The impact of electronic medical records on patient–doctor
communication during consultation: a narrative literature
Aviv Shachak PhD1and Shmuel Reis MD MHPE2
1Postdoctoral Fellow, Galil Center for Medical Informatics, Telemedicine and Personalized Medicine, The R&B Rappaport Faculty of Medicine,
Technion-Israel Institute of Technology, Haifa, Israel
2Chair, Galil Center for Medical Informatics, Telemedicine and Personalized Medicine, The R&B Rappaport Faculty of Medicine, Technion-Israel
Institute of Technology and Department of Medical Education, The R&B Rappaport Faculty of Medicine, Technion-Israel Institute of Technology,
clinical encounter, electronic medical record,
patient centredness, patient–doctor
communication, literature review, qualitative
Department of Health Policy,
Management and Evaluation
University of Toronto
155 College St.
Canada M5T 3M6
Accepted for publication: 21 May 2008
Rationale, aims and objective The effect of Electronic Medical Record (EMR) use on
Patient–Doctor Communication (PDC) has rarely been studied. As data accumulate, the
purpose of this article is to review the literature on EMR effect on PDC, to identify
recurring themes and to offer preliminary guidelines and future directions for medical
education and research.
Method A database search was conducted and 14 articles that met inclusion criteria
(published in the past 10 years, empirical investigations, direct assessment of the EMR
impact on patient–doctor communication) were selected for review. Aqualitative, grounded
theory-like approach was employed to analyse the data.
Results EMR use often has a positive impact on information exchange, but exerts a
negative inﬂuence on patient centredness. Some physician characteristics such as their
computer skills and behavioural style assist in overcoming this negative inﬂuence.
Conclusion The use of EMR exerts both positive and negative impacts on physician–
patient relationships. The negative impacts can be overcome by some simple means as well
as better designs of EMR systems and medical education interventions. Physicians’ every-
day practices of integrating EMR use into the clinical encounter as well as better design of
EMR systems and EMR and communication training may facilitate PDC in computerized
Electronic Medical Records (EMRs) are increasingly used in
healthcare organizations in general and ambulatory settings in
particular. Their use is being promoted by President Bush’s admin-
istration in the USA , and organizations such as the National
Health Service (NHS) in the UK, Canada Health Infoway, the US
Institute of Medicine (IOM) and the American Medical Informat-
ics Association (AMIA). A number of countries, among them
Denmark, Canada and Israel develop strategies towards integrative
national health record systems [2–4]. The potential beneﬁts of
computerization in healthcare have been discussed extensively
[1,5–8]. These include comprehensive documentation of a
patient’s medical history, easy access to medical data from remote
sites, improved communication among the various providers
involved in health care, easy access to medical information and
state of the art resources over the Internet (e.g. medical journals,
guidelines, Evidence-based Medicine databases, medication data-
bases, etc.) and clinical decision support. A recent systematic
literature review suggests that the use of information technology
improves healthcare by increasing adherence to guidelines or
protocol-based care, reduction of medical errors, and clinical
monitoring and data aggregation which are not feasible with
Despite these apparent beneﬁts, some disadvantages of EMR
use have also been reported. It has been demonstrated that the use
of EMR altered the process of clinical reasoning , resulting in
possible loss of information. Unintended adverse consequences of
medical information systems (e.g. EMR or CPOE – Computerized
Provider Order Entry) such as more or new work for clinicians,
unfavourable changes in clinical workﬂow, high system demands
and new types of errors have been reported [11–13].
