Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?

Issue Brief No. 131

April 2010

Ann S. O'Malley, Genna R. Cohen, Joy M. Grossman

Commercially available electronic medical records (EMRs) simultaneously support and impede physician interpersonal communication—real-time, in-person or telephone conversations—with patients and fellow clinicians, according to a new study by the Center for Studying Health System Change (HSC) drawing on detailed interviews with clinicians across 26 physician practices. EMRs facilitate real-time dialogue with patients during office visits, chiefly by providing instant access to patient data, which allows clinicians to engage in conversation rather than hunting through paper records for information. For certain clinicians, however, EMR features create distractions during encounters. Furthermore, some respondents suggested that clinicians may depend on EMRs for information collection and exchange at the cost of real-time interpersonal dialogue with patients and other providers. Considering the time constraints that already pervade many physician practices, modifications to EMR systems and office workflows could help ensure that EMRs improve care delivery without undermining interpersonal communication. Specifically, policies that encourage EMR adoption should consider incorporating communication-skills training for both medical trainees and practicing clinicians who use EMRs.

Deficiencies in Real-Time Communication Persist in Clinical Settings

Effective interpersonal communication—real-time, in-person or telephone conversations—enables clinicians (physicians, nurses, and other practitioners) to gather nuanced information from patients and fellow clinicians that is difficult to convey through medical records alone, including social circumstances, values, preferences, and issues unique to complex patients. [1] Stronger communication between patients and physicians, as well as between primary care physicians and specialists, is a fundamental element of care coordination and results in better patient outcomes. [2-4] Nevertheless, satisfaction with interpersonal communication among both patients and clinicians has been declining. [5, 6]

Interpersonal communication encompasses both patient-clinician communication, which forms part of a continuing relationship, and clinician-to-clinician communication, which primarily centers on discussing clinical decisions for patients they share. [7] EMRs have the potential to support both forms of communication.

Although EMRs are expected to enhance information sharing, it remains uncertain how their practical use influences interpersonal communication. This question is especially relevant given the recent federal push toward widespread EMR adoption [8] and the imperative to avoid further degrading already-poor communication with patients and among clinicians who share responsibility for patients. To explore this issue, 52 physicians and other staff members at 26 small and medium-sized physician practices using commercial ambulatory EMRs that had been in place for a minimum of two years were interviewed in depth about how EMRs affect communication with patients and other clinicians, as part of a broader study on EMRs' overall impact on care coordination. [9] Supplementary interviews were also conducted with chief medical officers at four EMR vendors and four nationally recognized experts involved in health information technology implementation (see Data Source).

Patient-Clinician Communication

Clinicians reported that EMRs supported communication with patients in numerous ways. Generally speaking, having immediate access to EMR data allowed them to concentrate on the patient instead of pulling together information from multiple paper sources during visits. As one physician described it, because "we do not have to call down the hall for a lab or test result, we spend more quality time [with the patient] in a more context-rich way." In a similar vein, because staff members can direct questions to physicians through the EMR's electronic instant messaging (IM) capability rather than physically opening the exam room door, doctor-patient conversations during a visit can proceed without physical interruptions.

Ready access to information also enriched patient education during visits. For instance, clinicians could display content from the patient's record—such as the problem list, medication list, and care plan—or pull up educational materials from the Internet to review on screen with patients and family members during the encounter. Some respondents reported providing printed copies of this information to the patient and family to reinforce the discussion.

Although not constituting real-time communication, e-mail was perceived to positively affect the timeliness of interpersonal exchanges. Clinicians who utilized the EMR's e-mail functionality with patients generally felt that e-mail "lowered communication barriers" and "improved the quality of the relationship" by enhancing access between visits and cutting down on phone tag. Demonstrating how e-mail increased the probability of opening lines of communication at critical moments, one internist reported, "My favorite example is getting a letter from a doctor telling me that the patient I sent to him has a new diagnosis. We want to reach out to the patient at that moment, but we'll probably have a pretty high threshold for making a phone call because it starts a telephone game. Now, I will routinely send the patient an e-mail saying, 'I got this information [from the specialist who gave you this diagnosis]; I'm here for you if you want to talk.' I think patients love that."

Potential Pitfalls

Respondents also highlighted that EMRs could present obstacles to interpersonal communication. For instance, operating a computer during a patient encounter can serve as a distraction—as one physician characterized it, "It's like having a two-year old in the room." As another physician remarked, "there are a lot of gadgets and gizmos and that can pull us away from our objective." Instant messages, while useful for communicating efficiently about care-related tasks and reducing physical interruptions during visits, can divert clinician attention from the patient if clinicians are unable to adequately manage or ignore IM notifications in the examination room.

