Purpose Few studies have quantitatively examined the degree to which the use of the computer affects patients’ satisfaction with the clinician and the quality of the visit. We conducted a study to examine this association.
Methods Twenty-three clinicians (21 internal medicine physicians, 2 nurse practitioners) were recruited from 4 Veteran Affairs Medical Center (VAMC) clinics located in San Diego, Calif. Five to 6 patients for most clinicians (one patient each for 2 of the clinicians) were recruited to participate in a study of patient-physician communication. The clinicians’ computer use and the patient-clinician interactions in the exam room were captured in real time via video recordings of the interactions and the computer screen, and through the use of the Morae usability testing software system, which recorded clinician clicks and scrolls on the computer. After the visit, patients were asked to complete a satisfaction survey.
Results The final sample consisted of 126 consultations. Total patient satisfaction (beta=0.014; P=.027) and patient satisfaction with patient-centered communication (beta=0.02; P=.02) were significantly associated with higher clinician “gaze time” at the patient. A higher percentage of gaze time during a visit (controlling for the length of the visit) was significantly associated with greater satisfaction with patient-centered communication (beta=0.628; P=.033).
Conclusions Higher clinician gaze time at the patient predicted greater patient satisfaction. This suggests that clinicians would be well served to refine their multitasking skills so that they communicate in a patient-centered manner while performing necessary computer-related tasks. These findings also have important implications for clinical training with respect to using an electronic health record (EHR) system in ways that do not impede the one-on-one conversation between clinician and patient.
Primary care physicians’ use of electronic health record (EHR) systems has markedly increased in recent years. For example, a 2008 study of more than 1000 randomly selected practicing physicians in Massachusetts found that 33% utilized an EHR.1 Many physicians believe that EHR systems are beneficial to patient care,2 and several studies have supported this perception, showing clear benefits of EHR use. A study of one component of EHR systems—computerized physician order entry (CPOE)—found that CPOEs resulted in a >50% decrease in serious medication errors.3 Other errors have declined with the use of EHR systems, as well; Virapongse et al1 found a trend towards fewer paid malpractice claims against physicians who used an EHR compared to those physicians using paper charting.
EHR systems may also improve efficiency. In a study of a health maintenance organization (HMO) model, initiating an EHR system improved efficiency by decreasing office visits.4 Widespread adoption of EHR systems could save an estimated $81 billion annually through reductions in errors and adverse events, and improved preventive care and chronic disease management.5 In a survey of approximately 300 patients who had been evaluated at a family medicine clinic for hypertension, high blood pressure without hypertension, or hyperlipidemia, 75% indicated that they felt EHRs had a positive impact on their care.6
However, some clinicians are concerned about the possible negative impact of EHR systems on health care. One major concern is that EHR systems might increase physician workload7 and the amount of time spent using a computer during patient visits. A study that examined physician EHR use found that while time spent on certain tasks, such as prescription writing and lab ordering, was reduced, there was an overall increase in time spent on computer tasks related to charting, preventive care, and chronic disease management.8 Baron et al9 also found an increase in time spent using the EHR during each clinic session in one private practice setting.
Physicians are also concerned that EHR systems might interfere with the patient-physician interaction (eg, maintaining eye contact, paying attention to patients’ concerns) by directing the physician’s attention away from the patient and toward the computer.10 In one study, this concern increased after physicians started utilizing a new EHR system.11 Although a survey of inpatients indicated that residents engaged in greater patient-physician communication after an EHR was implemented,12 a separate study conducted in an outpatient setting found physicians spent less time looking at patients after converting from a paper-based system to an EHR system.13
Very few studies have quantitatively examined the association of patient satisfaction with clinician EHR usage. The goal of this study was to examine the correlation of patient satisfaction with actual EHR usage in an ambulatory setting. The data reported in this paper are part of a larger study aimed at understanding EHR use in a VAMC.