1. Richard M. Frankel, PhD Center for Implementing Evidence Based Practice Roudebush VAMC Professor of Medicine and Geriatrics Senior Research Scientist Regenstrief Institute Indiana University School of Medicine VIReC Information Seminar December 19, 2006 CliniciansPatients Exam Room Computers The Effect of Computers at the Point of Care: Practical Implications for Physicians and Patients

2. 2 Today’s Presentation: Background and history Study Overview Findings and Lessons Implications

3. 3 Background: Clinician-patient relationships central to ambulatory care Increasing use of information technology (IT) in health care Increasing use of EMRs at the point of care, i.e., the exam room. Potential for IT to enhance clinical care Concerns that IT could create barriers for the relationship Limited information on IT effects on clinician- patient communication

4. 4 Study Question “How does the presence of a computer in the exam-room impact communication between patients and clinicians?”

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7. 7 Stakeholders in the Medical Record 1900 Patient Record of care Doctor Doctor’s private notes _________________________________________________

8. 8 Stakeholders in the Medical Record 1950 Patient Record of Care Doctor Public Health Clinical Researchers __________________________________________________

9. 9 Stakeholders in the Medical Record 2006 Patient Record of care Doctor 3 rd Party Payers Medicare Pt Safety/Quality Health Services Res. Policy Analysts Regulators Hospital Epi. _________________________________________________

10. 10 The Interaction Study Setting: Single outpatient center in a prepaid, integrated delivery system Population: –Primary care clinicians at the clinic –Regularly scheduled patients Sample: convenience sample

11. 11 Location: Clinicians’ regular exam-rooms Design: Longitudinal Video-based Study Three Observation Periods Analysis: Quantitative Analysis of questionnaires Qualitative Review of Videotapes Methods

12. 12 Changes in Patient Visit Satisfaction After the Introduction of the Computer Patients reporting Excellent or Very Good satisfaction. Differences statistically significant (p<0.05) after adjusting for age, gender, and self-reported health status, based on maximum-likelihood ordered logit model. jth: Nan

13. 13 Positive Patient Overall Perceptions of the Computer: Significant Improvements Over Time Patients reporting Strongly Agree or Agree. Differences statistically significant (P<0.05) after adjusting for age, gender, and self-reported health status, based on maximum-likelihood ordered logit model.

14. 14 Recurrent Patient Confidentiality Concerns “The use of computers makes me concerned about my privacy” 41% Totally Agree or Agreed, immediately after computer introduction 45% Totally Agree or Agreed, seven months after computer introduction and six months after training “Did the Clinician or the medical assistant explicitly discuss the confidentiality of electronic medical records or data security.” 4% Immediately after computer introduction 0% Seven months after computer introduction and six months after training

15. 15 Summary of Quantitative Findings Overall Patient Satisfaction was very high (88.8%) - No significant changes after the introduction of the computer Significant improvements in patient satisfaction with decision-making, clinician’s use of the computer, and focus on prevention after the introduction of the computer Patient overall perceptions of the computer were positive with some significant improvement over time Patient concerns about the confidentiality of information may not be adequately addressed at present ________________________________________________

16. 16 Qualitative Analysis Nine clinicians and 54 visits: two visits per period per clinician Variations in computer use across visits in all periods Variations in the quality of communication across visits in all periods Introduction of the computer appeared to enhance the quality of communication in some visits and created barriers to communication in others

17. 17 Quality of Communication Verbal Dialogue: Clinician maintains conversation, even while performing other tasks, e.g. physical exam or typing Visual Connection: Clinician maintains eye contact, even while performing visit tasks, e.g. Intermittently glances at the patient while entering data on the computer Postural Orientation: Clinician positions head and torso to align with patient and computer, e.g. positions own body and computer screen to avoid excluding the patient

18. 18 Video Coding Preliminary Coding Review of tapes by entire research team to develop initial themes Major Coding Categories –Visit organization –Interpersonal skills –Technical mastery skills –Spatial organization Coded by 2 Ph.D. qualitative researchers ________________________________________