Paradoxically, EMRs have enabled some clinicians to engage less with patients because, compared to paper charts, significantly more information is available before the clinician actually sees the patient. As one internist put it, "my concern now is that we're listening less because we have more information when we walk in the room, and it's not all trustworthy." Another internist, who practices in both outpatient and inpatient environments, expressed his worry that EMRs could substantially diminish real-time patient communication: "A lot of us feel like we're already seeing it. One of the hospitalists yesterday said 'This is great, I used the EMR before I came here. I was able to sit down with my bagel and coffee and do my rounds before I even got in.'"

Several physicians also observed that due to EMR design features, the temptation to concentrate on completing checkboxes within the EMR reduced the number of open-ended questions they posed to patients. While there are clear benefits to encouraging clinicians to more systematically inquire about specific elements of patients' histories and, ideally, entering structured and coded data that can be searched, relying exclusively on checkboxes when taking a patient history creates the risk that subtle or nuanced symptoms might be overlooked.

Seasoned EMR users identified several strategies to keep EMRs from undermining interpersonal communication with patients. For example, multiple physicians noted that displaying portions of patients' records on screen could support more accurate documentation and collaborative decision making, while helping patients avoid feeling alienated when the physician is looking at the computer. Pointing out that this practice helps ensure thorough and accurate documentation, one physician explained, "Before I examine a patient, [we] sit down and look at the problem list and the medication list together. It provides a nice triangular interaction" between the physician, the computer, and the patient.

Communication Between Clinicians

Electronic medical records offer rapid access to patient information, facilitating real-time dialogue about patients when a physician fields phone inquiries from other clinicians. As one primary care physician noted, "I know I can now so easily and quickly give information to specialists who call."

EMRs also cultivate a sense among clinicians that patient information is a shared resource when they are co-managing patients, as opposed to something one practice "owns." A national expert remarked that this dynamic improves interpersonal communication between clinicians because "EMRs move physicians away from the concept that, it [patient information] is mine and you can't look at it. It should be shared for teaching and management purposes in a secure way."

Electronic vs. Live Communication

Just as EMRs can tempt clinicians to disengage from patients, they can also detract from communication within a practice or between providers. The use of asynchronous EMR communication tools—such as e-mail and instant messaging, where a time lag exists between responses—can function as a double-edged sword, according to respondents.

On the one hand, the majority of respondents felt that tools such as IM, "tasking"—assigning responsibility for a specific task to a staff member through the EMR—and e-mail boosted efficiency for communications that do not require face-to-face interactions with staff, such as scheduling a follow-up appointment. On the other hand, some respondents indicated that the convenience of asynchronous communication within EMRs decreased the likelihood that real-time communication would take place when it was needed most, such as during patient emergencies. One physician underscored the importance of discussing with staff which types of urgent or sensitive matters should be communicated verbally, such as notifying a physician about a patient's arrival at the emergency department. "You have to use electronic communication when appropriate and voice when appropriate, and even paper when it's appropriate," he stated.

Another illustration was offered by one physician: "People will [use electronic communication] instead of knocking on the door or walking across the hall. You might not see your partner all day, whereas in the old days, we would ask what they think."

For complex patient situations, respondents were convinced that nothing should replace the interactive qualities of face-to-face or telephone conversations. As a cardiologist explained, "If I am implanting a defibrillator, the primary care physician may have some thoughts about the patient's true life expectancy that might influence our decision-making process about whether the device is appropriate for the patient. We need to do a better job [of communicating orally], because we [cardiologists] can't do it without input from the physicians that understand the patient's complex chronic conditions."

EMR users identified several approaches to prevent EMRs from undermining interpersonal communication with other clinicians and staff. For instance, establishing clear expectations with office staff about what is appropriate for electronic versus oral communication is essential. As multiple respondents pointed out, clinicians need to remind themselves—and the students and medical residents they train—about the significance of in-person or telephone conversations when warranted. As an EMR vendor and practicing physician noted, "The best way to ensure good coordination of care is for two physicians to speak with each other directly. You can't approach any technology solution, in as complex and risky a work environment as the practice of medicine, and have it be a substitute for appropriate human interactions."

Other Research

Other researchers have found that users of EMRs and computerized physician order entry systems tend to hold overly optimistic expectations regarding the accuracy and processing of data. [10] EMRs, like paper records, may contain errors; reports of providers' categorical reliance on this information underscore the need to encourage users to verify EMR data directly with patients, just as they would with a paper chart.

