MedicalResearch.com Interview with:
Neda Ratanawongsa, MD, MPH
CMIO for CareLinkSF
Associate Professor, Division of General Internal Medicine
UCSF Center for Vulnerable Populations
Physician, Richard H. Fine People’s Clinic (RHPC)
San Francisco, CA 94110
Medical Research: What is the background for this study?
Dr. Ratanawongsa: Many people are concerned about the growing intrusion of computers into the patient-provider relationship. Touted as systems that will make care safer and more cost-effective, electronic health records (EHRs) have proliferated rapidly across the country, fueled by HITECH funding. However, some health care professionals feel like computers keep them from connecting with their patients. Also prior research has shown that computer use can change communication in the exam room and shift agenda from patients’ concerns toward medical talk.
Safety net patients already face communication barriers in routine care, particularly language and literacy barriers. Although EHRs could help improve care and communication with these vulnerable patients by helping clinicians fill in the gaps (e.g., what happened in the ED, what medication were you given by that specialist), EHRs could also worsen communication by drawing clinicians’ focus away from patients during visits.
Medical Research: What are the main findings?
Dr. Ratanawongsa: In this 2011-2013 observational study in safety net primary and specialty care, both patients and clinicians in high computer use encounters used more “chit-chat.” This social talk can help patients connect with their providers. However, if done while providers are “multi-tasking” on the computer, this may not be authentic, and providers may miss important medical and emotional cues from patients.
We also found more “negative rapport-building” by high computer use clinicians. This occurs when a clinician disagrees with a patient’s statements, including clarifying information that they think patient doesn’t understand. Some disagreements were prompted by EHR information contradicting patients’ understanding about prior visits at that clinic or other settings, such as diagnoses or prescriptions. Disagreements can facilitate rapport because they reflect sufficient openness and trust to express disagreement, and they could help patients by correcting misunderstandings. However, patients may experience disagreements poorly, ultimately inhibit patient engagement.
Finally, patients in high computer use encounters were less likely to rate care as “excellent” (48% vs. 83%), compared to patients in low computer use encounters. Although patients felt early generation EHRs improved quality of care and remained satisfied with their providers’ communication, another recent study found that patients rated their primary care providers as less effective when providers spent more time looking at the computer.
Medical Research: What recommendations do you have for future research as a result of this study?
Dr. Ratanawongsa: Unlike prior studies of EHR use, this study focuses on a diverse safety net population and includes both English- and Spanish-speaking patients.
As a CMIO, I believe EHRs are necessary for our care delivery. At the same time, I would like their design and implementation – and the policies driving this implementation – to facilitate (not inhibit) our capacity to talk with our patients. Future studies should explore whether the communication differences associated with computer use ultimately affect health outcomes. In addition, these findings suggest a need for implementation research into the best EHR interfaces, infrastructural interventions, and skills-based curricula to foster relationship-centered communication and improve clinicians’ capacity to care for diverse patients.
Neda Ratanawongsa, MD, MPH (2015). Electronic Records Can Suppress Rapport Between Patients and Providers