Journal of Evaluation in Clinical Practice ISSN 1356-1294
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 641–649 641
A growing concern is the inﬂuence of computer use on patient–
doctor communication (PDC) during the patient visit. Communi-
cation is one of the ‘most powerful, encompassing, and versatile
instrument[s] available to the physician.’ . It is currently
widely accepted and evidence-based that patient–doctor commu-
nication is perhaps the most signiﬁcant component of the health-
care visit, with ramiﬁcations for patient satisfaction [15–17],
compliance/adherence , conﬂict-resolution  and clinical
outcomes [17,20]. A growing literature linking PDC to a host of
important patient outcomes has broadened deﬁnitions of medical
care quality to include physicians’ interpersonal skills in the
medical interview . Such outcomes have ranged from reports
of improved physical and emotional health status, and better per-
formance in activities of daily living, to enhancements in markers
of disease control such as Haemoglobin A1C and blood pressure
and ﬁnally to speciﬁc disease states such as Myocardial Infarction
It has been suggested that information systems have the poten-
tial to help sharing understanding between doctors and patients,
thereby educate and empower both and make the patient–doctor
encounter more effective [5,6]. However, the actual inﬂuences of
EMR use on PDC are just beginning to be realized.
The purpose of this paper is to review the existing research on
the effect of EMR on PDC, which accumulated during the last
decade. As the existing included literature is largely qualitative, the
paper’s goal is to report the results of a narrative analysis resulting
in synthetic recurring themes, adjustment of proposed best prac-
tices  and delineation of present knowledge gaps. Potential
implications for the design of EMRs, educational interventions
and future research are subsequently discussed.
A search of MEDLINE database was performed with the following
1patient AND doctor AND (communication OR relations* OR
interaction OR encounter)
2computer OR computers; limited to the Title and Abstract ﬁelds
3electronic medical record OR electronic health record; limited
to the Title and Abstract ﬁelds
4The above searches were combined as followed: #1 AND (#2
Search results were limited to papers in English, published in
the past 10 years. This timeframe has been chosen for two reasons.
First, widespread implementation of EMRs started in the mid
1990s. There is a limited number of studies on the use and impact
of EMRs prior to that time. Second, the technology itself rapidly
develops. Therefore, ﬁndings from old studies may not be relevant
today. The cut-off of 10 years reﬂects a balance between our need
to include as many papers as possible in this review and maintain-
ing relevance for the present technology. The database search
yielded a total of 167 articles as of April 17, 2007.
The titles and abstracts of the papers retrieved were manually
screened. Papers meeting the following inclusion criteria were
selected for the ﬁnal analysis: empirical investigations (quantita-
tive or qualitative); direct assessment of the EMR impact on
patient–doctor communication. Snowballing from found litera-
ture, that is, using a retrieved citation as a basis for a new search
based on the article’s bibliography, authors’names and the ‘related
articles’ search option was adopted when appropriate.
A qualitative–interpretive approach (grounded theory-like) to data
analysis was employed. Following the general principles of quali-
tative data analysis, researchers ﬁrst familiarized themselves with
the data by reading through the selected articles and reﬂecting on
them (e.g. by margin notes). Then, open coding – the process of
‘selectively attach[ing] meaningful tags to words, phrases, events,
situations, and so forth, naming what is potentially important
about them and distinguishing them from the rest of the data’ 
was employed. Next, thematic categories were developed and rela-
tionships between categories were determined. An analytic induc-
tion  process was employed to reach interpretation. Finally,
emergent themes were compared and contrasted with the tips
provided by Ventres et al.  to modify and provide potential
extensions to those tips.
To establish trustworthiness, the two authors, who have different
backgrounds, scrutinized the data independently. The ﬁrst author
holds a PhD in Information Science and specializes in Human–
Computer Interaction and Health Informatics while the second
author is a practicing family physician, medical educator and
researcher in communication in healthcare. Despite these different
backgrounds initial agreement on themes between researchers was
high. Open discussions were held to solve disagreements, reﬁne
and re-conceptualize themes, until reaching consensus.
A total of 14 papers met the inclusion criteria. In 11 of them
[27–37], the effect of computer usage on patient–doctor commu-
nication was the primary scope. One study  was aimed at
developing a methodology to transcribe data regarding computer–
patient–doctor communication and one study  investigated
patient–doctor communication in general. However both these
studies describe some results concerning the effect of computers
on patient–doctor communication and therefore, were included in
this review. Another study compared physicians’ satisfaction with
using desktop and mobile computers, and included patient–doctor
communication as one of the dependent variables .
