Clinician style and examination room computers: a video ethnography (original) (raw)
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Doctor, patient and computer - A framework for the new consultation
International Journal of Medical Informatics, 2009
Physician-patient relationship Medical informatics Qualitative research Office visits a b s t r a c t Purpose: The use of a computer during general/family practice consultations is on the rise across the world, yet little is known about the effect the use of a computer may have on the all important physician-patient relationship. This paper provides a framework for further analysis of computers influence on physician-patient interactions during general practice consultations.
Physicians, patients, and the electronic health record: an ethnographic analysis
The Annals of Family …, 2006
PURPOSE Little is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that influence the manner by which physicians use the EHR with patients.METHODS This ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offices in the Pacific Northwest; individual interviews with 52 patients, 12 office staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focus-group interviews with physicians and computer advocates. The main outcome measures were factors that influence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data.RESULTS This study identified 14 factors that influence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial—effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational—perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational—issues of developing physicians’ proficiency with and improving patients’ understandings about EHR use; and (4) structural—institutional and technological forces that influence how physicians perceived their use of EHR.CONCLUSIONS This study found that the introduction of EHRs into practice influences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships.
Journal of general practice (Los Angeles, Calif.), 2013
Researchers have been increasingly interested in the influence of computers on physician-patient communication in consultation rooms because of the substantial growth in the use of Electronic Health Records (EHRs) in the U.S. Previous research showed that physicians have different ways of interacting with patients and EHRs; and these styles may relate to different patterns of nonverbal interaction between the physicians and patients and influence the outcomes of the clinical visit. The purpose of this study was to identify the differences of eye gaze patterns in three EHR interaction styles: the technology-centered style, the human-centered style, and the mixed interaction style. 100 primary care visits with different interaction styles were videotaped. Eye gaze behaviors were coded and described as frequencies and durations of gaze. The dynamic eye gaze patterns of the physicians and patients, in terms of how their gaze behaviors were sequentially associated, were analyzed using la...
Patient Education and Counseling, 2006
Objectives: Within the context of medical care there is no greater reflection of the information revolution than the electronic medical record (EMR). Current estimates suggest that EMR use by Israeli physicians is now so high as to represent an almost fully immersed environment. This study examines the relationships between the extent of electronic medical record use and physician-patient communication within the context of Israeli primary care. Methods: Based on videotapes of 3 Israeli primary care physicians and 30 of their patients, the extent of computer use was measured as number of seconds gazing at the computer screen and 3 levels of active keyboarding. Communication dynamics were analyzed through the application of a new Hebrew translation and adaptation of the Roter Interaction Analysis System (RIAS). Results: Physicians spent close to one-quarter of visit time gazing at the computer screen, and in some cases as much as 42%; heavy keyboarding throughout the visit was evident in 24% of studied visits. Screen gaze and levels of keyboarding were both positively correlated with length of visit (r = .51, p < .001 and F(2,27) = 2.83, p < .08, respectively); however, keyboarding was inversely related to the amount of visit dialogue contributed by the physician (F(2,27) = 4.22, p <. 02) or the patient (F(2,27) = 3.85, p < .05). Specific effects of screen gaze were inhibition of physician engagement in psychosocial question asking (r = À.39, p < .02) and emotional responsiveness (r = À.30, p < .10), while keyboarding increased biomedical exchange, including more questions about therapeutic regimen (F(2,27) = 4.78, p < .02) and more patient education and counseling (F(2,27) = 10.38, p < .001), as well as increased patient disclosure of medical information to the physician (F(2,27) = 3.40, p < .05). A summary score reflecting overall patient-centered communication during the visit was negatively correlated with both screen gaze and keyboarding (r = À.33, p < .08 and F(2,27) = 3.19, p < .06, respectively). Discussion: The computer has become a 'party' in the visit that demanded a significant portion of visit time. Gazing at the monitor was inversely related to physician engagement in psychosocial questioning and emotional responsiveness and to patient limited socio-emotional and psychosocial exchange during the visit. Keyboarding activity was inversely related to both physician and patient contribution to the medical dialogue. Patients may regard physicians' engrossment in the tasks of computing as disinterested or disengaged. Increase in visit length associated with EMR use may be attributed to keyboarding and computer gazing. Conclusions: This study suggests that the way in which physicians use computers in the examination room can negatively affect patientcentered practice by diminishing dialogue, particularly in the psychosocial and emotional realm. Screen gaze appears particularly disruptive to psychosocial inquiry and emotional responsiveness, suggesting that visual attentiveness to the monitor rather than eye contact with the patient may inhibit sensitive or full patient disclosure. Practical implications: We believe that training can help physicians optimize interpersonal and educationally effective use of the EMR. This training can assist physicians in overcoming the interpersonal distancing, both verbally and non-verbally, with which computer use is
