Research Paper j
Health Information Technology and Physician-Patient
Interactions: Impact of Computers on Communication
during Outpatient Primary Care Visits
JOHN HSU, MD, MBA, MSCE, JIE HUANG, PHD, VICKI FUNG, NAN ROBERTSON, RPH,
HOLLY JIMISON, PHD, RICHARD FRANKEL, PHD
A b s t r a c t
technology (HIT) on physician-patient interactions during outpatient visits.
Objective: The aim of this study was to evaluate the impact of introducing health information
Design: This was a longitudinal pre-post study: two months before and one and seven months after introduction of
examination room computers. Patient questionnaires (n = 313) after primary care visits with physicians (n = 8) within
an integrated delivery system. There were three patient satisfaction domains: (1) satisfaction with visit components, (2)
comprehension of the visit, and (3) perceptions of the physician’s use of the computer.
Results: Patients reported that physicians used computers in 82.3% of visits. Compared with baseline, overall patient
satisfaction with visits increased seven months after the introduction of computers (odds ratio [OR] = 1.50; 95%
confidence interval [CI]: 1.01–2.22), as did satisfaction with physicians’ familiarity with patients (OR = 1.60, 95% CI:
1.01–2.52), communication about medical issues (OR = 1.61; 95% CI: 1.05–2.47), and comprehension of decisions made
during the visit (OR = 1.63; 95% CI: 1.06–2.50). In contrast, there were no significant changes in patient satisfaction with
comprehension of self-care responsibilities, communication about psychosocial issues, or available visit time. Seven
months post-introduction, patients were more likely to report that the computer helped the visit run in a more timely
manner (OR = 1.76; 95% CI: 1.28–2.42) compared with the first month after introduction. There were no other
significant changes in patient perceptions of the computer use over time.
Conclusion: The examination room computers appeared to have positive effects on physician-patient interactions
related to medical communication without significant negative effects on other areas such as time available for patient
concerns. Further study is needed to better understand HIT use during outpatient visits.
j J Am Med Inform Assoc. 2005;12:474–480. DOI 10.1197/jamia.M1741.
Innovations in health information technology (HIT) have
great potential for improving the practice of medicine; their
use is encouraged by groups including national governments,
the Institute of Medicine (IOM), and purchaser coalitions.1–6
In particular, computers at the point of care, e.g., in the exam-
ination room, provide physicians with real-time access to
resources such as an electronic health record, clinical decision
support tools, and order entry systems during the medical
visit. As examination room computing becomes more popu-
lar, it is important to understand the effects of HITon commu-
nication and the patient-physician relationship.
Some studies suggest thatHITcan improvethequality and ef-
ficiency of care delivery through better decision support.7
Documented benefits include greater adherence to preven-
tive careguidelines,reductionsin inpatient medication errors,
and reductions in the cost of care.8–10Other studies have
found that new technology can have unintended consequen-
ces, such as increased medication order errors or increased
physician time investments.11–16There is limited information
on how computer use affects interactions between physicians
and patients.17Previous studies have had limited ability to
differentiate between changes in physician-patient communi-
cation related to physicians initially learning how to use the
computer system and changes related to physicians integrat-
ing computer use into their clinical workflow.
In theory, greater and faster information availability could al-
low physicians more time to thoroughly explain diagnoses
Affiliations of the authors: Kaiser Permanente Medical Care Pro-
gram, Division of Research, Oakland, CA (JHs, JHu, VF); The
Robertson Group, Lake Oswego, OR (NR); Department of Medical
Informatics and Clinical Epidemiology, Oregon Health & Science
University, Portland, OR (HJ); Regenstrief Institute, Indiana Univer-
sity School of Medicine, Indianapolis, IN (RF).
Supported by the Garfield Memorial Fund. Neither the funding
agency nor the health system had any role in the analysis,
interpretation, writing of this report, or decision to submit this
manuscript for publication.
The authors thank all the participants of this study, especially the
clinicians, staff, and patients at the medical office building where
the study was conducted. They also thank Kathy Poteraj, James
Kinsman, Mary Reed, Alison Truman, and all the research assistants,
without whose assistance this study would not have been possible.
