View source for Effects of exam-room computing on clinician-patient communication: a longitudinal qualitative study

== Exam-Room Computing is Challenge but also Opportunity for Physician-Patient Communication==


Frankel R, et al.  Effects of Exam-Room Computing on Clinician-Patient Communication, A Longitudinal Qualitative Study.  J Gen Intern Med. 2005; 20:677-682.

==Question==

What is the impact of exam room computers on quality of communication between clinicians and patients?

==Design==

Longitudinal, qualitative study, using videotapes of clinician patient encounters before and after introduction of exam room computers.

==Setting==

Primary care clinic in an integrated care system.

==Participants==

Nine clinicians (6 physicians, 2 physician assistants, 1 nurse practitioner), and 54 patients (average age 53, 70% female, 85% white).

==Intervention==

Video recordings of patient encounters were obtained before, 1 and 7 months following introduction of computers to exam rooms.  The clinicians were experienced in using the electronic medical record by out of the room computer access for some time prior to the study.

==Main Outcome Measures==

Video recordings of encounters were evaluated by two medical sociologist reviewers using a model (Four Habits Communication Model) for optimal communication.  Because attention to patient is known to affect care outcomes, a focus of the study was on whether presence of the computer enhanced or interfered with attention.  Attention was assessed by evaluating verbal content (maintaining conversation while using the computer), visual content (eye contact at least every 15sec), and positioning (clinician’s physical orientation away from or toward the patient).  At least 2 encounters were analyzed for each clinician, for each time period, and analysis was based on these scores and field notes.

==Main Results==

Four domains are identified for which exam room computing appears to affect clinician-patient communication: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the room.  
Clinicians who demonstrated effective communication skills before introduction appeared to use the computer to advantage, in better accomplishing key communication tasks- organizing the visit, and maintaining verbal and visual attention.  Clinicians who were initially less skilled appeared to have increased difficulty with these tasks.  Computer mastery- navigation and use of content, enhanced communication attributes of the visit.  Spatial configuration of the room- positioning of the computer was not a barrier in itself but created significant challenges to effective communication.  Orientation that allowed visual contact with the patient, and allowed the clinician to visually share health record content with patients was more effective.

==Conclusions==

Computers introduced to the exam room, are used by clinicians with effective baseline communication skills to enhance patient experience.  Clinicians who are less proficient in communication skills are challenged by using computers in the exam room.  

==Commentary==

Effective clinical communication improves outcomes, patient satisfaction, and adherence and also reduces malpractice risk based on a growing body of evidence.
  
The exam room experience has changed with the introduction of computers- a third entity imposed on the traditional clinician-patient relationship.  Computers present much more clinical information, and more tasks to complete.  Human factors experts are describing “cognitive overload”.  Attention to the patient, fundamental to the therapeutic relationship, can suffer. 

Frankel finds, however, that many effective clinicians with baseline sound communication skills, use exam room computers to leverage patient experience in a positive way.  However, some clinicians are flustered and distracted losing track of the patient.  Attention is misdirected.

Another study, finds that time spent in a state of computer “gaze” is inversely proportional to physician-patient engagement.  The authors propose an intriguing strategy.  They note that “collaborative reading” of information displayed is a way to “enhance decision-making process, and empower patients to participate in their own care.” 

Clinician attitudes and basic communication skills predict effectiveness.  Effective clinician communicators use the computer as a tool to inform and teach patients. Proficient computer navigation skills and optimal computer placement in the exam room help. 

Our expectation is that the electronic health record will help to improve health outcomes.  To reach the full potential of new information technologies, we must be cognizant of how computers impact the exam room experience of not only clinicians but also patients.  While we need to understand more about how information technology is changing health care, exam room computers need not be seen as obstacle, but rather opportunity to enhance patient-centered and relationship-centered care. 

John Butler, MD, FACP 


References:

Frankel RM The Four Habits Approach to Effective Clinical Communication.  Oakland, CA; Kaiser Permanente; 2003.
Margalit RS, Electronic medical record use and physician-patient communication.  Patient Educ Couns. 2006 Apr;61(1):134-41

[[Category: BMI-512-F-07]]