By Dr. Geoffrey Modest
A small study was just published as a research letter looking at the impact on patient satisfaction when providers use computers in the exam room (see doi:10.1001/jamainternmed.2015.6186.). This was an observational study done from Nov 2011 to Nov 2013 in an academic safety-net public hospital in San Francisco.
- 47 patients (mean age 56.5, 55% women, 57% Hispanic/17% African-American/15% Asian/6% white, 55% primary Spanish speakers, 54% with high school education or less, 30% with inadequate health literacy as determined by their ability to fill out medical forms), and 39 clinicians (mean age 43.7, 64% women, 72% in primary care, 72% MDs, mean 13.9 years since getting professional degree)
- Provider-patient relationship was <1 year in 16%, 1-5 years in 54% and >5 years in 30%.
- Mean visit length was 24.6 minutes
- Clinician computer use was low in 27% of encounters, moderate in 38% and high in 35% (this score was compilation of time reviewing computer data, typing or clicking with mouse, lack of eye contact with patient, and noninteractive pauses)
- Rapport building included positive (laughter or agreement), negative (criticism or disagreement), emotional (empathy or partnership), and social (“chit-chat”) behavior
- Encounters were videotaped and analyzed
- Patients’ views in encounters with high computer use vs low:
- Care was rated as excellent in 48% vs 83% (p=0.04)
- There was more social rapport building by the patient (e.g. “you are wearing your hair that way…”; p=0.04) [though the authors note that in these high computer use encounters, this may not come across as “authentic engagement” and may lead to missed opportunities for developing deeper patient connections]
- Patients in encounters with moderate computer vs low, computer use had less positive rapport building (e.g. “thank you”) (p<0.01) but had more positive affect tone (p=0.02)
- Clinicians in encounters with high computer use:
- Engaged in more negative rapport building (e.g. “no, it looks like your specialist filled that medication for you, it has a refill”; p<0.01)
- Demonstrated less positive affect
So, as we head more and more towards computers being an integral part of the encounter (ménage-a-trois), there are some very real concerns:
- It is really clear to me that it is in the history-taking that the vast majority of diagnoses and treatments are based
- And, a therapeutic provider-patient relationship is really important in patient outcomes (and, I think, really very important in provider satisfaction as well)
- But a computer intervening in this relationship, not surprisingly, undercuts these:
- The computer systems I have seen (which are several of them) require focusing on the screen and, to some extent, pursuing questions as dictated by the screen. This is because much of the input is not free-text writing (which some of us can do without looking at the keyboard/screen), but navigating to sections of the screen, pushing on buttons there or filling in specific areas of the screen. And to the extent we are pursuing questions as dictated by the screen, we are not using the extremely important and often fruitful open-ended questions and then following up on the patient answers
- There is much more information to process than in the good (and bad) old days. The good part is that we have the consultant notes, lab reports, results of ER visits right there. The bad news is that we spend a lot of time looking at these results, leaving less time to focus on the patient in front of us (and, overall it is probably better care to have quick access to all of this information, and in a way that is readable, as opposed to the old written medical records. But there is a price to be paid in terms of time and attention to the patient….)
- So, what can be done?
- I think that, at a minimum, it is useful to spend the first 5 or so minutes of the encounter just talking to the patient and having consistent eye contact.
- And, of course, I think it is fundamentally absurd that those of us in primary care, who deal with pretty much all of the patients medical and psychosocial issues, have so little time to spend with the patient — to get to know the patient as a person and develop a caring relationship, get a good and accurate history, be able to help the patient to the extent we can, and to avoid unnecessary (and quite costly) visits to the ER or specialists for patient needs we could have taken care of in the first place.