Correspondence and reprints: John Hsu, MD, MBA, MSCE, Physi-
cian Scientist, 2000 Broadway, 3rd Floor, Oakland, CA 94612; e-mail:
Received for publication: 11/12/04; accepted for publication:
HSU ET AL., Computers in Outpatient Visits
and treatments or address patient concerns. Greater access to
information about previous care, medication prescriptions,
more productive discussions about medical issues. At the
same time, there might be unintended consequences of exam-
tion away from face-to-face engagement with the patient and
chosocial concerns.18–20Time spent navigating the computer
system, searching for information, and documenting visit ac-
tivities also could leave less time for patient needs, especially
given the limited time available for ambulatory visits.21–23
As with most change processes, potential adverse effects
might be particularly prominent in the period shortly after
We conducted a longitudinal quantitative study to investigate
how the use of computers in ambulatory primary care visits
affected physician-patient interactions. Using the longitudi-
nal experience of eight primary care physicians (PCPs), we
evaluated patient satisfaction with regularly scheduled visits
at three points in time: two months before and one and seven
months after the introduction of examination room com-
puters. We addressed three questions: (1) How did examina-
tion room computing affect patient satisfaction with various
components of the visit, such as time spent on patient con-
cerns? (2) How did examination room computing affect pa-
tient comprehension of the visit, such as understanding
diagnoses or postvisit needs? (3) How did patient perceptions
of the computer use change over time? We hypothesized that
patient satisfaction with communication about medical infor-
mation would increase after the introduction of the computer
and that the increased emphasis on medical issues would de-
crease time available for patient concerns. We also hypothe-
sized that patients would have greater comprehension of
the visit and their postvisit needs after the introduction of
the computer. Finally, we hypothesized that patient percep-
tions of computer use would improve significantly during
the initial seven months after the computer introduction.
We conducted the study in one freestanding medical office
building of Kaiser Permanente-Northwest, a prepaid, inte-
grated delivery system (IDS) in the greater Portland, OR, met-
Examination Room Computing
Although examination room computing was new to the
study site, PCPs in the four clinics had had access to a com-
mercially available electronic health record and order entry
system since 1994. The HIT, developed by Epic Systems,
was located in their personal offices but not in the examina-
tion room. Before the study, PCPs received basic training in
how to use the system, and regularly had to use the com-
puters to enter their progress notes as well as order medica-
tions or laboratory tests. All the physicians regularly used
the computer system to document visits and enter orders
but did not have the computers available in the examination
room before the study; this study site was deliberately se-
lected to permit evaluation of the introduction of examination
room computers on physician-patient interactions separate
from effects associated with learning how to use the system.
In August 2001, the IDS introduced the computer-based sys-
tem into all the examination rooms of the four clinics. The sys-
tem hardware consisted of a flat panel computer screen on an
adjustable, multidirectional arm, a keyboard and mouse, and
a wall-mounted central processing unit (CPU). The spatial re-
lationship between the computer CPU and monitor, the ex-
amination table, and the physician’s chair varied in each
examination room,depending in largepart on the room’s pre-
existing architecture. All physicians in the practice used the
same examination rooms when seeing their patients; there
were no systematic changes in examination room assign-
ments after examination room computers were introduced.
Between the second and third observation periods, PCPs re-
ceived training in how to integrate computers into the visit.
The two-hour on-site workshop involved a didactic lecture
on using the computer in an outpatient visit, group assess-
ment of a videotape of an artificial visit, and a role-playing
session. The workshop covered communication topics such
as making a connection with the patient, making decisions
collaboratively, establishing closure for the visit, and express-
ing empathy for the patient. All physicians in the study com-
pleted the training. In addition to the workshop, on-site
technical support was available during all clinic hours from
two part-time HIT staff persons (equal to one 100% full-time
Population and Study Design
Working with leadership of the clinic and the HIT implemen-
tation team, we designed a three-period longitudinal study
beginning with a baseline period (two months) before the in-
troduction of examination room computers (P1) and two sub-
sequent points: one month after (P2) and seven months after
(P3) their introduction. We recruited PCP volunteers from the
four clinics in the IDS. Eligible PCPs included physicians
trained in internal medicine and family practice who pro-
vided primary care to a regular panel of adult IDS members.
