Literature Review

The Impact of Electronic Medical Records on Patient-Doctor Communication during Consultation: A Narrative Literature Review

Article· Literature Review (PDF Available)inJournal of Evaluation in Clinical Practice 15(4):641-9 · July 2009with 3,527 Reads
DOI: 10.1111/j.1365-2753.2008.01065.x · Source: PubMed
Abstract
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. 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. A qualitative, grounded theory-like approach was employed to analyse the data. 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. 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' everyday 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 settings.
The impact of electronic medical records on patient–doctor
communication during consultation: a narrative literature
reviewjep_1065 641..649
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,
Haifa, Israel
Keywords
clinical encounter, electronic medical record,
patient centredness, patient–doctor
communication, literature review, qualitative
research
Correspondence
Aviv Shachak
Department of Health Policy,
Management and Evaluation
University of Toronto
155 College St.
Toronto
ON
Canada M5T 3M6
E-mail: aviv.shachak@utoronto.ca
Accepted for publication: 21 May 2008
doi:10.1111/j.1365-2753.2008.01065.x
Abstract
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
settings.
Introduction
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 [1], 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
paper [9].
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 [10], 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.’ [14]. 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 [18], conflict-resolution [19] 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 [21]. 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
[17,22,23].
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 [24] and delineation of present knowledge gaps. Potential
implications for the design of EMRs, educational interventions
and future research are subsequently discussed.
Methods
Paper selection
A search of MEDLINE database was performed with the following
Boolean queries:
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
OR #3).
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.
Data analysis
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’ [25]
was employed. Next, thematic categories were developed and rela-
tionships between categories were determined. An analytic induc-
tion [26] process was employed to reach interpretation. Finally,
emergent themes were compared and contrasted with the tips
provided by Ventres et al. [24] 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.
Results
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 [38] was aimed at
developing a methodology to transcribe data regarding computer–
patient–doctor communication and one study [39] 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 [40].
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 [30] and the Roter Interaction
Analysis System (RIAS) [34]. 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
Computer use
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
satisfaction
questionnaires,
videotaped encounters
and computer screen
Multivariate regression
models
[27]
2 10 GPs, accustomed to
using computers
Videotaped consultations Ethnography [28]
3 4 primary care practices,
urban & rural
23 physicians, 1 nurse,
12 clinic staff, 52 patients
In-depth & Brief interviews,
Videotaped encounters,
Focus group interviews,
Participant observation
Ethnography, various
perspectives
[29]
4 Urban academic medical
centre.
Controlled trial
3 physicians, 18 months
experience of EMR use,
3 control physicians.
204 encounters
Review of medical record,
videotaped encounters
Content analysis using
nominal (yes/no) checklist
of critical communication
tasks
[30]
5 Urban family practice Five family physicians,
29 encounters
Videotaped encounters Ethnography [31]
6 5 GPs, 39 encounters Videotaped encounters,
Patient and doctor
interviews while watching
their videos,
Qualitative (grounded-like) [32]
7 Primary care clinic.
Longitudinal study, pre-
and post-implementation
of exam room computers
6 physicians, 2 physician
assistants and 1 nurse,
Videotaped encounters Grounded theory [33]
8 3 Primary care clinics 3 physicians, 30 patients Videotapes of physicians
only during encounters
RIAS [34]
9 Cross-sectional study,
internal medicine clinic in
a veterans hospital
6 physicians, 50 encounters Direct observations and
videotaped encounters
Content analysis, based on
conversation analysis and
ethnomethodology
[35]
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’
questionnaires
Chi square and t-tests as
appropriate
[36]
11 Cross-sectional surveys of
patients in 2 EMR and 2
non-EMR primary care
clinics
249 patients from EMR and
184 from non-EMR clinics
Structured telephone
interview about
medication counseling.
