05 Jul Clinicians Multitask on Electronic Health Records 30% of Visit Time with Patients
MedicalResearch.com Interview with:
Neda Ratanawongsa, MD, MPH
Associate Chief Health Informatics Officer for Ambulatory Services, San Francisco Health Network
Associate Professor, Division of General Internal Medicine
UCSF Center for Vulnerable Populations
Physician, Richard H. Fine People’s Clinic (RHPC)
Zuckerberg San Francisco General Hospital
San Francisco, CA 94110
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: U.S. federal incentives allowed many safety net healthcare systems to afford fully functional electronic health record systems (EHRs). Although EHRs can help clinicians provide care to vulnerable populations, clinicians may struggle with managing the EHR workload, particularly in resource-limited settings. In addition, clinicians’ use of EHRs during clinic visits may affect how they communicate with patients.
There are two forms of EHR use during clinic visits. Clinicians can multitask, for example, by ordering laboratory tests while chatting with a patient about baseball. However, like distracted driving, using EHRs while talking with increases risks – in this case, the risk of errors in patient-provider communication or in the EHR task. Alternatively, clinicians can use EHRs in complete silence, which may be appropriate for high-risk tasks like prescribing insulin. However, silence during visits has been associated with lower patient satisfaction and less patient-centered communication.
So we studied how primary and specialty care clinicians used EHRs during visits with English- and Spanish-speaking patients in a safety net system with an EHR certified for Centers for Medicare & Medicaid Services meaningful use incentive programs. We found that multitasking EHR use was more common than silent EHR use (median of 30.5% vs. 4.6% of visit time). Focused patient-clinician talk comprised one-third of visit time.
We also examined the transitions into and out of silent EHR use. Sometimes clinicians explicitly stated a need to focus on the EHR, but at times, clinicians drifted into silence without warning. Patients played a role in breaking silent EHR use, either by introducing small talk or by bringing up their health concerns.
MedicalResearch.com: What should clinicians and patients take away from your report?
Response: Clinicians have always needed to multitask during part of their visits, looking up test results in paper charts or writing prescriptions. However, newer EHRs contain a massive amount of complex information and do not always make it easy for clinicians to complete tasks that must be done before a patient leaves, like writing prescriptions. Delaying EHR use until after the visit may increase other risks, including inaccurate documentation, forgotten orders, or clinician burnout due to after-hours charting.
Some patients may actually benefit from some silence during a visit. Usually, doctors talk more than patients, allowing less space for patients to voice their concerns. During moments of silence, some patients may be able to process their reactions to what clinicians are saying and speak up about their own concerns. However, clinicians must be able to recognize those concerns as they emerge. Then, clinicians must decide, “Do I politely ask my patient to ‘hold that thought’ until I’m done, do I stop the EHR task to focus on my patient, or do I try to multitask through the conversation?” The right answer in each situation may be different, depending on the EHR task, the clinician, the patient, and their relationship.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: Studies should explore relationship-centered strategies for how clinicians and patients can negotiate the amount of (and transitions between) multitasking and silent EHR use. This research should include diverse patients – including those with limited health literacy and limited English proficiency – offering input on how they want to be engaged by clinicians using EHRs. Implementation research should investigate EHR design and optimization toward maximizing clinicians’ ability to “hear” emerging patient concerns.
MedicalResearch.com: Is there anything else you would like to add?
Response: Meaningful use of EHRs is only achieved when clinicians can form meaningful therapeutic alliances with their patients. I have no conflicts of interest to disclose.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Ratanawongsa N, Matta GY, Lyles CR, Koenig CJ, Barton JL, Yu K, Schillinger D. Multitasking and Silent Electronic Health Record Use in Ambulatory Visits. JAMA Intern Med. Published online July 03, 2017. doi:10.1001/jamainternmed.2017.2668
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