Eligible patient subjects included all regularly scheduled IDS
members for the PCP. We obtained written consent from all
patients, accompanying family members, staff, and physi-
cians involved in the study. The Kaiser Foundation Research
Institute Institutional Review Board approved the study.
During the study period between June 2001 and April 2002,
there were 17 PCPs trained in internal medicine and family
practice who provided care in four clinics at the study site.
Of these 17 PCPs, eight agreed to participate in the study.
Among patients, the overall participation rate among eligible
subjects was 80%.
During one to two days per physician per observation period,
research assistants approached all patients in each physician’s
waiting room.We excluded patients receiving a gynecological
examination during the visit. For each consenting patient, we
administered pre- and postvisit patient questionnaires, video-
taped physician-patient interactions, and videotaped the
computer screen. For the videotapes, we mounted one digital
video camcorder from the examination room ceiling corner;
we used a second camcorder to capture the video feed be-
tween the computer and the computer monitor. In this article,
we report only on findings from the questionnaires.
In our effort to minimize any intrusions on the medical visit,
research assistants performed all the equipment setup, tape
Journal of the American Medical Informatics AssociationVolume 12Number 4Jul / Aug 2005
changes, and clean up. Physicians, staff, and patients were
not responsible for any part of the data collection. The cam-
eras were minimally intrusive; a small red light indicated
that the camera was recording. Noise from the cameras was
negligible. Physicians, staff, and patients could either cover
the camera lens using a special lens net or turn off the camera
using a remote control at any point during the encounter.
We pretested the written self-administered questionnaire to
assess its general clarity and comprehensibility.Afterconsent-
ing to the study and before seeing the physician, subjects
completed a one-page previsit questionnaire. Immediately af-
ter their visit, subjects completed a postvisit questionnaire,
which assessed satisfaction with the visit, comprehension of
diagnosis and treatment plan, satisfaction with examination
room computer use, and sociodemographic characteristics.
Subjects who were unable to fill out the questionnaire on
site had the option of returning it by mail or completing it
via telephone interview. Questionnaires were deliberately
anonymous to encourage patient participation and candor.
Outcome Variables: Visit Satisfaction
Using items based in part on the Medical Outcomes Study,24
the survey questions addressed patient satisfaction with three
visit-related domains: (1) visit components, e.g., overall visit
satisfaction, PCP’s familiarity with the patient, communica-
tion about medical issues, communication about psychosocial
issues, and time spent on patient concerns; (2) comprehension
of thevisit, e.g., understanding visit activities, such as diagno-
sis or treatment plans and determinations, and postvisit self-
careneeds, such as potential side effectsorcomplications; and
(3) examination room computing, e.g., impact of computer
use on comprehension and personalization of care, visit ef-
ficiency and flow, and overall satisfaction with computer
use (Table 1 for additional details on the wording of each
item).24,25Rather than create summary scores for each group
of satisfaction measures (e.g., satisfaction with visit compo-
nents or satisfaction with psychosocial communication), we
present all scores individually to allow readers to interpret
each item (Table 1). Responses were based on a six-point
Likert scale, which ranged from 1 (excellent) to 6 (very
poor), with an additional option of N/A (not applicable).
The unit of analysis was the patient visit. We first compared
characteristics of subjects in P2 and P3 with P1; then we eval-
uated all the satisfaction item responses in P2 and P3 with P1
of examination room computing on satisfaction levels using
three different coding schemes for the outcome variables: (1)
dichotomous, wherein responses of ‘‘excellent’’ were com-
pared with all other responses; (2) a six-level categorical vari-
(very good), and 3 (good, fair, poor, and very poor). We col-
lapsed the last category due to the few responses in the lowest
four levels. We excluded N/A responses and missing values;
however, we repeated analyses coding both or either value as
either high or low satisfaction. Overall, the findings were ro-
bust across all approaches. In this article (Tables 1 and 2), we
present the unadjusted percentage of ‘‘excellent’’ responses,
i.e., the number of subjects who had excellent satisfaction on
each item, and the model results that treated the outcomes
as a three-level ordered categorical variable.