The methodological approaches of the various studies included
in this review are summarized in Table 1. The majority of studies
used videotape recording of clinical encounters as a primary data
collection method, sometimes in combination with interviews or
observation. A qualitative approach to data analysis was taken in
the majority of these studies; speciﬁc methods include ethnogra-
phy, grounded theory and conversation analysis. Two studies,
however, analysed videotaped encounters quantitatively using a
checklist of communication tasks  and the Roter Interaction
Analysis System (RIAS) . Other studies used physician and/or
patient satisfaction written questionnaires or patient telephone
structured interviews for data collection [27,36,37,40].
Our review suggests four major themes discussed by the litera-
ture on patient–doctor–computer communication. These are: com-
puter use, effect of EMR use on PDC, factors affecting PDC in
computerized settings and classiﬁcation of physicians’ behaviour.
EMR and patient–doctor communication A. Shachak and S. Reis
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd642
Five papers discussed issues related to computer use. Computers
were employed for various purposes: general review of patients’
medical record, checking medications taken by the patient, retriev-
ing test results, entering information, writing prescriptions and
letters, and, occasionally, displaying changes in clinical data over
time to patients and printing educational material for them [28–31].
The intensity of computer use is discussed in two studies. In one
of them, usage intensity during the visit was low, and paper records
Table 1 Methodological approaches of studies on patient–doctor–computer relationships
Study Setting & design Sample Data collection method Data analysis method Reference
1 Primary care, longitudinal
pre- and post-study
113 Patients Pre- and post-visit
and computer screen
2 10 GPs, accustomed to
Videotaped consultations Ethnography 
3 4 primary care practices,
urban & rural
23 physicians, 1 nurse,
12 clinic staff, 52 patients
In-depth & Brief interviews,
Focus group interviews,
4 Urban academic medical
3 physicians, 18 months
experience of EMR use,
3 control physicians.
Review of medical record,
Content analysis using
nominal (yes/no) checklist
of critical communication
5 Urban family practice Five family physicians,
Videotaped encounters Ethnography 
6 5 GPs, 39 encounters Videotaped encounters,
Patient and doctor
interviews while watching
Qualitative (grounded-like) 
7 Primary care clinic.
Longitudinal study, pre-
of exam room computers
6 physicians, 2 physician
assistants and 1 nurse,
Videotaped encounters Grounded theory 
8 3 Primary care clinics 3 physicians, 30 patients Videotapes of physicians
only during encounters
9 Cross-sectional study,
internal medicine clinic in
a veterans hospital
6 physicians, 50 encounters Direct observations and
Content analysis, based on
conversation analysis and
10 Cross-sectional surveys of
physicians and patients in
a VA primary care clinic
12 internal medicine
residents and 11 faculty
internists; 155 patients
Physicians’ and patients’
Chi square and t-tests as
11 Cross-sectional surveys of
patients in 2 EMR and 2
non-EMR primary care
249 patients from EMR and
184 from non-EMR clinics
Frequencies, Chi square and
t-test as appropriate
12 Methodology development, 16 pre-implementation and
developed in the study
13 Observations at primary
care clinics, part of a
general study of
16 healthcare centres, 127
students’ reports in 2002
and 118 reports in
Written reports of students’
Coding according to agreed
14 RCT comparing desktop and
mobile computer users
10 emergency physicians,
each working randomly 5
shifts with desktop and 5
shifts with mobile
End of shift satisfaction
GP, general practitioner; EMR, Electronic Medical Record; VA, Veterans Affairs; RIAS, Roter Interaction Analysis System; RCT, randomized controlled
A. Shachak and S. Reis EMR and patient–doctor communication
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd 643
were used to a greater extent than EMR. In the other, physicians
screen gaze averaged 23%, and in some cases reached about 40%
of the visit time. Heavy keyboard typing was observed in 24% of
the visits. Data entry procedures varied between settings. While in
some cases data entry was carried out during the visit, in other
cases it was done after the patient left. One study reports data entry
by dictating to a clinical assistant. This depended on monetary
considerations, as typing by the physician seemed as a way to limit
Another use of computers was encounter management. The
computer guided physicians’ questions and information gathering,
dependent on physician style as discussed below. Physicians’ ges-
tures involving the computer (e.g. turning gaze to or from the
screen, typing or putting a hand on the mouse), were employed to
indicate changes in conversation topic, physician’s attention or
conversation rhythm and were used as non-verbal cues to conclude
the visit. Physicians employed the computer to take a break in
order to solve a problem or rest [31,32]. In the early days of
computer implementation, the computer was sometimes used as a
‘magic box’ that gives a higher value to medical statements: phy-
sicians looked at the screen or pointed to it before making impor-
tant medical statements . This behaviour has not been reported
in later studies.
