Patients unhappy with doctors’ EHR use

No surprise here-patients say they are usually less satisfied with their doctor’s care when computers were used during appointments, according to a recent JAMA Internal Medicine study.

“Many clinicians worry that electronic health records (EHRs) keep them from connecting with their patients,” Neda Ratanawongsa, MD, MPH, associate professor at the University of California-San Francisco, who co-authored the research letter, told Reuters. “So it's not surprising that we found differences in the way clinicians and patients talk to each other.”

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For the study, researchers interviewed 47 patients diagnosed with at least one chronic condition who visited one of 39 doctors at a public hospital between 2011 and 2013. The interviews were conducted before and after the appointment, and in post-appointment interviews patients were asked to rate the quality of their care over the last six months.

Further, the researchers videotaped the appointments and reviewed the footage, rating the length of time the doctor spent using a computer to access EHRs. The EHRs could be used to review test results, prescribe medications, track healthcare maintenance and refer patients to specialists.

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The results showed that patients rated their care as “excellent” in about 50% of the 25 encounters with high computer use, compared with more than 80% of the 19 encounters with low computer use.

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Physicians who spent more time using a computer were found to have spent less time making eye contact with their patients and were more likely to do more “negative rapport building,” such as correcting patients about their medical history or drugs taken in the past based on information stored in their EHR.

Nevertheless, Ratanawongsa emphasizes that these actions are not necessarily bad, noting, “(EHRs) give important health information to clinicians, which may help safety-net patients with communication barriers like limited health literacy and limited English proficiency.”

While EHRs may bring benefits, many physicians remain discouraged about them.

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“(These) results don't surprise me much, since I predicted this would be the case more than 10 years ago when I was a family medicine resident and our clinic switched from paper to laptops in my third year of residency,” says Alexandria Tien, MD, supervising physician at the University of Massachusetts Dartmouth. “I expressed my misgivings back then, but the tech-happy attendings prevailed.”

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Brandon Peters, MD, expresses similar feelings.

“Where I see the EHR interfering with my visits is trying to capture the entire visit, including complaint ROS exam and plan, in real time,” says Peters, staff physician at Vidant Family Medicine in Edenton, North Carolina. “I find myself looking at a screen pushing buttons and not at the patient, (and) as we all know, many of the most important data points derive from a careful nuanced interview, not from making sure we asked about or examined enough body systems to justify an appropriate code.” 

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Using EHRs has transformed his patient visits from therapeutic care sessions to more like a data collection session, he said.

A solution to the headache, Peters explained, could be a universally accessible and accurate history of patients that physicians review and “fine tune” at each visit.

“Then, we could reduce the degree of data recording that we reproduce at each visit, often inaccurately in my experience,” he said. “(I) should be paid for time, not number (of) boxes checked.”

Medical Economics Advisory Board Member Melissa E. Lucarelli, MD, shared her tips for improving patient satisfaction when using EHRs, which she said, causes patients to witness “first-hand” frustrations of documentation and coordination of care from their doctors.

“To counteract this effect, I try to make a conscious effort to look away from the screen and make eye contact with the patient as often as possible during an office visit, and it is even more important than ever to exchange personal greetings and to take time to listen to their concerns,” says Lucarelli, who is also president and medical director of Randolph Community Clinic in Randolph, Wisconsin.

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Another strategy that can help to improve satisfaction with patients, she says, is to show them what you are doing and to acknowledge the elephant in the room-the EHR.

Lucarelli explains that during patient visits she shows patients their test reports on the screen, points out when their prescriptions have been updated and refills have been sent to the pharmacy, and occasionally even reads out loud the referral note she is sending to a specialist.

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“In addition, I try to reassure patients that although the computer can seem intrusive into our medical visit, that it is as much a clinical tool as a stethoscope or an ECG, and unlike those diagnostic tools, the computer provides an option for two-way communication-something which should ultimately improve patient satisfaction.”