Frequencies, Chi square and
t-test as appropriate
[37]
12 Methodology development, 16 pre-implementation and
6 post-simulated
encounters
Videotaped simulated
encounters
Transcription method,
developed in the study
[38]
13 Observations at primary
care clinics, part of a
general study of
patient–doctor
communication
16 healthcare centres, 127
students’ reports in 2002
and 118 reports in
2003–2004
Written reports of students’
observations
Coding according to agreed
categories
[39]
14 RCT comparing desktop and
mobile computer users
10 emergency physicians,
each working randomly 5
shifts with desktop and 5
shifts with mobile
computer
End of shift satisfaction
questionnaires
Repeated-measure analysis
of variance
[40]
GP, general practitioner; EMR, Electronic Medical Record; VA, Veterans Affairs; RIAS, Roter Interaction Analysis System; RCT, randomized controlled
trial.
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
expenditures [28,29,31,34].
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 [32]. 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
[27,30,34,35,37].
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 [35]. 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 [37].
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
domains [33].
Factors affecting PDC in computerized
settings
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 [33]. 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 [29].
Physician behaviour classification
Ventres et al. [29,31] and Booth et al. [28] 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
interpersonal style.
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 [28].
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
[29,31].
Discussion
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
encounter.
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 [54]. 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 [34], 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
behavioural management.
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
interpersonal style.
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. [24] 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
education.
‘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
encounter management.
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-
tion education.
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 [57]. 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
patients’ needs
Integrate typing around your patients’ needs. (no modification)
4 Reserve templates for
documentation
Reserve templates for documentation (no modification)
5 Separate some routine data entry
and healthcare maintenance
issues from your patient
encounters
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 [58].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 [59]. 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
occurrences.
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. [29]. 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?’ [29] 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) [62] 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?’ [29] 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 [63]
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?’ [29] 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.
Conclusion
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
encounter.
Acknowledgements
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
appreciated.
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© 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd 649
  • ... Clinician attitudes toward the EHR can affect the attitudes of patients and the quality of clinician-patient communication in its presence [6]. It can be useful for clinicians to learn to touch type and/or consider the use of scribes to help optimize face-to-face communication [7][8][9][10][11][12]. Quieter keyboards can also be less disruptive to flow of communication [2]. ...
    ... It is helpful for clinicians to review the record ahead of time to identify interval events and data, and to review the patient's social history, so that communication during the patient visit is more valuable, personalized, and less superfluous [10,12,24,25]. Clinicians can use the EHR to remind them of current life events of patients, to help personalize the visit and couch discussion of health care issues in the context of their lives [26]. ...
    ... Multiple strategies can be used to improve patient engagement in visits through conscientious use of the EHR. One of these is the use of "transition phrases" or "signposting" when moving from the patient to the EHR and back [2,12,16,30,31,[40][41][42]. It is also wise to use a language of collaboration when discussing the EHR and to address openly issues of confidentiality [23]. ...
  • ... Electronic records are more likely to include copied and repetitive notes [5,9]. Some reports indicate that constant use of a keyboard and a mouse results in less eye-to- eye contact between doctors and patients [4,10,11]. Therefore, some physicians consent to the adoption of an EHR system only if it permits handwriting on paper. ...
  • ... That is to say, the use of eCRs can exert both positive and negative impacts on physician-patient relationships. The negative impacts can be overcome by some simple means as better designs of eCR systems and medical education interventions [25]. ...
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  • ... 17 The EMR has been shown to be in- dispensable in various applications including population health management and medication safety 18 ; however, because it "organizes encoun- ters around data gathering demands rather than patients' narratives," the EMR has had mixed effects in the physician-patient communication domain. 19 This hospitalist group's experience with the ScOAP note template demonstrates that patient input can shape EMR improve- ment and that an intervention using the EMR has the potential to enhance patient-centered communication. ...
