The use of electronic health records during patient encounters has the potential to negatively impact patient-physician interactions, according to a study that used a qualitative analysis of comments from hospital- and office-based physicians.

Researchers at Brown University and Healthcentric Advisors conducted the analysis of comments, which were submitted in response to a Rhode Island Health Information Technology Survey, conducted in 2014 by the state’s Department of Health—744 doctors provided feedback about their EHR use and how it affects their interactions with patients.

“We were really struck by the difference between how the inpatient physicians view their EHRs and how it affects their actions, compared with those in the office space,” says Rebekah Gardner, MD, an associate professor of medicine at Brown University’s Warren Alpert Medical School and a senior medical scientist with Healthcentric Advisors. Result of the study were recently published in the Journal of Innovation in Health Informatics.

Researchers found that hospital-based physicians commented most frequently that they spend less time with patients because they have to spend more time on computers for documentation. By contrast, office-based physicians commented most frequently on EHRs worsening the quality of their interactions and relationships with patients.

Rebekah Gardner, MD

Also See: Why the EHR documentation burden needs to be solved

“Although hospital-based physicians report benefits ranging from better information access to improved patient education and communication, unintended negative consequences are more frequent themes,” the researchers wrote.

The research found other responses differed across settings. “When comparing themes across settings, hospital-based physicians more frequently comment on the use of EHRs to feel more prepared for the clinical encounter, while office-based physicians more frequently comment on alteration of workflow and the depersonalization of relationships.”

At the same time, the authors point out that comments from physicians that were “generally positive and comments that detailed the patient’s perspective comprised the least commonly observed themes for both (hospital and office) settings.”

According to Gardner, the study indicates the need for different solutions to improve how EHRs are used in inpatient versus office-based settings, given the different ways in which doctors in those environments perform their jobs.

She notes that hospital-based physicians frequently use computers situated outside of patient rooms, while office-based physicians increasingly bring laptops into exam rooms.

Outpatient doctors “will be documenting and going through the EHR while they are sitting there talking to the patient, so it’s literally sitting there between them, distracting the physician from making eye contact and taking their attention away from the patient,” says Gardner, who recommends that doctors “honor the golden minute” when they first enter an exam room—not turning on their computer, giving patients their undivided attention and engaging them in conversation.

She also advises that after the computer is turned on, physicians should turn the screen in such a way that patients can view it. Doctors should “narrate” what they are doing in the EHR to be more inclusive of the documentation process, according to Gardner.

On the other hand, Gardner says inpatient physicians “who take care of patients on hospital floors, in the ICU and ER, when they’re in the room with a patient, the computer often isn’t there—they’re going outside of the room and documenting later.” As a result, researchers report that when doctors use computers for EHR documentation in inpatient settings, it limits time spent directly interacting with patients.

“With our inpatient findings, it really speaks to the volume of documentation that’s required and clunky EHR user interfaces,” says Gardner, who calls for making these interfaces more intuitive as well as decreasing the documentation burden on physicians.

Gardner and her colleagues acknowledge that one of the limitations of the survey is that it was administered in a single state. However, they contend that the large sample size, high response rate, range of represented specialties and array of EHR vendors may mitigate this limitation.

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