Effect of EMR use on PDC
Although patient surveys report high overall satisfaction with phy-
sicians’ use of computers, including high levels of satisfaction with
face to face communication, physicians’ listening to their concerns
and the quality of explanations provided by the physician [27,41],
a more detailed analysis suggests both positive and negative
inﬂuences on patient–doctor communication.
Electronic Medical Records use had a positive inﬂuence on
exchange of medical information. Physicians who used EMR
accomplished information related tasks such as checking and clari-
fying information, encouraging patients to ask questions and
ensuring completeness at the end of visit to a greater extent than
physicians who used paper records. Computer use was positively
related to biomedical exchange, including questions about
therapeutic regimen, patient education and counselling as well
as patient disclosure of medical information to the physician.
Patients’ satisfaction with physicians’ familiarity with them,
communication about medical issues and comprehensiveness of
medical decisions increased after EMR implementation
As a subset of this general theme, two articles discuss the effect
of EMR use on information exchange speciﬁcally regarding medi-
cations. The EMR assisted physicians in preparing medication
lists, reﬁlls and checking prescriptions by other physicians. When
patients talked about medications, they often gave general descrip-
tions of the medications that they were taking rather then generic
or brand names. In such cases the EMR was employed by physi-
cians to identify medication names. The EMR enhanced infor-
mation exchange about active medications, helped in immediate
renewal of prescriptions, facilitated discussion about pharmacy
procedures and assisted in identifying mailing problems and moni-
toring adherence . Patients from EMR clinics reported signiﬁ-
cantly higher rate of multi-mode medication counselling, which
included both oral and written counselling, than patients from
paper record clinics. However, they obtained less oral counselling
on medication indications. Lower rate of oral counselling on indi-
cations and multi-mode counselling were associated with higher
rates of asking the doctors questions about medications .
In contrast with the positive effect on information exchange,
EMR use usually had negative effect on patient centredness. It has
been reported that physicians most commonly walked straight to
the monitor after only a short greeting, screen gaze averaged about
one quarter of the visit time and heavy keyboarding was recorded
in about 24% of the encounters. The computer often caused phy-
sicians to lose rapport with patients; for example, physicians
logged into the computer or screen gazed while talking to patients
or while the patient was talking. Screen gaze was inversely related
to physicians’ engagement in psychosocial question asking and
emotional responsiveness [28–30,34,39]. On the other hand, in
some cases computer implementation assisted physicians in visit
organization and had a positive inﬂuence on verbal and non-verbal
communication. As discussed below, it has been suggested
that EMR use ampliﬁed physicians’ baseline skills in these two
Factors affecting PDC in computerized
Several factors affected PDC in computerized setting, including
cognitive limitations, physician characteristic and spatial organi-
zation of the clinic.
In some cases the introduction of computers provided a tool to
organize data and visit tasks. In other cases it added complexity to
the visit and introduced new tasks. It has been suggested that both
computer use and communicating with the patient require the
physician’s focused attention, and that multi-tasking or computer
use in the background are not possible [28,33].
Physicians’ characteristics affected their ability to handle the
additional cognitive load imposed by computer. Computer mastery
enhanced PDC in a computerized setting. Typing skills were
viewed by physicians as crucial for using the EMR effectively
during the clinical encounter, reduced physicians’ need to focus
attention on the computer, and positively affected PDC [29,30,33].