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    Background: Effective communication between family physicians and their patients is crucial to improving healthcare outcomes and patients' satisfaction. However, the barriers to effective communication have been weakly studied in the Gulf region with no reported studies in Dubai. This study aims to identify the main perceived barriers to effective communication between patients and their family physicians in Dubai from both the physicians' and the patients' viewpoints. Methods: The study was conducted at 12 primary healthcare centres in Dubai between October 2016 - July 2017. Two self-administered questionnaires were used, one measuring the patients' perceived frequency of encounters with barriers to communication, while the other was for the family physicians' perceived level of risk to communication posed by the barriers. The barriers were assessed in the following four domains: personal characteristics and attitudes, organisational factors, communication of information, and linguistic and cultural factors. Results: There were a total of 1122 patients and 170 family physicians, with 75% and 85% response rates, respectively. Having a time limitation was the highest ranking barrier, with 23.4% of patients encountering it half of the time-always, and 50.6% of physicians perceiving it as moderate-very high risk. This was followed by barriers in the communication of information domain, especially not checking the patient's understanding and not educating the patient (16.0-16.9%) from the patients' perception and presentation with multiple problems and not following with a treatment plan (51.2% and 35.9%, respectively), from the physicians' perception. Preoccupation with medical records ranked in the second pentile for the physicians, and in the lowest pentile for the patients. Barriers related to the failure of rapport building and linguistic/cultural factors ranked in the fourth and fifth pentiles for both patients and physicians. Conclusion: Time pressure is the major perceived barrier to communication between patients and family physicians. In addition, a greater focus needs to be placed on training the physicians to convey their messages to the patients clearly, checking their understanding and managing poor historians.
  • Chapter
    In the last twenty years, health organizations have started the gradual shift from paper-based information systems to digital systems for recording internal and external communication [1–3]. This is an epochal change, which is going through all the productive systems, yet in the health systems this passage is particularly prolonged and difficult [4], mainly due to the complexity of the clinical and care activities [5], the variety of organizations that produce services [6] and a hyper-regulated institutional context [7]. These three factors typical of the health system have generated a tension on the clinical level between standardization and personalization of care, on the organizational level between autonomy and integration of health providers, at the institutional level between centralization and location of planning and control functions. This tension is reflected in projects and programs for the development and implementation of digital healthcare, which have sometimes failed miserably despite the investments and commitment of key stakeholders [4], due to inconsistencies generated on the clinical, organizational and institutional levels, or open clashes between professionals, managers and policy makers for decision-making power on technological innovation [8].
  • Article
    Background: Medical scribes are a clinical innovation increasingly being used in primary care. The impact of scribes in primary care remain unclear. We aimed to examine the impact of medical scribes on productivity, time spent facing the patient during the visit, and patient comfort with scribes in primary care. Methods: We conducted a prospective observational pre-post study of 5 family and internal medicine-pediatrics physicians and their patients at an urban safety net health clinic. Medical scribes accompanied providers in the examination room and documented the clinical encounter. After an initial phase-in period, we added an additional 20-minute patient slot per 200-minute session. We examined productivity by using electronic medical record data on the number of patients seen and work relative value units (work RVUs) per hour. We directly observed clinical encounters to measure the amount of time providers spent facing patients and other visit components. We queried patient comfort with scribes by using surveys administered after the visit. Results: Work RVUs per hour increased by 10.5% from 2.59 prescribe to 2.86 post-scribe (P < .001). Patients seen per hour increased by 8.8% from 1.82 to 1.98 (P < .001). Work RVUs per patient did not change. After scribe implementation, time spent facing the patient increased by 57% (P < .001) and time spent facing the computer decreased by 27% (P = .003). The proportion of the visit time that was spent face-to-face increased by 39% (P < .001). Most (69%) patients reported feeling very comfortable with the scribe in the room, while the proportion feeling very comfortable with the number of people in the room decreased from 93% to 66% (P < .001). Conclusions: Although the full implications of medical scribe implementation remain to be seen, this initial study highlights the promising opportunity of medical scribe implementation in primary care.
Literature Review
  • Chapter
    This chapter focuses on teaching and learning interviewing through direct observation and discussion of actual interviews. We primarily describe a learning situation involving a teacher, a small group of learners, and access to real patients, standardized patients, and/or taping (audio or video) equipment. The teacher usually reviews the experience of an interview with the interviewer and other group members at the time of the interview. However, the interview may be done at some time prior to the teaching session and recorded on video or audiotape with review and discussion centered on the tape.
