its negative impact in patient centered orientation. Medical education programs aiming to enhance specific communication skills and to better integrate computer use in primary care settings are needed.

Work system factors influencing physicians' screen sharing behaviors in primary care encounters

OBJECTIVE

While the use of electronic health records (EHRs) in primary care has increased dramatically, its potential benefits need to be considered in light of potential negative impacts on physician-patient interactions and the increase in physician cognitive workload. This study aims to understand work system factors contributing to physicians' use of the EHR as a communication tool during primary-care encounters.

METHODS

We interviewed 14 primary care physicians on their use of EHRs as a communication tool in patient visits. A qualitative content analysis guided by the work system model identified factors influencing physicians' decisions to share or not share the computer screen with their patients.

RESULTS

The analysis revealed 26 factors that influenced physicians' decisions to share the screen, most related to the "task" (reviewing lab records), "tools and technology" (using algorithm calculators for risk prediction), or "individual" (patient interest) elements of the work system. The analysis revealed 15 factors that influenced physicians' decisions not to share the screen, most related to the "individual" (patient's acute pain), "organization" (insufficient time), or "task" (documenting embarrassing information) elements of the work system.

CONCLUSION

Eleven physicians made individual decisions to share or not to share the screen in a particular visit based on work-system related factors. Three doctors always shared the screen, based on the idea that it is polite and builds trust. However, several physicians also reported that it was time consuming and caused unnecessary distractions. Understanding these factors is essential to effective EHR redesign and training for improving physician-patient communication.

How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care

OBJECTIVE

Use of electronic health records (EHRs) in primary-care exam rooms changes the dynamics of patient-physician interaction. This study examines and compares doctor-patient non-verbal communication (eye-gaze patterns) during primary care encounters for three different screen/information sharing groups: (1) active information sharing, (2) passive information sharing, and (3) technology withdrawal.

METHODS

Researchers video recorded 100 primary-care visits and coded the direction and duration of doctor and patient gaze. Descriptive statistics compared the length of gaze patterns as a percentage of visit length. Lag sequential analysis determined whether physician eye-gaze influenced patient eye gaze, and vice versa, and examined variations across groups.

RESULTS

Significant differences were found in duration of gaze across groups. Lag sequential analysis found significant associations between several gaze patterns. Some, such as DGP-PGD ("doctor gaze patient" followed by "patient gaze doctor") were significant for all groups. Others, such DGT-PGU ("doctor gaze technology" followed by "patient gaze unknown") were unique to one group.

CONCLUSION

Some technology use styles (active information sharing) seem to create more patient engagement, while others (passive information sharing) lead to patient disengagement.

PRACTICE IMPLICATIONS

Doctors can engage patients in communication by using EHRs in the visits. EHR training and design should facilitate this.

Effects of Revised Consultation Room Design on Patient–Physician Communication

Objective:

To evaluate the impact of a revised consultation room design on patient–physician interaction in an outpatient setting.

Background:

The growth of ambulatory medical care makes outpatient facilities the primary point of health care contact for many Americans. However, the outpatient consultation room design remains largely unchanged, despite its increased use and the adoption of technology-mediated information sharing in clinical encounter.

Methods:

A randomized controlled trial used a postvisit questionnaire to assess six domains of interest (satisfaction with the visit and the consultation room, mutual respect, patient trust in the physician, communication quality, people–room interaction, and interpersonal–room interaction) in two different room designs (a traditional room and an experimental room in which a pedestal table had replaced the examination table).

Results:

Interpersonal–room interaction was enhanced in the experimental consultation room when compared to the traditional consultation room ( p = .0038). Participants in the experimental consultation room had better access to the computer screen, increased provider information sharing, and more time engaging providers in conversation about information on the monitor.

Conclusions:

Changing the layout of a consultation room has the potential to improve interpersonal communication through better information sharing. Clinicians who are interested in maximizing the benefits of their clinical encounter should consider changing the layout of their consultation room, especially the positioning of the computer screen.

More screen time, less face time - implications for EHR design

RATIONALE, AIMS AND OBJECTIVES

Understanding the impact of health information technology on doctor-patient interaction is vital to designing better electronic health records (EHRs). This article quantitatively examines and compares clinically experienced physicians' interactions with patients using paper or EHRs in ambulatory primary care settings.

METHODS

Clinical encounters using paper or EHRs were recorded with high-resolution video cameras to capture physicians' interactions with the health records and patients. All videos were coded using quantified video coding methodology to understand how physicians interacted with EHRs and patients through measuring eye gaze durations. Statistical analysis was conducted to compare the results of the paper and EHR visits.