Physicians’ ability to navigate the computer, search for and orga-
nize information was also associated with their ability to commu-
nicate with patients effectively . Physicians’ experience and
baseline communication skills have been proposed to affect PDC
in a computerized setting. Patients in a Veterans Affairs (VA)
medical centre, who were seeing residents, were signiﬁcantly
more likely to agree that the EMR had a negative effect on the time
physicians spent talking, looking at and examining them than
patients seeing faculty physicians. Similar trends, though not sta-
tistically signiﬁcant, were reported by the physicians. Basic com-
munication skills were highly related to the quality of PDC, and
the computer seemed to amplify both positive and negative pre-
implementation communication patterns [33,36]. Another physi-
cian characteristic which inﬂuenced PDC in computerized setting
was their behavioural style. This issue is discussed in detail below.
Spatial organization of the computerized environment affected
physicians’ ability to utilize the EMR effectively. In some cases
location of the screen interfered with eye contact. Fixed position-
ing limited physicians’ ability to face patients directly, sometimes
forcing them to shift their body or move the chair to face patients
EMR and patient–doctor communication A. Shachak and S. Reis
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd644
[29,30,33]. In other cases, location of the screen or using ﬂat
monitors on mobile arms helped sharing information with patients;
thereby facilitating PDC and patient education. However, in
another study, post-shift surveys of emergency physicians did not
ﬁnd signiﬁcant difference in perceived effect on PDC between
using desktop and mobile computers [29,33,40].
In one study, the accessibility of computer created a need to
immediately enter data into the EMR resulting in a conﬂict
between this need and the need to pay full attention to the patient.
On the other hand, the opportunity to access EMR from different
locations gave both patients and doctors a feeling of seamless
communication over time and location .
Physician behaviour classiﬁcation
Ventres et al. [29,31] and Booth et al.  classify physicians’
behavioural style, which affected PDC in computerized settings.
Although they use different terminology, there are many simi-
larities in the behavioural styles reported. Therefore, we
suggest a uniﬁed classiﬁcation consisting of three major styles:
informational-ignoring style, controlling-managerial style and
The informational-ignoring style is characterized by its focusing
on details of information and extensive information gathering,
which is often computer-driven [29,31]. Informational-ignoring
physicians tended to lose rapport with patients while engaged with
the EMR, leaving patients idle while they enter data. They fre-
quently talked while screen gazing, hardly faced the patient while
working with the computer and did not usually utilize the com-
puter to share information with patients [28,31].
The controlling-managerial style is characterized by controlling
the encounter’s dynamic to separating computer use from PDC.
Physicians with this style alternated their attention between patient
and computer in deﬁned intervals or stages of the encounter.While
with the patient, they turned away from the computer and vice
versa [28,29,31]. Controlling-managerial physicians often indi-
cated switches of attention between patient and computer by ges-
tures such as turning body or gaze [28,31]. A variant of this style
is the responsive-opportunistic physician, who utilizes gaps in the
ﬂow of consultation to use the computer .
The third behavioural style is the interpersonal style, character-
ized by focusing on the patient. Physicians of this style did not talk
while using the computer; oriented themselves to the patient even
when using the EMR and utilized the computer to share and review
information together with the patient. They had little or no com-
puter guided questions, spent less time entering data and refrained
from using the computer in the beginning of the encounter
EMR impact on PDC
There is a wealth of research in recent years regarding the effect of
Information and Communication Technology (ICT) on health care.
Numerous studies deal with issues surrounding the implementa-
tion of EMRs, CPOE and Decision Support Systems, their effect
on patient safety, quality of care as well as their unintended con-
sequences [9,11,42–46]. In respect to communication, many
papers deal with the inﬂuences of ICTs such as email, and health
information on the web, on patient–doctor relationships [47–50].
The present literature review attempts to highlight a speciﬁc angle
of these relationships, which has received less attention, but nev-
ertheless inﬂuences quality of care: the impact of using EMR
systems on patient–doctor communication during the clinical
This review of the literature revealed four major themes: EMR
uses, effect of EMR on PDC, factors affecting PDC in EMR
settings and Physician behavioural styles. Several uses of the com-
puter had been discussed, including some that are probably
unplanned and unintended, such as using the EMR to manage the
encounter, take a break for problem solving or rest.
