The VA has been a national leader in electronic health record (EHR) implementation including the availability of Computerized Patient Record System (CPRS) enabled workstations in ambulatory exam rooms. Despite this fact, there is evidence of wide variability in CPRS use by individual providers and across VA facilities during ambulatory encounters. This variation in computer use before, during, and after the patient encounters leads to questions of how best to integrate CPRS into clinical workflow and how this variation in computer use impacts patient-centered care. Veterans' health outcomes may ultimately be compromised by variations in the implementation of this technology. For example, where CPRS use in encounters is low, physicians may not consistently receive all clinical reminders and patients may not receive all interventions that might improve their outcomes. Likewise, visits in which physicians spend an inordinate amount of time looking at the computer may result in patients' perceiving that their physician cares more about their record of care than they do about them as living, breathing human beings who may be suffering. Finally, there are no national standards on where computers should be placed in the exam room to optimize interpersonal interaction and work flow creating additional variation in how physicians employ computers during ambulatory visits.
The objective of this proposal is to understand variations in the use of CPRS- enabled exam room computers and how use or non-use affects patient-centered communication and clinical workflow during outpatient primary care visits. We have two specific aims:
Specific Aim 1. Describe variations in how providers employ CPRS during ambulatory care encounters at 3 VA facilities.
Specific Aim 2. Identify barriers and facilitators to the integration of CPRS into routine ambulatory care workflow.
This was a multi-site, multi-method study with two main components: 1) ethnographic observations of CPRS and video recordings of the patient physician interaction during the ambulatory visit (Aim 1); and 2) in-depth interviews and surveys to ascertain individual and facility-level perceptions of barriers and facilitators associated with CPRS usage (Aim 2). The ethnographic team content analyzed barriers and facilitators to computer use before, during and after the visit. The video review team used microinteractional analysis to describe variations in eye contact and non-verbal behavior during episodes of computer use and their effect(s) on patient-centeredness and workflow. Toward the conclusion of the study, findings from the ethnographic team and the video review team were merged to create a richer more dynamic picture of the impact of exam room computing on the physician patient relationship.
-Across the 3 study sites there was significant variation in the extent to which PCPs used computers during their ambulatory encounters. These variations do not appear to be based on regional differences or facility rules and regulations but seem instead to be a natural outgrowth of individual preference and style in the absence of any national standards or recommendations. Some physicians spent as much as 85% of the visit time looking at the computer while others spent an equal amount of time looking at the patient. Using these findings we broadly characterized visits as being either "computer-focused" or "patient-focused.
-Currently, CPRS is not supporting PCPs' needs in the patient visit. Both the physical placement and the user interface of the current electronic medical record create barriers to providing efficient, patient centered care. In addition PCPs are imposing their own structure on the data from CPRS. Many physicians take the time to review patients' past medical history before the visit but some do not and the lack of preparation often results in greater reliance and time spent looking at the computer screen and CPRS data which takes time away from the interpersonal and relational side of a medical visit. Another significant barrier is the interaction between paper artifacts and CPRS. We observed a number of encounters in which the physician had prepared written notes which added complexity to the task of managing computer based, written and interpersonal sources of information in real time. The next-generation VA EHR will need to take these barriers into consideration in terms of its design and usability.
-Recognition of the EHR as a 3rd presence in the room and a rationale for its use is critical to good clinical practice. It is clear from our observations that the computer is not a docile element of the clinical encounter but is, rather, an active presence and participant. The implications of this observation for educating physicians in good clinical practice are several-fold. First, joint focus of attention (i.e., where two parties are attending to and conversing about the same thing at the same time) is a preferred state in interpersonal relationships and is associated with high fidelity information transfer and retention. Maintaining the relationship at the same time that one is searching for evidence of, or documenting, care can be challenging without practice and education. Second, situation awareness, (i.e., attending to multiple levels of action in complex human and mechanical systems) is a key to providing high quality patient-centered care. Third, providing a rationale to the patient for what one is doing on the computer (e.g., "I'm going to be using the computer from time to time during our visit. I apologize if this takes away from eye contact with you, but I will try my best to keep this to a minimum") can help overcome the interpersonal barriers created by using the electronic health record during the encounter.
-Reviewing CPRS notes prior to visits is an important habit of practice to cultivate for giving patient centered care. We observed a number of visits in which the PCP did not consult the electronic record of care before seeing the patient. This behavior may be due to increasing time demands on PCP's to see more patients in shorter amounts of time, knowing one's patients well enough not to need to review the medical record or simply not feeling that reviewing the record is necessary. Opportunistic interviews with PCPs revealed that time pressure seems to be the greatest barrier to not reviewing CPRS notes. We have labeled the visits in which notes are not reviewed, "improvised visits" and the data suggests that these visits are less well-organized, are more computer-focused and more "mechanistic" than visits in which visit preparation included CPRS review.
-Studies of the effect(s) of computer focused versus patient focused visits are needed. The present study did not look at any patient end-points such as satisfaction, adherence, or comprehension of recommendations or instructions. Outcome-based studies of "computer-focused" and "patient-focused" visits are necessary to confirm that these differences have real-world effects.
This study will impact the Veterans Healthcare Association by providing informatics tools that facilitate patient centered care while being mindful of regulatory documentation requirements. Informatics tools, if designed correctly, inform the clinician of pertinent information in advance of an exam so the clinician is focused completely on the patient and their needs. Attention to exam room computing also holds the potential for improving patient retention of information, satisfaction with care and adherence with medical recommendations.
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