In this longitudinal study of the impact of examination room computing on physician-patient interactions, overall visit satisfaction, satisfaction with the physician's level of familiarity, communication about medical issues, and the degree of comprehension with decisions made during the visit all improved significantly by seven months after implementation. Surprisingly, we did not find that the enhanced medical communication “crowded out” discussions about psychosocial issues or time for patient concerns from the patient perspective, even during the period immediately after implementation. We also did not detect any significant changes in comprehension about post-visit needs or satisfaction with the physician's personal manner, level of concern for the patient, or level of listening. Finally, we detected few changes in patient perceptions of computer use between one month and seven months after implementation.
We originally hypothesized that examination room computing might make the medical decision-making process more transparent and collaborative. In fact, patients reported that their physicians were more familiar with them, communication about medical care was better, and they understood and participated more in the medical decision-making process on average. Increases in satisfaction with the physician's use of the latest technology and familiarity with patients were expected after implementation and serve as a validity check on patient perceptions.
The lack of change from baseline to P2 in satisfaction with available time during visits was surprising. We had anticipated that physicians might have difficulty integrating computer use into their workflow during the initial months, leaving less time for patient needs, i.e., the computer would distract the PCP from the patient. We also hypothesized that availability of computer-based information could place greater emphasis on the medical aspects of the visit, thereby limiting the amount of time available for psychosocial aspects of care; however, patient satisfaction levels do not indicate that either the distraction or crowd-out phenomenon occurred. It is possible that previous experience with the computer-based electronic health record system used in the clinic could account for the absence of patient dissatisfaction after implementation.
Although the findings are generally reassuring, the data suggest opportunities for improving physician-patient interactions. For example, the level of patient comprehension of postvisit needs did not change significantly despite improvement in comprehension about what happened during the visit. Patient perceptions of the quality of computer use also did not appear to change over time, suggesting that time alone might not improve the quality of use. It may be important to continue to monitor computer use well after the initial implementation. Further research is needed to better understand the learning curve associated with successfully integrating examination room computing into ambulatory visits.
Previous studies on the impact of examination room computers are mixed. A few studies have found that introducing computers into examination rooms had an adverse effect on physician-patient communication.18,19,23
For example, using videos of ambulatory care visits, Greatbatch et al.20
found that physicians tended to be preoccupied with computer tasks, which hindered the flow of communication with their patients. These studies may have had limited ability to differentiate between the effects of physicians learning to use computers and electronic health records in the examination room and the office and experienced computer users attempting to integrate computers into the examination room during outpatient visits. A number of studies have found that examination room computers do not diminish patient satisfaction.21,27,28,29,30,31
In some cases, computer use may actually improve certain aspects of physician-patient communication, such as physicians taking a more active role in clarifying information or encouraging patient questions, a finding similar to ours in this study.18
Our findings might differ from other studies because we focused on sampling at three time points rather than a single cross-sectional sample. By measuring multiple time points for each physician, we were better able to control for individual physician behaviors. In addition, by including a second postimplementation period, we were able to account for changes that may have occurred due to greater physician experience in integrating the computer into the visit. Our study also gauged the quality of physician-patient interactions by querying patients directly about their satisfaction levels and separated the responses by measures expected to improve with greater information availability and measures expected to worsen because of greater visit complexity or increased emphasis on medical information. Last, many previous studies were conducted in the late 1980s or early to mid-1990s, when computer systems might have been less user-friendly or physicians and patients less computer savvy.
This study has several notable limitations. First, this was an observational study that relied on a convenience sample of physicians and patients. Because participation in the study was voluntary, there is the potential for selection bias, e.g., early adopters or individuals more predisposed to favor computers in the examination room may be more likely to participate. The observation process and especially the videotaping also could have influenced behavior or perceptions. The study, however, focused on relative changes over time; there is no reason to expect that there would be differential effects across the three time periods.
In addition, we studied a small number of PCPs who practiced in a single clinic, within a single, integrated system. We had limited power to detect small change in our outcomes; nevertheless, we found several significant findings consistent with our hypotheses. We also relied on patient perceptions and did not attempt to directly assess areas such as patient comprehension of self-care practices. Moreover, the setting, types of physicians, and previous experience of all the physicians with the electronic health record may limit the generalizability of these findings to other contexts. We also could not adjust for any secular trends in satisfaction or in ambulatory visits, given the absence of a concurrent control group. To our knowledge, however, there were no such changes during the study period at this clinic. Finally, we did not adjust the statistical analyses for multiple comparisons.26
In conclusion, this early study suggests that soon after the introduction of HIT into examination rooms, physicians used the computers in the majority of ambulatory care visits and that these activities appeared to have positive effects on several aspects of physician-patient interactions including overall visit satisfaction, satisfaction with the physician's level of familiarity, communication about medical decisions, and patient understanding of the medical decisions. There did not appear to be significant negative effects on other aspects of the relationship such as communication about psychosocial needs or available time for patients' concerns. Although these findings are generally positive, much additional research is needed to confirm and elaborate on these findings, and much opportunity remains for improving the quality of physician-patient communication and for improving the integration of computers into the clinical interaction.