  • Article
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    To describe physicians' patterns of using an Electronic Medical Record (EMR) system; to reveal the underlying cognitive elements involved in EMR use, possible resulting errors, and influences on patient-doctor communication; to gain insight into the role of expertise in incorporating EMRs into clinical practice in general and communicative behavior in particular. Cognitive task analysis using semi-structured interviews and field observations. Twenty-five primary care physicians from the northern district of the largest health maintenance organization (HMO) in Israel. The comprehensiveness, organization, and readability of data in the EMR system reduced physicians' need to recall information from memory and the difficulty of reading handwriting. Physicians perceived EMR use as reducing the cognitive load associated with clinical tasks. Automaticity of EMR use contributed to efficiency, but sometimes resulted in errors, such as the selection of incorrect medication or the input of data into the wrong patient's chart. EMR use interfered with patient-doctor communication. The main strategy for overcoming this problem involved separating EMR use from time spent communicating with patients. Computer mastery and enhanced physicians' communication skills also helped. There is a fine balance between the benefits and risks of EMR use. Automaticity, especially in combination with interruptions, emerged as the main cognitive factor contributing to errors. EMR use had a negative influence on communication, a problem that can be partially addressed by improving the spatial organization of physicians' offices and by enhancing physicians' computer and communication skills.
  • Article
    ( This reprinted article originally appeared in Science, 1977, Vol 196[4286], 129–236. The following abstract of the original article appeared in PA, Vol 59:1423. ) Although it seems that acceptance of the medical model by psychiatry would finally end confusion about its goals, methods, and outcomes, the present article argues that current crises in both psychiatry and medicine as a whole stem from their adherence to a model of disease that is no longer adequate for the work and responsibilities of either field. It is noted that psychiatrists have responded to their crisis by endorsing 2 apparently contradictory positions, one that would exclude psychiatry from the field of medicine and one that would strictly adhere to the medical model and limit the work of psychiatry to behavioral disorders of an organic nature. Characteristics of the dominant biomedical model of disease are identified, and historical origins and limitations of this reductionistic view are examined. A biopsychosocial model is proposed that would encompass all factors related to both illness and patienthood. Implications for teaching and health care delivery are considered.
  • Article
    The exclusion of nonmaterial human phenomena mandated by medical science's continuing allegiance to a 17th century scientific world view has constituted a major obstacle to medicine's scientific maturation as a human discipline. But 20th century conceptual changes even in physics (not to mention the influence of the theory of evolution) now renders that exclusion untenable and in effect legitimizes efforts to devise scientific means appropriate for the human domain. Practical as well as theoretical issues involved in such an undertaking are discussed within the framework of a 20th century scientific world view as represented by the biopsychosocial model, a counterpart to the traditional biomedical model.
  • Article
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    The results of previous studies on the relationship between patient satisfaction and specific interviewing behaviors have been difficult to generalize because most studies have examined small samples of patients at one clinical location, and have used initial or acute care visits where the patient and physician did not have an established relationship. The present collaborative study of medical interviewing provided an opportunity to collect interviews from 550 return visits to 127 different physicians at 11 sites across the country. Tape recordings were analyzed using the Roter Interaction Analysis System, and postvisit satisfaction questionnaires were administered to patients. A number of significant relationships were found between communication during the visit and the various dimensions of patient satisfaction. Physician question asking about biomedical topics (both open- and closed-ended questions) was negatively related to patient satisfaction; however, physician question asking about psychosocial topics was positively related. Physician counseling for psychosocial issues was also positively related to patient satisfaction. Similarly, patient talk about biomedical topics was negatively related to satisfaction, while patient talk regarding psychosocial topics was positively related. Furthermore, patients were less satisfied when physicians dominated the interview by talking more or when the emotional tone was characterized by physician dominance. The findings suggest that patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.