Effects of exam-room computing on clinician-patient communication
Journal of General Internal Medicine, 2005
OBJECTIVE: To evaluate the impact of exam-room computers on communication between clinicians and patients. DESIGN AND METHODS: Longitudinal, qualitative study using videotapes of regularly scheduled visits from 3 points in time: 1 month before, 1 month after, and 7 months after introduction of computers into the exam room. SETTING: Primary care medical clinic in a large integrated delivery system. PARTICIPANTS: Nine clinicians (6 physicians, 2 physician assistants, and 1 nurse practitioner) and 54 patients. RESULTS: The introduction of computers into the exam room affected the visual, verbal, and postural connection between clinicians and patients. There were variations across the visits in the magnitude and direction of the computer's effect. We identified 4 domains in which exam-room computing affected clinician-patient communication: visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the exam room. We observed a range of facilitating and inhibiting effects on clinician-patient communication in all 4 domains. For 2 domains, visit organization and verbal and nonverbal behavior, facilitating and inhibiting behaviors observed prior to the introduction of the computer appeared to be amplified when exam-room computing occurred. Likewise, exam-room computing involving navigation and mastery skills and spatial organization of the exam-room created communication challenges and opportunities. In all 4 domains, there was little change observed in exam-room computing behaviors from the point of introduction to 7-month follow-up. CONCLUSIONS: Effective use of computers in the outpatient exam room may be dependent upon clinicians' baseline skills that are carried forward and are amplified, positively or negatively, in their effects on clinician-patient communication. Computer use behaviors do not appear to change much over the first 7 months. Administrators and educators interested in improving exam-room computer use by clinicians need to better understand clinician skills and previous work habits associated with electronic medical records. More study of the effects of new technologies on the clinical relationship is also needed.
Patient Education and Counseling, 2014
Objective-The computer with the electronic health record (EHR) is an additional 'interactant' in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit. Methods-Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via videorecording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient
Analysing the doctor_patient_computer relationship: the use of video data
Journal of Innovation in Health Informatics, 2006
This paper examines the utility of using digital video data in observational studies involving doctors' and patients' use of computers in the consultation. Previous observational studies have used either direct observations or analogue videotapes. We describe a method currently in use in a study examining how doctors, patients and computers interact in the consultation. The study is set in general practice as this is the most clinically computerised section of the Australian healthcare system. Computers are now used for clinical functions in 90% of doctors' surgeries. With this rapid rise of computerisation, concerns have been expressed as to how the computer will affect the doctor-patient relationship. To assess how doctors, patients and computers interact, we have chosen an observational technique, namely to make digital videotapes of actual consultations. This analysis is based on a theoretical framework derived from dramaturgical analysis. Data are gathered from general practitioners who are high-level users of computers, as defined by their use of progress notes, as well as prescribing and test ordering. The subsequent digital data is then transferred onto computer and analysed according to our conceptual framework, making use of video-tagging software.
2012
The implications of the patient-physician relationship and communication on healthcare quality have been widely discussed in previous research. Communication has been characterized as one of the most powerful, encompassing, and versatile instruments available to the physician and it has been suggested that good patient-physician communication can improve healthcare outcomes. The incorporation of Electronic Medical Records (EMRs) in primary care provides an opportunity for improving healthcare services and quality of care. EMRs have, without a doubt, transformed the dynamics of the medical encounter. Implications of EMRs on the patient-physician communication, and thus on healthcare quality, have not yet reached a full understanding. Existing physician communication skills assessment tools do not take into account the physician's need to divert his/her attention from the patient to the computer, and vise versa. One such tool is the SEGUE. This research-in-progress paper aims to d...
Journal of Evaluation in Clinical Practice, 2009
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. A qualitative, 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 physicianpatient 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.