Working with an Electronic Medical Record in Ambulatory Care: A Study of Patient Perceptions of Intrusiveness

by Milisa K Rizer, MD, MPH; Cynthia Sieck, PhD, MPH; Jennifer S. Lehman; Jennifer L. Hefner, PhD, MPH; Timothy R. Huerta, PhD, MS; and Ann Scheck McAlearney, ScD, MS

Abstract

Objective: To assess patient perceptions of electronic medical record (EMR) intrusiveness during ambulatory visits to clinics associated with a large academic medical center.

Methods: We conducted a survey of patients seen at any of 98 academic medical center clinics. The survey assessed demographics, visit satisfaction, computer use, and perceived intrusiveness of the computer.

Results: Of 7,058 patients, slightly more than 80 percent reported that the physician had used the computer while in the room, but only 24 percent were shown results in the EMR. Most patients were very satisfied or satisfied with their visit and did not find the computer intrusive (83 percent). Younger respondents, those shown results, and those who reported that the physician used the computer were more likely to perceive the computer as intrusive. Qualitative comments suggest different perceptions related to computer intrusiveness than to EMR use more generally.

Discussion: Patients were generally accepting of EMRs and therefore use of computers in the exam room. However, subgroups of patients may require greater study to better understand patient perceptions related to EMR use and intrusiveness.

Conclusion: Results suggest the need for greater focus on how physicians use computers in the exam room in a manner that facilitates maintaining good rapport with patients.

Keywords: electronic medical records, patient assessment, academic medical center, medical education, ambulatory

Introduction

The rate of electronic medical record (EMR) adoption by office-based providers continues to rise in response to federal legislation.1, 2 EMR technology can have a positive impact on the quality, cost, and efficiency of health care;3–5 however, this proliferation is not without consequence. Accessing the EMR during a patient visit has the potential to alter the clinical encounter: the computer takes the role of a “third party” in the room,6 potentially diminishing rapport and engagement with the patient.7, 8

Frankel et al. identified four areas in which the computer in the exam room may have an impact: organization of the visit, verbal/nonverbal behavior, provider ease of computer navigation, and the layout of the exam room itself.9 Use of the computer can organize the data collection element of a visit, but providers must still adapt when a patient’s concerns do not follow the discussion trajectory of the EMR. The verbal and nonverbal behavior of providers, including when and how they utilize the computer, can influence their interaction with the patient. Relatedly, provider comfort and skill with use of the computer can have an effect. Finally, the computer should be positioned in the exam room so that the provider can face the patient and share the screen as appropriate to facilitate more effective communication.

In addition, Duke et al. document that physicians spend up to 55 percent of the visit looking at the computer screen and not at the patient.10 This time may have a significant effect on the patient’s perception of the visit because patients report lower satisfaction with providers who spend a significant portion of the visit facing the computer.11 Further, physician-computer interaction may reduce dialogue with the patient because the physician appears busy and patients may be reluctant to interrupt.12 Studies of physician-patient communication suggest that excellent communicators have higher patient and provider satisfaction ratings, better symptom resolution, improved functioning, greater efficiency, and fewer malpractice suits.13–15 The American Medical Association recognized the importance of this issue by providing their members with advice on effective computer use as well as suggesting measures to assess their effect.16 However, current approaches to EMR training for physicians typically focus primarily on the technical aspects of utilization, and little on incorporating use of the computer into the visit.17–19

The intersection of EMR use and provider communication skills is an important area for understanding how patients feel about EMR and computer use during the visit. While studies have examined satisfaction with the visit, our review of the literature revealed no post-visit studies evaluating patients’ assessments of intrusiveness of the EMR in the physician-patient interaction during an office visit. We believe this distinction is important because satisfaction can be influenced by a variety of factors. To address this issue and assess the extent to which patients believe EMR use is intrusive to the physician-patient interaction during an office visit, our study examines patients’ reports of their experiences directly following an encounter in which the EMR is used.

