title: Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters.
abstract: OBJECTIVE
  The computer with the electronic health record (EHR) is an additional 'interactant' in the medical consultation, as clinicians must simultaneously or in alternation engage patient and computer to provide medical care. Few studies have examined how clinicians' EHR workflow (e.g., gaze, keyboard activity, and silence) influences the quality of their communication, the patient's involvement in the encounter, and conversational control of the visit.
  
  
  METHODS
  Twenty-three primary care providers (PCPs) from USA Veterans Administration (VA) primary care clinics participated in the study. Up to 6 patients per PCP were recruited. The proportion of time PCPs spent gazing at the computer was captured in real time via video-recording. Mouse click/scrolling activity was captured through Morae, a usability software that logs mouse clicks and scrolling activity. Conversational silence was coded as the proportion of time in the visit when PCP and patient were not talking. After the visit, patients completed patient satisfaction measures. Trained coders independently viewed videos of the interactions and rated the degree to which PCPs were patient-centered (informative, supportive, partnering) and patients were involved in the consultation. Conversational control was measured as the proportion of time the PCP held the floor compared to the patient.
  
  
  RESULTS
  The final sample included 125 consultations. PCPs who spent more time in the consultation gazing at the computer and whose visits had more conversational silence were rated lower in patient-centeredness. PCPs controlled more of the talk time in the visits that also had longer periods of mutual silence.
  
  
  CONCLUSIONS
  PCPs were rated as having less effective communication when they spent more time looking at the computer and when there was more periods of silence in the consultation. Because PCPs increasingly are using the EHR in their consultations, more research is needed to determine effective ways that they can verbally engage patients while simultaneously managing data in the EHR.
  
  
  CONCLUSIONS
  EHR activity consumes an increasing proportion of clinicians' time during consultations. To ensure effective communication with their patients, clinicians may benefit from using communication strategies that maintain the flow of conversation when working with the computer, as well as from learning EHR management skills that prevent extended periods of gaze at computer and long periods of silence. Next-generation EHR design must address better usability and clinical workflow integration, including facilitating patient-clinician communication.
authors.affiliation: Department of Communication, Texas A&M University, College Station, USA; Department of Medicine, Baylor College of Medicine, Houston, USA; Houston VA Center for Innovations in Quality, Effectiveness and Safety, USA. Electronic address: r-street@tamu.edu.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Street
authors.affiliation: Department of Family and Preventive Medicine, University of California, San Diego USA.
authors.forename: Lin
authors.initials: L
authors.lastname: Liu
authors.affiliation: Department of Medicine, University of California, San Diego USA.
authors.forename: Neil J
authors.initials: NJ
authors.lastname: Farber
authors.affiliation: Department of Informatics, University of California, Irvine, USA.
authors.forename: Yunan
authors.initials: Y
authors.lastname: Chen
authors.affiliation: Veterans Medical Research Foundation, VASDHS, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Calvitti
authors.affiliation: Hunter College, City University of New York, USA.
authors.forename: Danielle
authors.initials: D
authors.lastname: Zuest
authors.affiliation: Department of Medicine, University of California, San Diego USA.
authors.forename: Mark T
authors.initials: MT
authors.lastname: Gabuzda
authors.affiliation: Department of Internal Medicine, VA San Diego Health Care System, USA.
authors.forename: Kristin
authors.initials: K
authors.lastname: Bell
authors.affiliation: Veterans Medical Research Foundation, VASDHS, USA.
authors.forename: Barbara
authors.initials: B
authors.lastname: Gray
authors.affiliation: Veterans Medical Research Foundation, VASDHS, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Rick
authors.affiliation: Veterans Medical Research Foundation, VASDHS, USA.
authors.forename: Shazia
authors.initials: S
authors.lastname: Ashfaq
authors.affiliation: Department of Medicine, University of California, San Diego USA; West Health Policy Center, West Health Institute, San Diego, California, USA.
authors.forename: Zia
authors.initials: Z
authors.lastname: Agha
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000554:Ambulatory Care Facilities; D003142:Communication; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010358:Patient Participation; D017060:Patient Satisfaction; D018802:Patient-Centered Care / Q000379:methods*; D010817:Physician-Patient Relations; D010818:Practice Patterns, Physicians'; D011320:Primary Health Care; D011787:Quality of Health Care; D012017:Referral and Consultation; D014481:United States; D014493:United States Department of Veterans Affairs; D014743:Videotape Recording
keywords: Electronic medical records; Patient centered communication; Physician workflow