Our present understanding of PDC is grounded in the biopsy-
chosocial model [51–53], which places suffering, disease and
illness in the broad context of biological, psychological and social
dimensions. From this orientation, the concept of ‘Patient-centred
Care’ evolved. Patient-centred care acknowledges the web of rela-
tionships and contexts within which a patient exists, allowing the
physician to understand both the disease and the patient. It pro-
motes patient partnership and encourages empowerment and
involvement . Focusing the biopsychosocial view on the clini-
cal encounter, the three function model of the medical interview
offers a useful framework to discuss our ﬁndings. The model
suggests three core functions of PDC: data gathering, establishing
rapport and responding to the patient and, patient education and
behaviour management [55,56].
Multiple additional models and assessment tools exist. One tool
(RIAS) which is theory-driven was applied in one study , but
no attempt to inform theory building for this speciﬁc subset can be
gleaned from this review.
Patients were usually satisﬁed with their physician’s use of
EMR. However, a detailed analysis highlights the diverse effects
of EMR on patient doctor communication. While having a positive
impact on information related tasks and information exchange
(the ﬁrst function of the medical interview), particularly about
medications, EMR had a negative impact on the second function
– psychological and emotional talk, establishing rapport with
patients and patient centredness. There is some indication that the
introduction of the EMR organizes encounters around data gath-
ering demands rather than patients’ narratives. Our analysis sug-
gests that physicians rarely used the computer for the third
function of the medical interview, that is, patient education and
Weidentiﬁed a number of factors affecting PDC in EMR settings,
including cognitive limitations, spatial organization and physician
characteristics. One of the most important physician characteristics
which affected PDC in EMR settings was their behavioural
style. As discussed above we propose a three-style classiﬁcation:
informational-ignoring style, controlling-managerial style and
However, the negative impact of EMR on the second function
of the clinical encounter (development of rapport) could be over-
come, at least in part, by enhanced computer and communication
skills and physician experience. Recently, Ventres et al.  pro-
posed 10 tips to physicians for effective PDC in EMR settings.
Based on the present literature review and personal experience of
working in a computerized setting (S Reis), we propose some
extensions to these tips (Table 2). For example:
A. Shachak and S. Reis EMR and patient–doctor communication
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd 645
•‘Learn to type’: Our review suggests that blind typing, although
highly important, is part of a larger set of computer mastery skills
which include computer navigation, fast screen scanning and Inter-
net surﬁng. These skills would enable physicians to focus their
attention on the patient, thereby contributing to a seamless clinical
encounter. Extrapolating from this set, Internet surﬁng skills and
familiarity with decision support and evidence resources would
enable physicians to better employ the computer in patient
•‘Separate some routine data entry and healthcare maintenance
issues from your patient encounters’: Our analysis indicates that
dividing attention between the patient and EMR is difﬁcult. There-
fore, separating them is a useful approach that should be extended
beyond data entry.We propose that scanning the EMR for problem
list, constant medication and previous visit precedes calling the
patient in. Gaps between or within encounters (e.g. when patient
dresses after physical examination) may be used for typing.
•‘Start with your patients’ concerns’: This review suggests that in
some cases the clinical encounter may increasingly become infor-
mation gathering-driven. It is therefore important not only to start
with the patients’ concerns, but also to ensure the encounter is
driven by them and the patient’s narrative.
•‘Look at your patients’: Our review suggests that eye contact is
just one aspect of non-verbal communication involving the com-
puter. Body language and gestures – for example, turning body
towards the patient, taking hands off the keyboard and mouse and
pushing the monitor away – are as much as important for indicat-
ing that the physician’s full attention is to the patient as well as for
More generally, we propose basic and continuing medical edu-
cation as the main strategies to enhance PDC in a computerized
setting. As EMR use continues to grow, EMR training should
focus not only on the technical aspects of using it, but also on how
to incorporate it into a seamless patient–doctor encounter. Some
simple means such as blind typing could have a great inﬂuence on
the efﬁciency of EMR use as well as its effect on communication.