In the multivariate logistic and ordinal logistic regression
models, we included all the patient demographic characteris-
tics, i.e., age, gender, self-reported health status, race/ethnic-
ity, annual household income, education, and whether the
patient had previously seen the PCP. We also examined the
contribution of physician characteristics to patient satisfac-
tion in bivariate analyses but excluded them from the multi-
variate models. Instead, we adjusted for potential clustering
of patient responses by PCP through a generalized estimating
equation (GEE) approach (PROC GENMOD procedure with
REPEATED option in SAS 8.2). We present the data without
any specific adjustments for multiple comparisons to allow
readers to make their own inferences about the appropriate
confidence intervals (CIs).26In the text, we also focus on the
comparison between P3 (seven months after introduction)
and P1 (baseline), although the tables show both P2 vs. P1
and P3 vs. P1 comparisons.
Eight PCPs and 313 patients participated in the study: 107 pa-
tients in the precomputer baseline period (P1), 81 in the first
month after the computer introduction (P2), and 125 in the
seventh month after the computer introduction (P3). Table 3
displays the characteristics of the patient subjects. The mean
age was 55.2 years old (standard deviation [SD] = 16.5); 63.9%
were female; 28.5% reported being in excellent or very good
health; 75.4% reported being of white race/ethnicity; 31.6%
reported having at least a college degree; 27.2% reported an
annual household income of less than $35,000; and 79.9% re-
ported having a previous visit with the PCP before the study
visit. There were no statistically significant differences in pa-
tient characteristics across the three time periods. Table 4 dis-
plays the characteristics of the PCPs participating in all three
study periods. The PCPs were evenly divided between the
Departments of Family Practice and Internal Medicine; 62.5%
were male; 62.5% reported being of white race/ethnicity,
and 50% had 31 years’ experience within the health system.
Patients reported that their physician used the computer in
the examination room in 82.3% of visits: 84.1% and 81.3% of
visits in P2 and P3, respectively. As expected, patient satisfac-
tion with the physician’s use of the latest medical technology
increased after the computer introduction with 35.4%, 55.7%,
and 59.1% reporting ‘‘excellent’’ satisfaction in P1, P2, and P3,
respectively (odds ratio [OR] = 1.71, 95% CI: 1.05–2.79 for P2
vs. P1; OR = 2.03; 95% CI: 1.47–2.80 for P3 vs. P1).
Postvisit Satisfaction with Visit Components
In general, patients reported high levels of satisfaction with
the visit. Table 1 displays the percentage reporting ‘‘excellent’’
satisfaction with various visit-related items, i.e., a score of one
out of six possible choices. There was a significant increase in
the level of overall patient satisfaction with the PCP during
the visit after the introduction of the computer into the exam-
ination room in the seventh month after introduction as
compared with baseline, i.e., P3 vs. P1 (OR = 1.50, 95% CI:
1.01–2.22), adjusting for patient age, gender, self-reported
health status, whether the visit was an initial visit, household
income, and educational attainment, while allowing for clus-
tering by physician. In addition, there was no significant drop
HSU ET AL., Computers in Outpatient Visits
in overall satisfaction immediately after the computer intro-
duction (P2 vs. P1).
Familiarity and Medical Communication
Compared with the baseline period, patients in P3 also
were more likely to report that physicians were familiar with
them as persons (OR = 1.60, 95% CI: 1.01–2.52) and familiar
with their medical history (OR = 1.42, 95% CI: 1.03–1.96).