Methods

Study Design

This study was conducted at 98 ambulatory clinics affiliated with a major academic medical center that had implemented an ambulatory EMR system prior to the study. Participants included patients seen by a provider at one of the ambulatory clinics, responding to an anonymous survey immediately following the clinic visit. Participants were at least 18 years of age, demonstrated the ability to speak and read English, and were able to give voluntary informed consent. This study was deemed exempt from review by the center’s Institutional Review Board.

Measures

The survey developed for this study (see Table 1) asked about patient sociodemographics and about visit characteristics including a patient’s history with the provider, visit satisfaction, computer and EMR use during the visit, and perceived intrusiveness of the computer. An open-ended item was included at the end of the survey in which the respondent was asked to share any additional thoughts regarding use of an EMR.

Quantitative Analysis

Univariate analyses explored associations between survey items and patient demographics and responses to the question about intrusiveness of the exam room computer, using ANOVA or the nonparametric equivalent Kruskal-Wallis tests (continuous variables) and the Pearson chi-square or Fisher exact tests (categorical variables). Multinomial logit models were used to examine adjusted associations (odds ratios) between patient ratings of computer intrusiveness and each of the remaining survey items. The models represent the log odds of each category compared to the “not intrusive” category. All statistical analyses were conducted in SAS version 9.2.

Qualitative Analysis

Verbatim comments from the open-ended portion of the survey were analyzed using the constant comparative analytic approach using both inductive and deductive methods.20 The coding team reviewed comments to identify broad themes and developed a preliminary coding dictionary. We then coded the data into broad theme categories, and discussed potential subthemes as they emerged,21 meeting regularly throughout the process to clarify coding decisions and ensure that we reached consensus about themes and subthemes in the data.

Results

A total of 7,058 patients responded to the survey (see Table 1). Respondents were mostly female and white, with a mean age of 51.1 years (SD, 15.7; range, 18–99 years; 6,944 respondents). Most were returning patients who had an existing relationship with the provider. Slightly more than 80 percent reported that the physician had used the computer while in the room with them, and 24 percent had been shown results in the EMR. Most patients were very satisfied or satisfied (76 percent and 20 percent respectively) with their office visit. The majority (83 percent) did not find the computer in the exam room to be intrusive.

Table 2 presents odds ratios and frequencies for the three variables significantly associated with perceived computer intrusiveness in the multivariate model. Younger respondents, those who were shown results during the visit, and those who reported that the physician used the computer while in the room were significantly more likely to perceive the computer as intrusive (p < .0001).

Patients’ comments from the open-ended survey (n = 2,245) suggested different thoughts about the presence of the computer than about the use of the EMR more generally (see Table 3). Those who reported greater computer intrusiveness also discussed positive EMR factors including increased efficiency, convenience of a unified record, data sharing among providers, and improved care. Patients’ negative comments related to data security, suggesting acceptance of EMRs generally, but lingering concerns about data storage, accuracy, and privacy. The few comments related to interaction with the physician or medical staff and the computer noted benefits of an EMR but also reflected respondents’ perceptions that patient-provider interaction without the computer was important.

Discussion

A main finding of this study is that most patients reported that they did not find the computer to be intrusive. Qualitative comments were also mostly positive. Further, even patients who did perceive the computer to be intrusive were still satisfied with their visit, supporting findings in the literature related to patient satisfaction.22, 23 Nonetheless, some patient subgroups perceived greater levels of intrusiveness than others. For example, patients who were shown elements of the EMR during the visit had 50 percent higher odds of reporting computer intrusiveness. This finding may reflect deficiencies in current teaching approaches that emphasize triangulation of the computer, patient, and physician in the exam room,24 and provides a reminder for physicians to continue to be attentive to the individual needs of patients through eye contact and touch.

Further, younger patients, specifically millennials aged 18 to 34 years, perceived greater intrusiveness than older patients. Millennials are typically considered to be enthusiastic about technology and comfortable with electronic sharing of information. Their greater sense of intrusiveness may be due to concern about the digital use of their medical information over which they have no control. It is also possible that because millennials themselves are fairly adept at incorporating technology into their regular interactions, they may be more sensitive to providers who are less comfortable with technology in the exam room.