Conversely, the changing environment should be considered and
the use of EMR integrated into the standard medical communica-
Overcoming the negative inﬂuences of EMR on communication
is just a ﬁrst step. Computers have the potential to enhance
patient–doctor communication, sharing understanding and
patient education, thereby positively affect patient satisfaction,
compliance/ adherence and, possibly, clinical outcomes [5,6].
However, our review of the literature suggests that the EMR is
rarely utilized for these purposes. Simple tips such as using ﬂat
mobile monitors, pointing to the screen, showing the patient what
the physician is doing and encouraging patients to participate in
building their own charts as well as promoting electronic commu-
nication (Table 2; tips 1, 7–9) can help utilizing the potential of
EMRs to a greater extent.
Implications to design of EMR systems
The design of successful EMR systems requires careful consider-
ation of the user, system and task characteristics . PDC is an
important component of the task supported by the EMR – provid-
ing high quality care – which has often been ignored. This review
of the literature implies that EMRs are successful in supporting the
primary task for which they were designed, that is, collecting and
documenting patient information. This is evident from the positive
impact on information exchange.
However, EMRs have a greater potential to improve other aspects
of healthcare quality but documentation. One such aspect is the
physician’s ability to share information with patients, for example,
by showing trends of lab results over time, use of risk calculating
Table 2 Tips for effective use of Electronic Medical Record
Tip No. Original tip (Ventres) Modiﬁed tip
1 Use mobile computer monitors Use mobile computer monitors (no modiﬁcation)
2 Learn to type Learn to type; enhance your surﬁng skills for patient education, decision support and evidence
resources and practice fast screen scanning
3 Integrate typing around your
Integrate typing around your patients’ needs. (no modiﬁcation)
4 Reserve templates for
Reserve templates for documentation (no modiﬁcation)
5 Separate some routine data entry
and healthcare maintenance
issues from your patient
separate some data entry from the encounter; review problem list and previous visit before you
call patient in, use time of patient’s undressing and putting cloths on (when contextually
appropriate, not in the USA) for data entry
6 Start with your patients’ concerns Start with your patients’ concerns, and make sure the encounter is driven by them. Data gathering
is important, but secondary
7 Tell your patients what you are
doing – as you’re doing it
Tell your patients what you are doing as you’re doing it. Verbalize shifts to the computer by
apologizing or asking permission. If possible, keep the conversation going
8 Point to the screen Point to the screen; highlight the discussed data; print out when appropriate
9 Encourage patients’ participation
in building their charts
Encourage patients’ participation in building their charts. Promote future supplementary virtual
communication. Create interface with on call, house calls
10 Look at your patients Look at your patients. Make sure your full attention is in listening to the patient, especially in the
encounter beginning-patient monologue and when sensitive issues are brought up. Indicate this
by pushing monitor away, positioning yourself facing the patient with eye contact, and have your
hands off keyboard and mouse
EMR and patient–doctor communication A. Shachak and S. Reis
© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd646
software, links to external credible health information resources,
printing patient handouts and using anatomical images to explain
medical problems. Our analysis suggests that these potential func-
tions are hardly used. Future designs of EMR systems should
contain functions to assist physicians in patient education as well as
reduce time and cognitive load associated with EMR use, for
example, easy to share and visually scan screens with problem lists,
previous visit and summary, access to digital data from other
relevant sources, pre-prepared templates for routine tasks and inte-
gration of decision support and evidence into the chart screen.
Voice recognition, handwriting recognition and touch screens are
powerful means to improve data entry .As this review indicates
typing has a negative impact on communication. Therefore, these
technologies may strongly enhance PDC while using the EMR.
Although EMRs with voice recognition are being implemented in
some settings, there is a dearth in research regarding the impact of
this technology on clinical practice. Some results indicate that
compared with electronic signature of letters typed by experienced
transcriptionist and imported into the EMR, using voice recognition
software for writing letters required additional physicians’ time, is
less accurate and more costly . However, to our knowledge
currently there is no comparison of using EMR with voice recog-
nition and typing by physicians during the clinical encounter.