Similarly, patients were more likely to be satisfied with the
level of communication about their medical care, including
the explanation of diagnoses and treatments (OR = 1.61,
95% CI: 1.05–2.47), their participation in the decision-making
process (OR = 1.94, 95% CI: 1.12–3.38), and the focus on pre-
venting illness and promoting good health (OR = 1.61, 95%
Psychosocial Communication and Available Time
Patients’ satisfaction with communication about psychosocial
concerns was not significantly different after the computer in-
troduction compared with the baseline: satisfaction with the
personal manner of their PCP (P3 vs. P1, OR = 1.21, 95%
CI: 0.70–2.09), with the PCP’s concern for their emotional
Table 1 j Patient Satisfaction with the Visit
Satisfaction with Visit
Unadjusted % Reporting
Excellent SatisfactionP2 vs. P1 P3 vs. P1
P1P2 P3OR 95% CIOR 95% CI
Your overall satisfaction with
the PCP during the visit
How familiar the PCP was with
you as a person
How familiar the PCP was with
your medical history
Explanation of your diagnoses
How much you participated in
your medical care decisions
Focus on preventing illness and
promoting good health
The personal manner of the
Concern for your emotional and
How carefully the PCP listened
Time spent discussing your
main reason for the visit
Time spent discussing any
Time available to address all
Satisfaction with visit
Comprehension: visit activities
diagnosis or treatment plan
needed to improve health
Understanding the potential
side-effects or complications
55.3 66.762.8 1.640.83–3.241.50 1.01–2.22
47.763.5 58.61.96 1.16–3.321.60 1.01–2.52
42.246.349.61.15 0.69–1.92 1.42 1.03–1.96
47.161.261.3 1.67 0.85–3.271.61 1.05–2.47
35.4 31.8 41.71.14 0.72–1.801.94 1.12–3.38
47.661.5 59.6 1.68 0.91–3.111.61 1.07–2.43
68.279.1 71.7 1.670.95–2.941.21 0.70–2.09
59.0 62.7 60.01.05 0.57–1.970.99 0.55–1.79
63.6 65.7 64.60.95 0.52–1.751.02 0.61–1.70
52.962.757.9 1.360.74–2.50 1.180.70–1.99
42.541.7 50.00.850.52–1.36 1.230.74–2.05
46.462.1 57.3 1.961.20–3.20 1.631.06–2.50
41.351.6 49.5 1.600.98–2.601.290.73–2.27
This table displays the unadjusted percentage of patients in each period who reported having excellent satisfaction with aspects of their visit and
with the visit overall. The table also displays the odds of having a higher percentage of patients with excellent postvisit satisfaction during each
of the postimplementation periods (P2 or P3) compared with the baseline period (P1). We calculated the odds ratios using ordinal logistic
regression, which adjusted for age, gender, self-reported health status, previous visits, household income, and educational attainment and
allowed for clustering by physician.
OR = odds ratio; CI = confidence interval; PCP = primary care physician.
Journal of the American Medical Informatics Association Volume 12 Number 4Jul / Aug 2005
and physical well-being (P3 vs. P1, OR = 0.99, 95% CI: 0.55–
1.79) or with how carefully the PCP listened to them (P3 vs.
P1, OR = 1.02, 95% CI: 0.61–1.70).
There also were no significant differences in satisfaction with
the amount of time available during the visit across the three
study periods. For example, there were no statistically signif-
icant differences in satisfaction with time spent discussing the
main reason for the visit (P3 vs. P1, OR = 1.18, 95% CI: 0.70–
1.99), emotional concerns (P3 vs. P1, OR = 1.23, 95% CI: 0.74–
2.05), or the total time available to address all concerns (P3 vs.
P1, OR = 1.17, 95% CI: 0.70–1.95).
Patient Comprehension of the Visit
Table 1 displays patients’ satisfaction levels with their com-
prehension of the visit. Consistent with satisfaction regarding
medical communication, patients at seven months reported
having greater comprehension about their medical care dur-
ing the visit, including understanding of their diagnosis or
treatment plan (OR = 1.63, 95% CI: 1.06–2.50), and under-
standing how their diagnosis or treatment was determined
during the visit (OR = 1.65, 95% CI: 1.09–2.50).
There were no significant differences in patient comprehen-
sion of medical advice at seven months after computer intro-
duction compared with the baseline. For example, there were
no statistically significant changes in understanding self-care
activities needed to improve health (P3 vs. P1, OR = 1.29,
95% CI: 0.73–2.27) or knowledge of the potential side effects
or complications associated with their treatments or diagno-
ses (P3 vs. P1, OR = 0.89, 95% CI: 0.53–1.50).