RESULTS

Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits, 40 with paper and 40 with EHRs were recorded. The proportion of time physicians spent gazing at medical records during EHR visits was significantly more than in paper chart visits (35.2 versus 22.1%, P = 0.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared with when using a paper chart (52.6 versus 45.6%, P = 0.041).

CONCLUSIONS

For this group of family medicine physicians, more time was spent looking at the EHR screen than paper records and a little less time looking at the patient. These findings may negatively affect the patient perception of the visit with the physician and have implications for the design of future EHRs.

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

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.

Displays of authority in the clinical consultation: a linguistic ethnographic study of the electronic patient record

The introduction of computers into general practice settings has profoundly changed the dynamics of the clinical consultation. Previous research exploring the impact of the computer (in what has been termed the 'triadic' consultation) has shown that computer use and communication between doctor and patient are intricately coordinated and inseparable. Swinglehurst et al. have recently been critical of the ongoing tendency within health communication research to focus on 'the computer' as a relatively simple 'black box', or as a material presence in the consultation. By re-focussing on the electronic patient record (EPR) and conceptualising this as a complex collection of silent but consequential voices, they have opened up new and more nuanced possibilities for analysis. This orientation makes visible a tension between the immediate contingencies of the interaction as it unfolds moment-by-moment and the more standardised, institutional demands which are embedded in the EPR ('dilemma of attention'). In this paper I extend this work, presenting an in-depth examination of how participants in the consultation manage this tension. I used linguistic ethnographic methods to study 54 video recorded consultations from a dataset collected between 2007 and 2008 in two UK general practices, combining microanalysis of the consultation with ethnographic attention to the wider organisational and institutional context. My analysis draws on the theoretical work of Erving Goffman and Mikhail Bakhtin, incorporating attention to the 'here and now' of the interaction as well as an appreciation of the 'distributed' nature of the EPR, its role in hosting and circulating new voices, and in mediating participants' talk and social practices. It reveals - in apparently fleeting moments of negotiation and contestation - the extent to which the EPR shapes the dynamic construction, display and circulation of authority in the contemporary consultation.

The computerized medical record as a tool for clinical governance in Australian primary care

Background

Computerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence.

Objective

The objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance.

Methods

We conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures.

Results

The lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized.

Conclusions

The current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels.

Informatics as tool for quality improvement: rapid implementation of guidance for the management of chronic kidney disease in England as an exemplar

Objectives

Chronic kidney disease (CKD) is an important cause of excess cardiovascular mortality and morbidity; as well as being associated with progression to end stage renal disease. This condition was largely unheard of in English primary care prior to the introduction of pay-for-performance targets for management in 2006. A realist review of how informatics has been a mechanism for national implementation of guidance for the improved management of CKD.

Methods

Realist review of context, the English National Health Service with a drive to implement explicit national quality standards; mechanism, the informatics infrastructure and its alignment with policy objectives; and outcomes are describe at the micro-data and messaging, meso-patient care and quality improvement initiatives, and marco-national policy levels.

Results

At the micro-level computerised medical records can be used to reliably identify people with CKD; though differences in creatinine assays, fluctuation in renal function, and errors in diabetes coding were less well understood. At the meso-level more aggressive management of blood pressure (BP) in individual patients appears to slow or reverse decline in renal function; technology can support case finding and quality improvement at the general practice level. At the macro-level informaticians can help ensure that leverage from informatics is incorporated in policy, and ecological investigations inform if there is any association with improved health outcomes.

Conclusions

In the right policy context informatics appears to be an enabler of rapid quality improvement. However, a causal relationship or generalisability of these findings has not been demonstrated.

Talking with the alien: interaction with computers in the GP consultation

This study examines New Zealand GPs’ interaction with computers in routine consultations. Twenty-eight video-recorded consultations from 10 GPs were analysed in micro-detail to explore: (i) how doctors divide their time and attention between computer and patient; (ii) the different roles ascribed to the computer; and (iii) how computer use influences the interactional flow of the consultation. All GPs engaged with the computer in some way for at least 20% of each consultation, and on average spent 12% of time totally focussed on the computer. Patterns of use varied; most GPs inputted all or most notes during the consultation, but a few set aside dedicated time afterwards. The computer acted as an additional participant enacting roles like information repository and legitimiser of decisions. Computer use also altered some of the normal ‘rules of engagement’ between doctor and patient. Long silences and turning away interrupted the smooth flow of conversation, but various ‘multitasking’ strategies allowed GPs to remain engaged with patients during episodes of computer use (e.g. signposting, online commentary, verbalising while typing, social chat). Conclusions were that use of computers has many benefits but also significantly influences the fine detail of the GP consultation. Doctors must consciously develop strategies to manage this impact.