Richard M. Frankel, PhD Center for Implementing Evidence Based PracticeRoudebush VAMCProfessor of Medicine and GeriatricsSenior Research Scientist Regenstrief InstituteIndiana University School of Medicine                                                                           VIReC Information Seminar                                                          December 19, 2006

The Effect of Computers at the Point of Care: Practical Implications for Physicians and Patients 	    

Clinicians

Patients

Exam Room Computers

Today’s Presentation: 
        - Background and history
        - Study Overview
        - Findings and Lessons
        - Implications

Background:
        - Clinician-patient relationships central to ambulatory care
        - Increasing use of information technology  (IT) in health care 
        - Increasing use of EMRs at the point of care, i.e., the exam room.
        - Potential for IT to enhance clinical care
        - Concerns that IT could create barriers for the relationship
        - Limited information on IT effects on clinician-patient communication

Concerns over safety identified by the IOM have led to an interest in the use of exam room computers to create more accurate and available records.  In many practices in the era of paper charts, there was a 50-50 chance of having the chart available when the patient appeared for care.

According to George Engel, the father of the biopsychosocial model of care, “The interview (and relationship) are the most powerful, encompassing and versatile instrument available to the physician.

Study Question

“How does the presence of a computer in the exam-room impact communication between patients and clinicians?”

Stakeholders in the Medical Record 1900

 Patient       

Record

of

care

Doctor

Doctor’s private notes

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Stakeholders in the Medical Record 1950

 Patient        

Record

of

Care 

Doctor

Public Health

Clinical Researchers

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Stakeholders in the Medical Record 2006

 Patient       

Record

of

care

  Doctor

  3rd Party Payers

  Medicare

  Pt Safety/Quality

  Health Services Res.

  Policy Analysts

  Regulators

  Hospital Epi.

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The Interaction Study
        - Setting: Single outpatient center in a prepaid, integrated delivery system
        - Population: 
        - Primary care clinicians at the clinic
        - Regularly scheduled patients
        - Sample: convenience sample

Location:

Clinicians’ regular exam-rooms

Design:

Longitudinal Video-based  Study                         Three Observation Periods

Analysis:

Quantitative Analysis of questionnaires

Qualitative Review of Videotapes

Methods

Analysis involved 2 study team members using a variant of grounded theory making detailed field notes of their observations of the tapes.  Skeptical peer review and constant comparison used to assure the trustworthiness of the data 

Changes in Patient Visit Satisfaction After the Introduction of the Computer

Patients reporting Excellent or Very Good satisfaction. Differences statistically significant (p<0.05) after adjusting for age, gender, and self-reported health status, based on maximum-likelihood ordered logit model.

jth: Nan

Positive Patient Overall Perceptions of the Computer: Significant Improvements Over Time

Patients reporting Strongly Agree or Agree. Differences statistically significant (P<0.05) after adjusting for age, gender, and self-reported health status, based on maximum-likelihood ordered logit model. 

Recurrent Patient Confidentiality Concerns

“The use of computers makes me concerned about my privacy”
        - 41% Totally Agree or Agreed, immediately after computer introduction
        - 45% Totally Agree or Agreed, seven months after computer introduction and six months after training

“Did the Clinician or the medical assistant explicitly discuss the confidentiality of electronic medical records or data security.”
        - 4% Immediately after computer introduction
        - 0% Seven months after computer introduction and six months after training

Summary of Quantitative Findings
        - Overall Patient Satisfaction was very high (88.8%) - No significant changes after the introduction of the computer
        - Significant improvements in patient satisfaction with decision-making, clinician’s use of the computer, and focus on prevention after the introduction of the computer
        - Patient overall perceptions of the computer were positive with some significant improvement over time
        - Patient concerns about the confidentiality of information may not be adequately addressed at present

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Qualitative Analysis
        - Nine clinicians and 54 visits: two visits per period per clinician
        - Variations in computer use across visits in all periods
        - Variations in the quality of communication across visits in all periods
        - Introduction of the computer appeared to enhance the quality of communication in some visits and created  barriers to communication in others

Quality of Communication
        - Verbal Dialogue: Clinician maintains conversation, even while performing other tasks, e.g. physical exam or typing

Visual Connection: Clinician maintains eye contact, even while performing visit tasks, e.g.  Intermittently glances at the patient while entering data on the computer

Postural Orientation: Clinician positions head and  torso to align with patient and computer, e.g. positions own body and computer screen to avoid excluding the patient 

After reviewing the literature on clinician patient communication we identified three dimensions of communication that relate to both quality and outcome: Verbal, visual and postural.  

While optimal communication likely involves all three dimensions simultaneously, we credited clinicians if they used any of the dimensions while also using an exam room computer. 

Video Coding
        - Preliminary Coding      Review of tapes by entire research team to               develop initial themes  
        - Major Coding Categories  
        - Visit organization 
        - Interpersonal skills
        - Technical mastery skills
        - Spatial organization  
        - Coded by 2 Ph.D. qualitative researchers

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Baseline Visit Organization Skills

	Without a computer, not eliciting an agenda can make a visit 

Inefficient

Disorganized

Run over schedule

Visit Organization (Baseline/Negative)

   In this baseline visit, no formal agenda is set.  The patient has multiple medical concerns, including sarcoid.  Problems are discussed serially as the patient brings them up and without any indication of how many concerns the patient has, how much time they will take to discuss and how they might be related.  The visit appears quite inefficient and poorly organized 

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Amplification Effect

   Previous baseline skills may affect how exam room computers are used and the extent to which they facilitate or create additional barriers to clinician patient communication.