Limitations and directions for future research
The present study has a number of limitations. First, only 14 papers
met inclusion criteria. Therefore, we could not reach theoretical
saturation. Still, we were able to identify a number of overarching
recurrent themes as discussed above. Moreover, the qualitative–
interpretive approach used for analysing the data allowed us to
highlight some isolated ﬁndings that may be interesting to study in
future investigations, though not necessarily representative. An
example is the use of computers to give credibility to clinical
statements, which has been reported by one article.
Present theories and models of PDC, as far as we can detect
in the literature (by 1 February 2008) have not yet included the
computer. We are able to ﬁnd only two examples of instructional
modules supporting introduction of computers to clinical care
settings [60,61], neither of which include a theoretical framework.
This review attests to this need. As present theories and models are
based on encounter recordings and theory-driven analysis, the
incorporation of the impact of the computer on PDC into these
frameworks will probably follow a similar route.
As non-verbal communication (such as eye-gaze, body position-
ing and hands place on/off keyboard and mouse etc.) are crucial to
PDC as this review demonstrates, it will behove future researchers
to video record encounters and make sure to capture these nuances.
One necessary additional technology may be eye-tracking cameras
placed on desktop screens. A necessary additional methodology to
be employed may be ‘think aloud’ of both patient and clinician,
while observing recordings of encounters, recalling their cogni-
tions and emotions in particular instances of computer-related
A set of questions for future studies on EMR in PDC, which
may facilitate the development of such theories, has been proposed
by Ventres et al. . Here we elaborate on some of these ques-
tions and the ﬁndings of this review to propose directions and
potential methods for future research:
•‘Can EHR software be designed to facilitate communication
between physicians and patients?’  To answer this question,
there is a need to better understand the cognitive elements in using
EMR during the patient–doctor encounter, such as focus of atten-
tion, memory load and automaticity of actions. Methodologies
drawn from Cognitive Sciences and Human–Computer Interaction
(e.g. Cognitive Task Analysis)  may shed light on these ele-
ments and provide useful guidelines for design of EMR systems
that support patient–doctor communication. Another direction is to
evaluate the impact of new technologies and designs on PDC
during the patient visit, compared with present systems. A case in
point, which as discussed above has rarely been studied, is EMR
with embedded voice recognition.
•‘Are there examples of best practices – standard procedures or
phrases – that physicians can use to assist patients as they are
introduced to the EHR?’  To identify best practices of EMR
use and effective strategies for incorporating it into PDC, it would
be useful to compare experts (in PDC, clinically and in EMR use)
with novices and intermediates. Our research in progress 
already revealed some of the strategies and job smarts developed
by experts to overcome the negative inﬂuence of EMR on com-
munication (e.g. dividing the visit into separate patient- and
EMR-centred stages, typing while patients dress after physical
examination and reading out loud while typing).
•‘When and how should medical educators introduce the EHR to
students and residents, especially given the current emphasis on
training patient-centred interviewing skills?’  Expert strategies
and best practices may be employed to developing medical edu-
cation interventions aimed at facilitating PDC in a computerized
setting. Then, alternative educational approaches to employ these
strategies should be developed and evaluated by comparing control
and intervention groups pre- and post-intervention.
This review indicates that the use of EMR has a positive inﬂu-
ence on information sharing between patients and doctors, but
exerts a negative impact on patient centredness, emotional and
psychological communication and establishing rapport between
physicians and patients. The negative impact on communication
can be partially overcome by spatial organization of the doctor’s
ofﬁce and by physician computer skills and behavioural style.
This review highlights the need to extend present communi-
cation theories to incorporate computer use during the clinical
The ﬁrst author was supported by a fellowship from the Israel
Council of Higher Education and Galil Center for Medical Infor-
matics, Telemedicine and Personalized Medicine. The admini-
strative assistance of Mrs Ivette Trujillo-Mordetzki is greatly
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