Patient Perceptions of Computer Use
during the Visit
Patients reported positive overall impressions of examination
room computer use during the visit. The majority of patients
(85.4%) reported that they totally agreed (51.4%) or agreed
(34.0%) that they liked the way that their PCP used the com-
puter during the visit. In contrast, only 6.2% of patients re-
ported that the computer use created a distraction during
the visit; 3.8% and 7.7% in P2 and P3, respectively (p = 0.37
in both bivariate and multivariate analyses). Table 2 displays
the changes in perceptions of computer use between P2 and
P3. The only statistically significant change in patient percep-
tions from P2 to P3 was an increase in satisfaction with the
computer’s effect on timeliness of visit activities (OR = 1.76,
95% CI: 1.28–2.42).
In this longitudinal study of the impact of examination room
computing on physician-patient interactions, overall visit
satisfaction, satisfaction with the physician’s level of familiar-
ity, communication about medical issues, and the degree of
comprehension with decisions made during the visit all im-
proved significantly by seven months after implementation.
Surprisingly, we did not find that the enhanced medical com-
munication ‘‘crowded out’’ discussions about psychosocial is-
sues or time for patient concerns from the patient perspective,
even during the period immediately after implementation.
We also did not detect any significant changes in comprehen-
sion about post-visit needs or satisfaction with the physician’s
personal manner, level of concern for the patient, or level
of listening. Finally, we detected few changes in patient
Table 2 j Patient Perceptions of Computer Use during
the Visit in the First and Seventh Months after
Agree P3 vs. P2
Computer Satisfaction Item P2P3OR 95% CI
The computer use helped
me better understand
what happened today
The computer helped the
PCP know about all the
things happening in my
The computer helped the
PCP make my care more
The computer use helped
the visit run in a more
The computer use fit well
into the overall flow of
Overall, I liked the way
that the PCP used the
computer in today’s visit
45.1 53.31.45 0.80–2.62
This table displays the unadjusted percentage of patients in each
period who totally agreed with statements about the quality of
computer use during the visit. The table also displays the odds of
having a higher percentage of patients reporting ‘‘totally agree’’ in
the late postimplementation period (P3) compared with the early
postimplementation period (P2). We calculated the odds ratios using
ordinal logistic regression, which adjusted for age, gender, self-
reported health status, previous visits, household income, and
educational attainment and allowed for clustering by physician.
OR = odds ratio; CI = confidence interval; PCP = primary care
Table 3 j Characteristics of Patient Participants
(N = 313)
(N = 107)
(N = 81)
(N = 125)
Age category, yr
Excellent or very good
Annual household income
Previous visit with PCP
None of the differences across the study periods were statistically
significant at a p-value of 0.05.
HSU ET AL., Computers in Outpatient Visits
perceptions of computer use between one month and seven
months after implementation.
We originally hypothesized that examination room comput-
ing might make the medical decision-making process more
transparent and collaborative. In fact, patients reported that
their physicians were more familiar with them, communica-
tion about medical care was better, and they understood
and participated more in the medical decision-making pro-
cess on average. Increases in satisfaction with the physician’s
use of the latest technology and familiarity with patients were
expected after implementation and serve as a validity check
on patient perceptions.
The lack of change from baseline to P2 in satisfaction with
available time during visits was surprising. We had antici-
pated that physicians might have difficulty integrating com-
puter use into their workflow during the initial months,
leaving less time for patient needs, i.e., the computer would
distract the PCP from the patient. We also hypothesized
that availability of computer-based information could place
greater emphasis on the medical aspects of the visit, thereby
limiting the amount of time available for psychosocial aspects
of care; however, patient satisfaction levels do not indicate
that either the distraction or crowd-out phenomenon oc-
curred. It is possible that previous experience with the com-
puter-based electronic health record system used in the
clinic could account for the absence of patient dissatisfaction
Although the findings are generally reassuring, the data sug-
gest opportunities for improving physician-patient interac-
tions. For example, the level of patient comprehension of
postvisit needs did not change significantly despite improve-
ment in comprehension about what happened during the
visit. Patient perceptions of the quality of computer use also
did not appear to change over time, suggesting that time
alone might not improve the quality of use. It may be impor-
tant to continue to monitor computer use well after the initial
implementation. Further research is needed to better under-
stand the learning curve associated with successfully inte-
grating examination room computing into ambulatory visits.
