EHR use and patient satisfaction: What we learned
In this study, how much time a physician spent looking at the patient predicted greater patient satisfaction. Overall, however, patients were highly satisfied with their physicians despite high EHR usage.
DISCUSSION
In this study, patients were highly satisfied with their clinicians despite often high usage of the EHR. Gadd and Penrod11 reported that patients perceived no impact on communication or eye contact with the clinician despite the initiation of an EHR system in 6 large academic medical practices. Another study demonstrated no significant differences in patient satisfaction with their physicians when comparing patients whose physicians used a paper charting system with those who used an EHR system.14
The fact that patients demonstrated high levels of satisfaction with patient-clinician communication even for clinicians with high EHR usage is somewhat surprising. However, Hsu et al15 found patients’ satisfaction with their clinicians’ communication about medical issues and familiarity with them increased 7 months after implementing an EHR system. In a different study that analyzed videotaped interactions between patients and 5 physicians, the patients found it disturbing not knowing what their doctor was doing when he or she worked on the computer, and preferred being able to see the computer screen.16 This study suggests that it’s advisable for clinicians to describe what they are doing when they use the computer, so that patients better understand how this time spent inputting data actually benefits them.
EHRs can be time-consuming. Physicians and nurses in our study interacted with the EHR a great deal during the office visit, as evidenced by the large average number of clicks and scrolls. This finding confirms clinicians’ perceptions of the amount of work the EHR system requires. For example, in a semi-structured interview of physicians regarding their use of a VA EHR system,10 one respondent noted that the reminders in the EHR required hundreds of clicks.
In our study, the average number of clicks and scrolls during the visit was 192, with some clinicians registering hundreds more. In fact, concerns about the time involved in the use of the EHR and about the adequacy of data collection may lead some clinicians who currently don’t have an EHR system to be reluctant to integrate one into their practices.17
Makoul et al18 found that compared with physicians who used a paper chart, physicians who used an EHR system were more active in clarifying information from the patient and encouraging patient questions during visits, although the study found a trend toward less active roles in more patient-centered communication when using an EHR system. This latter finding is similar to the concerns raised in our study.
Clinical and communication skills are factors, too. One study found that compared to patients who were cared for by more experienced physicians, patients seen by residents using EHRs were more likely to feel that the physician spent less time talking with them and examining them; they were also more likely to report that the visit felt less personal.19 Another study found that clinicians with poor baseline communication skills had more difficulties interacting with patients when an EHR system was introduced than those who had better baseline communication skills.20
Training needed to improve communication during EHR use. Research has shown that when used properly and thoughtfully, EHR use can result in greater patient engagement.21 But, as noted above, there are challenges, suggesting a need for training clinicians to more successfully use an EHR system while simultaneously communicating with their patients.
Study limitations. This study was conducted at a single site, using a single EHR system deployed in the VA clinics. We cannot generalize our findings to other sites or types of clinic systems. Other EHR systems may have different functionalities, which may affect the time required to provide the same type of medical care.
In addition, the study involved only 23 physicians and nurses in a single health system. Other clinicians may have patterns different from those we studied, although a wide range of patterns was seen among the participants, as demonstrated by the large variation in the number of clicks and scrolls. Another limitation is that study patients were not randomly selected, but rather referred by the provider, and the visits were not blinded to either the provider or patient. This may cause some selection bias.
In this study of VA clinicians’ EHR use, patients expressed satisfaction with the clinicians’ clinical skills and patient-centered communication when the clinician spent more time and a greater percentage of the visit engaging the patient. EHR systems need to be designed in a clinician-friendly manner that allows for increased time during the interaction for face-to-face communication between the clinician and the patient, and to ease the workload of EHR documentation. In the meantime, clinicians should be trained in how to expedite their use of the EHR during the clinical visit as well as outside of the exam room in order to improve their patients’ satisfaction.