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Amplification of Visit Organization Skills  (Post introduction)

    The same clinician seems to get confused between patient agenda items and information on the computer screen.  Each time the computer is consulted current problems are deferred and are dealt with some time later, confusing the patient.  The presence of the computer multiplies the sense of disorganization, and extends the length of the visit.  The clinician also seems to get lost in a maze of windows while looking for a test result and at times inquires about items the MA has already checked on.

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Interpersonal Skills

Clinicians with good interpersonal skills

Encourage patient input

Listen to patients’ concerns 

Maintain eye contact

Chart intermittently or not at all during visit

Pre-computer Visit:

   In this visit, the clinician sits on a stool across from the patient and maintains eye contact with the patient when she speaks. The clinician writes on the paper medical chart intermittently throughout the visit, and only when the patient has finished speaking. The patient appears to have the complete verbal, visual, and physical attention of the clinician during the visit.

Amplification of Interpersonal Skills (Positive)

Increased Quality of Communication
        - The computer served as another tool to help the clinician communicate or remain more familiar with the patient

The net computer effect was a higher quality of clinician-patient communication:

More verbal dialogue about the patient’s problems

Enhanced visual interaction - shared review of information on the computer

Continued clinician physical alignment with the patient, e.g. tilting the screen so both can see

Post-computer Visit:   

    In this visit, the same clinician sees a patient, who comes in after several ED visits for the same complaint. Using the computer, the clinician notices that the patient is taking a medication, which could explain the patient’s symptoms; the clinician tells the patient that the medication may not be appropriate. During the interaction, the clinician tilts the computer screen and invites the patient to review the visit notes together. The clinician then reinforces and amplifies the message by pushing away the computer screen establishing eye contact and explaining the drug’s paradoxical effects to the patient.

Interpersonal Skills  (Baseline/ Positive)

    During this Period 1 visit, the clinician sits    

    on a low  stool across from the patient and  

    maintains gaze focused on the patient when 

    speaking. Information is entered onto the paper chart intermittently and only when the patient has finished speaking. 

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Amplification of Interpersonal Skills (Post Introduction/Positive)

   The same clinician sees a patient in Period 2, who comes in after several ER visits for panic attacks.  The clinician notices that the patient is on a medication known to cause similar symptoms and tells her that it may not be appropriate for her, all the while tilting the computer screen so that they can both review the notes. The clinician then reinforces and amplifies the message by pushing away the computer screen establishing eye contact and explaining the drug’s paradoxical effects to the patient.

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Technical Skills

Inability to successfully navigate program leads to:

Inability to access data consistently

Wastes of time

Frustration for clinicians and patients   

Post-computer Visit: 

    In this visit, the clinician uses the computer to emphasize several clinical points. During a discussion about the importance of controlling the patient’s blood pressure (BP), the clinician graphs the patient’s BP trends over the past two years. In the same visit, the clinician also graphs the patient’s hemoglobin A1C levels over time to reassure the patient and his wife that the patient’s blood sugar control has been good. The clinician is able to perform these graphs effortlessly and on demand while simultaneously talking with the patient and intermittently maintaining eye contact with both the patient and his wife.

Technical Skills Post Introduction/Negative

   In this visit the clinician is looking for recent medical hx using the computer. The patient tries to tell the clinician, who is busy on the computer, that she has a list of meds but it is to no avail. She succeeds in her 2nd try and the clinician takes the list and starts copying the information to a paper chart that will have to be typed back into the computer at a later point.  Both clinician and patient seem frustrated with the process which takes a long time to complete.

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Spatial Organization of the Visit

Re-enactment: Clinician and Patient Using the Computer Together

In this visit, the computer screen is easily visible to both the clinician and the patient. When the clinician uses the computer, the patient watches the screen. During one discussion about test results, the clinician pauses, turns the screen more towards to the patient, and begins talking about the results. Throughout the visit, the clinician turns her body or her head towards the patient when talking.

J Hsu:

In this visit, the computer screen is easily visible to both the clinician and the patient. When the clinician uses the computer, the patient watches the screen. During one discussion about test results, the clinician pauses, turns the screen more towards to the patient, and begins talking about the results. Throughout the visit, the clinician turns her body or her head towards the patient when talking.

Re-enactment: The Computer Creating a Barrier to Communication

Summary
        - Variations in computer use and the quality of clinician-patient communication during visits
        - Digital Amplification: Computer use could increase or decrease the quality of communication between clinicians and patients
        - Key Factors Modifying the Computer Effects:
        - Visit Organization
        - Interpersonal Skills
        - Technical Computer Skills
        - Spatial Orientation

Limitations
        - Small, convenience sample 
        - Primary care visits only
        - Normative measures of communication quality
        - Qualitative analyses only
        - Single clinic within a prepaid, integrated delivery system
        - Experience during initial seven months after the introduction of computers into the exam-room 

Implications
        - Use of computers has the potential to increase or decrease the quality of clinician-patient communication
        - Four factors appear to influence the direction of this digital amplification
        - More research is needed to understand the potential impact of IT innovations on the clinician-patient relationship
        - Guidelines and training programs could help clinicians use the new technology more effectively  

Thank you for your time and attention !