title: Office-Based Tools and Primary Care Visit Communication, Length, and Preventive Service Delivery.
abstract: BACKGROUND
  The use of physician office-based tools such as electronic health records (EHRs), health risk appraisal (HRA) instruments, and written patient reminder lists is encouraged to support efficient, high-quality, patient-centered care. We evaluate the association of exam room use of EHRs, HRA instruments, and self-generated written patient reminder lists with patient-physician communication behaviors, recommended preventive health service delivery, and visit length.
  
  
  METHODS
  Observational study of 485 office visits with 64 primary care physicians practicing in a health system serving the Detroit metropolitan area. Study data were obtained from patient surveys, direct observation, office visit audio-recordings, and automated health system records. Outcome measures included visit length in minutes, patient use of active communication behaviors, physician use of supportive talk and partnership-building communication behaviors, and percentage of delivered guideline-recommended preventive health services for which patients are eligible and due. Simultaneous linear regression models were used to evaluate associations between tool use and outcomes. Adjusted models controlled for patient characteristics, physician characteristics, characteristics of the relationship between the patient and physician, and characteristics of the environment in which the visit took place.
  
  
  RESULTS
  Prior to adjusting for other factors, visits in which the EHR was used on average were significantly (p < .05) longer (27.6 vs. 23.8 minutes) and contained fewer preventive services for which patients were eligible and due (56.5 percent vs. 62.7 percent) compared to those without EHR use. Patient written reminder lists were also significantly associated with longer visits (30.0 vs. 26.5 minutes), and less use of physician communication behaviors facilitating patient involvement (2.1 vs. 2.6 occurrences), but more use of active patient communication behaviors (4.4 vs. 2.6). Likewise, HRA use was significantly associated with increased preventive services delivery (62.1 percent vs. 57.0 percent). All relationships remained significant (p > .05) in adjusted models with the exception of that between HRA use and preventive service delivery.
  Office-based tools intended to facilitate the implementation of desired primary care practice redesign are associated with both positive and negative cost and quality outcomes. Findings highlight the need for monitoring both intended and unintended consequences of office-based tools commonly used in primary care practice redesign.
authors.affiliation: Department of Social and Behavioral Health, School of Medicine, and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA.
authors.forename: Jennifer Elston
authors.initials: JE
authors.lastname: Lafata
authors.affiliation: Department of Health Promotion and Behavioral Sciences, University of Texas School of Public Health, San Antonio, TX.
authors.forename: L Aubree
authors.initials: LA
authors.lastname: Shay
authors.affiliation: Department of Social and Behavioral Health, School of Medicine, and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA.
authors.forename: Richard
authors.initials: R
authors.lastname: Brown
authors.affiliation: Department of Communication, Texas A&M University, College Station, TX.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Street
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003142:Communication; D005260:Female; D006801:Humans; D007256:Information Systems / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D009819:Office Visits / Q000706:statistics & numerical data*; D010358:Patient Participation; D010818:Practice Patterns, Physicians'; D011314:Preventive Health Services / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000458:organization & administration* / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013997:Time Factors
keywords: Electronic health record; health risk appraisal tools; patient question lists; patient-physician communication; physician visit duration; preventive service delivery