Previous studies on the impact of examination room com-
puters are mixed. A few studies have found that introducing
computers into examination rooms had an adverse effect on
physician-patient communication.18,19,23For example, using
videos of ambulatory care visits, Greatbatch et al.20found
that physicians tended to be preoccupied with computer
tasks, which hindered the flow of communication with their
patients. These studies may have had limited ability to differ-
entiate between the effects of physicians learning to use com-
puters and electronic health records in the examination room
and the office and experienced computer users attempting to
integrate computers into the examination roomduring outpa-
tient visits. A number of studies have found that examination
room computers do not diminish patient satisfaction.21,27–31
In some cases, computer use may actually improve certain
aspects of physician-patient communication, such as physi-
cians taking a more active role in clarifying information or en-
couraging patient questions, a finding similar to ours in this
Our findings might differ from other studies because we fo-
cused on sampling at three time points rather than a single
cross-sectional sample. By measuring multiple time points
for each physician, we were better able to control for individ-
ual physician behaviors. In addition, by including a second
postimplementation period, we were able to account for
changes that may have occurred due to greater physician ex-
perience in integrating the computer into the visit. Our study
also gauged the quality of physician-patient interactions by
querying patients directly about their satisfaction levels and
separated the responses by measures expected to improve
with greater information availability and measures expected
to worsen because of greater visit complexity or increased
emphasis on medical information. Last, many previous stud-
ies were conducted in the late 1980s or early to mid-1990s,
when computer systems might have been less user-friendly
or physicians and patients less computer savvy.
This study has several notable limitations. First, this was an
observational study that relied on a convenience sample of
physicians and patients. Because participation in the study
was voluntary, there is the potential for selection bias, e.g.,
early adopters or individuals more predisposed to favor com-
puters in the examination room may be more likely to partic-
ipate. The observation process and especially the videotaping
also could have influenced behavior or perceptions. The
study, however, focused on relative changes over time; there
is no reason to expect that there would be differential effects
across the three time periods.
In addition, we studied a small number of PCPs who prac-
ticed in a single clinic, within a single, integrated system.
We had limited power to detect small change in our out-
comes; nevertheless, we found several significant findings
consistent with our hypotheses. We also relied on patient per-
ceptions and did not attempt to directly assess areas such as
patient comprehension of self-care practices. Moreover, the set-
ting, types of physicians, and previous experience of all the
physicians with the electronic health record may limit the
generalizability of these findings to other contexts. We also
could not adjust for any secular trends in satisfaction or in
ambulatory visits, given the absence of a concurrent control
during the study period at this clinic. Finally, we did not
adjust the statistical analyses for multiple comparisons.26
In conclusion, this early study suggests that soon after the in-
troduction of HIT into examination rooms, physicians used
the computers in the majority of ambulatory care visits and
that these activities appeared to have positive effects on sev-
eral aspects of physician-patient interactions including over-
all visit satisfaction, satisfaction with the physician’s level of
familiarity, communication about medical decisions, and
Table 4 j Characteristics of Physician Participants
(N = 8)
Family practice department
Internal medicine department
Tenure ,3 yr in health system
Tenure 3–14 yr in health system
Tenure 151 yr in health system
Journal of the American Medical Informatics Association Volume 12 Number 4Jul / Aug 2005
patient understanding of the medical decisions. There did not
appear to be significant negative effects on other aspects of
the relationship such as communication about psychosocial
needs or available time for patients’ concerns. Although these
findings are generally positive, much additional research is
needed to confirm and elaborate on these findings, and
much opportunity remains for improving the quality of phy-
sician-patient communication and for improving the integra-
tion of computers into the clinical interaction.
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