19. 19 Baseline Visit Organization Skills Without a computer, not eliciting an agenda can make a visit Inefficient Disorganized Run over schedule

20. 20 Visit Organization (Baseline/Negative) In this baseline visit, no formal agenda is set. The patient has multiple medical concerns, including sarcoid. Problems are discussed serially as the patient brings them up and without any indication of how many concerns the patient has, how much time they will take to discuss and how they might be related. The visit appears quite inefficient and poorly organized ________________________________________________

21. 21 Amplification Effect Previous baseline skills may affect how exam room computers are used and the extent to which they facilitate or create additional barriers to clinician patient communication. ___________________________________________

22. 22 Amplification of Visit Organization Skills (Post introduction) The same clinician seems to get confused between patient agenda items and information on the computer screen. Each time the computer is consulted current problems are deferred and are dealt with some time later, confusing the patient. The presence of the computer multiplies the sense of disorganization, and extends the length of the visit. The clinician also seems to get lost in a maze of windows while looking for a test result and at times inquires about items the MA has already checked on. _______________________________________________

23. 23 Interpersonal Skills Clinicians with good interpersonal skills Encourage patient input Listen to patients’ concerns Maintain eye contact Chart intermittently or not at all during visit

24. 24 Amplification of Interpersonal Skills (Positive) Increased Quality of Communication The computer served as another tool to help the clinician communicate or remain more familiar with the patient The net computer effect was a higher quality of clinician-patient communication: -More verbal dialogue about the patient’s problems -Enhanced visual interaction - shared review of information on the computer -Continued clinician physical alignment with the patient, e.g. tilting the screen so both can see

25. 25 Interpersonal Skills (Baseline/ Positive) During this Period 1 visit, the clinician sits on a low stool across from the patient and maintains gaze focused on the patient when speaking. Information is entered onto the paper chart intermittently and only when the patient has finished speaking. ________________________________________________

26. 26 Amplification of Interpersonal Skills (Post Introduction/Positive) The same clinician sees a patient in Period 2, who comes in after several ER visits for panic attacks. The clinician notices that the patient is on a medication known to cause similar symptoms and tells her that it may not be appropriate for her, all the while tilting the computer screen so that they can both review the notes. The clinician then reinforces and amplifies the message by pushing away the computer screen establishing eye contact and explaining the drug’s paradoxical effects to the patient. ____________________________________________

27. 27 Technical Skills Inability to successfully navigate program leads to: Inability to access data consistently Wastes of time Frustration for clinicians and patients

28. 28 Technical Skills Post Introduction/Negative In this visit the clinician is looking for recent medical hx using the computer. The patient tries to tell the clinician, who is busy on the computer, that she has a list of meds but it is to no avail. She succeeds in her 2nd try and the clinician takes the list and starts copying the information to a paper chart that will have to be typed back into the computer at a later point. Both clinician and patient seem frustrated with the process which takes a long time to complete. ____________________________________________________

29. 29 Spatial Organization of the Visit

30. 30 Re-enactment: Clinician and Patient Using the Computer Together

31. 31 Re-enactment: The Computer Creating a Barrier to Communication

32. 32 Summary Variations in computer use and the quality of clinician- patient communication during visits Digital Amplification: Computer use could increase or decrease the quality of communication between clinicians and patients Key Factors Modifying the Computer Effects: –Visit Organization –Interpersonal Skills –Technical Computer Skills –Spatial Orientation

33. 33 Limitations Small, convenience sample Primary care visits only Normative measures of communication quality Qualitative analyses only Single clinic within a prepaid, integrated delivery system Experience during initial seven months after the introduction of computers into the exam-room

34. 34 Implications Use of computers has the potential to increase or decrease the quality of clinician-patient communication Four factors appear to influence the direction of this digital amplification More research is needed to understand the potential impact of IT innovations on the clinician-patient relationship Guidelines and training programs could help clinicians use the new technology more effectively

35. 35 Thank you for your time and attention !