Open-ended comments suggest that patients have somewhat mixed feelings about EMRs and computers. Positive and negative comments focused on very different aspects of technology, with the former noting the value added to the visit and care process and the latter related to fears about data security and privacy. Patients recognized the conveniences associated with EMRs, including having records easily accessible in one location and the ability to quickly look up results during the visit. However, some expressed concerns about the potential loss or theft of electronic data, wanting to understand the security in place to protect their data and to control access only to those who were involved in providing care. Another theme among negative comments centered on interactions with the provider, computer, and patient. A portion of patients, though small in number, commented that they felt the computer distracted the provider’s attention away from the patient.

While most patients did not perceive the computer as intrusive, our study identifies potential areas for future research. For example, patients expressed concerns related to the security of the data. Studies comparing methods for presenting the steps health systems take to store and protect patient data may help to identify how patients understand data security and what factors are most important to them. Additionally, studies on the use of medical scribes could provide guidance on alternative methods for entering data into the EMR. Finally, our finding that millennials viewed the computer as more intrusive than did other age groups suggests that more research is needed to understand what factors may lead this age group to view the computer as intrusive.

Practice Implications

This study highlights the need for greater attention to how physicians work with the EMR during the patient visit. In a review of technical training for medical providers, Duke et al. offer some important considerations for more smoothly integrating the computer into the patient interaction,25 including keeping the patient, not computer entry, as the focus through eye contact, learning to type to allow for greater eye contact with the patient, and beginning each encounter with the patient’s concerns even if those do not align with the EMR data entry flow. Further, these authors recommend steps to increase engagement with the patient and the patient’s EMR by showing the patient the computer screen, telling the patient what is being entered, and encouraging patients to participate in a review of results and medications. Our results, however, suggest that some patients may prefer not to be shown the computer screen because they see it as an intrusion in their visit, and that some physicians may not incorporate the EMR into the visit in a comfortable manner. These findings thus further emphasize the importance of teaching skills related to appropriate incorporation of EMRs into the patient visit, as well as recognizing patient preferences.

Conclusion

Our results suggest several important considerations for physicians attempting to incorporate EMRs in a way that is engaging to patients. While patients may be generally accepting of EMRs, not all patients feel the same way, and providers need to remain attentive to patients’ reactions to their use of the computer. Sensitive attention to these issues may foster greater engagement between the physician and patient, and help to alleviate concerns about technology intrusiveness in healthcare.

 

Milisa K Rizer, MD, MPH, is professor of family medicine and biomedical informatics in the Departments of Family Medicine and Biomedical Informatics in the College of Medicine of The Ohio State University and chief medical information officer of the Ohio State University Wexner Medical Center in Columbus, OH.

Cynthia Sieck, PhD, MPH, is an assistant professor of family medicine in the Department of Family Medicine in the College of Medicine of The Ohio State University in Columbus, OH.

Jennifer Lehman is clinical research manager in the Department of Family Medicine in the College of Medicine of The Ohio State University in Columbus, OH.

Jennifer L. Hefner, PhD, MPH, is an assistant professor of family medicine in the Department of Family Medicine in the College of Medicine of The Ohio State University in Columbus, OH.

Timothy R. Huerta, PhD, MS, is associate professor of family medicine and biomedical informatics in the Departments of Family Medicine and Biomedical Informatics in the College of Medicine of The Ohio State University in Columbus, OH.

Ann Scheck McAlearney, ScD, MS, is professor and vice chair for research in the Department of Family Medicine in the College of Medicine of The Ohio State University and research director for the Central Ohio Practice-Based Research Network in Columbus, OH.


Notes

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  3. Chaudhry, B., et al. “Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care.” Annals of Internal Medicine 144, no. 10 (2006): 742–52.
  4. Buntin, M. B., et al. “The Benefits of Health Information Technology: A Review of the Recent Literature Shows Predominantly Positive Results.” Health Affairs (Project Hope) 30, no. 3 (2011): 464–71.
  5. Rollman, B. L., et al. “A Randomized Trial Using Computerized Decision Support to Improve Treatment of Major Depression in Primary Care.” Journal of General Internal Medicine 17, no. 7 (2002): 493–503.
  6. Ventres, W. B., and R. M. Frankel. “Patient-centered Care and Electronic Health Records: It’s Still about the Relationship.” Family Medicine 42, no. 5 (2010): 364–66.
  7. Wald, H. L., et al. “Accuracy of Electronic Surveillance of Catheter-associated Urinary Tract Infection at an Academic Medical Center. Infection Control and Hospital Epidemiology 35, no. 6 (2014): 685–91.
  8. Haq, C., et al. “Integrating the Art and Science of Medical Practice: Innovations in Teaching Medical Communication Skills.” Family Medicine 36, suppl. (2004): S43–S50.
  9. Frankel, R., et al. “Effects of Exam‐Room Computing on Clinician–Patient Communication: A Longitudinal Qualitative Study.” Journal of General Internal Medicine 20, no. 8 (2005): 677–82.
  10. Duke, P., R. M. Frankel, and S. Reis. “How to Integrate the Electronic Health Record and Patient-centered Communication into the Medical Visit: A Skills-based Approach.” Teaching and Learning in Medicine 25, no. 4 (2013): 358–65.
  11. Street, R. L., et al. “Provider Interaction with the Electronic Health Record: The Effects on Patient-centered Communication in Medical Encounters.” Patient Education and Counseling 96, no. 3 (2014): 315–19.
  12. Wald, H. L., et al. “Accuracy of Electronic Surveillance of Catheter-associated Urinary Tract Infection at an Academic Medical Center.
  13. Ventres, W. B., and R. M. Frankel. “Patient-centered Care and Electronic Health Records: It’s Still about the Relationship.”
  14. Haq, C., et al. “Integrating the Art and Science of Medical Practice: Innovations in Teaching Medical Communication Skills.”
  15. Stewart, M. Patient-centered Medicine: Transforming the Clinical Method. Oxon, United Kingdom: Radcliffe, 2003.
  16. Robeznieks, A. “Communication Skills Key to Exam Room Computing: AMA Report.” Modern Healthcare, May 13, 2013. Available at http://www.modernhealthcare.com/article/20130513/NEWS/305139945 (accessed June 6, 2016).
  17. Ventres, W. B., and R. M. Frankel. “Patient-centered Care and Electronic Health Records: It’s Still about the Relationship.”
  18. Wald, H. S., et al. “Electronic Health Record Training in Undergraduate Medical Education: Bridging Theory to Practice with Curricula for Empowering Patient- and Relationship-centered Care in the Computerized Setting.” Academic Medicine 89, no. 3 (2014): 380–86.
  19. Milano, C. E., et al. “Simulated Electronic Health Record (Sim-EHR) Curriculum: Teaching EHR Skills and Use of the EHR for Disease Management and Prevention.” Academic Medicine 89, no. 3 (2014): 399–403.
  20. Glaser, B. G., and A. L. Strauss. “The Constant Comparative Method of Qualitative Analysis.” In The Discovery of Grounded Theory: Strategies for Qualitative Research. New York: Aldine de Gruyter, 1967, 101–15.
  21. Ventres, W. B., and R. M. Frankel. “Patient-centered Care and Electronic Health Records: It’s Still about the Relationship.”
  22. Ibid.
  23. Wald, H. S., et al. “Electronic Health Record Training in Undergraduate Medical Education: Bridging Theory to Practice with Curricula for Empowering Patient- and Relationship-centered Care in the Computerized Setting.”
  24. Ibid.
  25. Frankel, R., et al. “Effects of Exam‐Room Computing on Clinician–Patient Communication: A Longitudinal Qualitative Study.”

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Milisa K Rizer, MD, MPH; Cynthia Sieck, PhD, MPH; Jennifer S. Lehman; Jennifer L. Hefner, PhD, MPH; Timothy R. Huerta, PhD, MS; and Ann Scheck McAlearney, ScD, MS. “Working with an Electronic Medical Record in Ambulatory Care: A Study of Patient Perceptions of Intrusiveness.” Perspectives in Health Information Management (Winter 2017): 1-11.

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