EMR use has been associated in some studies with reduced face-to-face engagement with patients, making it harder for clinicians to direct their attention toward certain aspects of patient-centered communication, such as establishing the patient's agenda, exploring psychosocial and emotional concerns, discussing how health conditions affect a patient's daily life, and determining the timeline of events necessary to assess patients' problems. [11-13]

Conversely, a national survey of physicians [14] and a study of patients [15] determined that EMRs in the exam room had either a neutral or positive effect on perceptions of patient-physician communication regarding the overall quality of discussions about medical issues and psychosocial concerns. Other researchers have found that how computers are utilized in the exam room may hinge on a clinician's baseline patient-communication abilities prior to EMR adoption. [16] The differing findings from these studies likely reflect their measurement of distinct aspects of communication, but the variation highlights the need to develop a more thorough understanding of how specific dimensions of interpersonal communication are influenced by EMR use.

Policy Implications

According to physicians currently utilizing commercial EMRs, the technology can both facilitate and hinder communication with patients and other clinicians. These findings carry implications for the support and training of healthcare professionals in interpersonal-communication skills when EMRs are present.

Insufficient communication between physicians regarding shared patients stems partly from the absence of payment for these types of coordination activities and the associated opportunity costs of phone or face-to-face conversations that can disrupt the flow of office visits. [17] EMRs and their associated electronic communication tools can help address this challenge by making information sharing more efficient. However, real-time communication will remain essential in many circumstances, and greater reliance on EMRs and electronic communication, if not managed appropriately, may erode interpersonal communication. With this in mind, policy makers might consider creating incentives for communication among clinicians about the patients they share.

Overcoming EMR-related barriers to interpersonal communication will likely require ongoing refinement of system design by vendors and usage practices by clinicians to minimize the potential for distraction during patient encounters. Health information technology implementation efforts at both the federal and clinical practice levels might incorporate training designed to strengthen interpersonal communication skills for practitioners and medical trainees who work with EMRs. Adjustments to office processes and clinical workflows aimed at maximizing interpersonal communication while using an EMR are also likely to prove beneficial.

Notes

1. Weiner, Saul J., et al., "Processes for Effective Communication in Primary Care," Annals of Internal Medicine, Vol. 142, No. 8 (April 19, 2005).

2. Ibid.

3. Beck, Rainer S., Rebecca Daughtridge and Philip D. Sloane, "Physician-Patient Communication in the Primary Care Office: A Systematic Review," Journal of the American Board of Family Practice, Vol. 15, No. 1 (January/February 2002).

4. Stille, Christopher J., et al., "Coordinating Care Across Diseases, Settings and Clinicians: A Key Role for Generalist in Practice," Annals of Internal Medicine, Vol. 142, No. 8 (April 19, 2005).

5. Montgomery, Jana E., et al., "Primary Care Experiences of Medicare Beneficiaries, 1998 to 2000," Journal of General Internal Medicine, Vol. 19, No. 10 (October 2004).

6. Epstein, Ronald M., "Communication Between Primary Care Physicians and Consultants," Archives of Family Medicine, Vol. 4, No. 5 (May 1995).

7. Weiner (April 19, 2005).

8. American Recovery and Reinvestment Act (ARRA), Health Information Technology for Economic and Clinical Health Act, P.L. 111-5 (Feb. 17, 2009).

9. O'Malley, Ann S., et al., "Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices," Journal of General Internal Medicine, Vol. 25, No. 3 (March 2010).

10. Campbell, Emily M., et al., "Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry," American Medical Informatics Association Annual Symposium Proceedings, (Oct. 11, 2007).

11. Makoul, Gregory, Raymond H. Curry and Paul C. Tang, "The Use of Electronic Medical Records: Communication Patterns in Outpatient Encounters," Journal of the American Medical Informatics Association, Vol. 8, No. 6 (November/December 2001).

12. Patel, Vimla L., Jose F. Arocha and Andre W. Kushniruk, "Patients' and Physicians' Understanding of Health and Biomedical Concepts: Relationship to the Design of EMR Systems," Journal of Biomedical Informatics, Vol. 35, No. 1 (February 2002).

13. Shachak, Aviv, et al., "Primary Care Physicians' Use of an Electronic Medical Record System: A Cognitive Task Analysis," Journal of General Internal Medicine, Vol. 24, No. 3 (March 2009).

14. DesRoches, Catherine M., et al., "Electronic Health Records in Ambulatory Care—A National Survey of Physicians," New England Journal of Medicine, Vol. 359, No. 1 (July 3, 2008).

15. Hsu, John, et al., "Health Information Technology and Physician-Patient Interactions: Impact of Computers on Communication During Outpatient Primary Care Visits," Journal of the American Medical Informatics Association, Vol. 12, No. 4 (July/August 2005).

16. Frankel, Richard, et al., "Effects of Exam-Room Computing on Clinician-Patient Communication," Journal of General Internal Medicine, Vol. 20, No. 8 (August 2005).

17. Weiner (April 19, 2005).

18. O'Malley (March 2010).

Data Source

A total of 60 telephone interviews were conducted between January and August 2008 with 52 clinicians in primary care and specialty practices using commercial ambulatory care EMRs that had been in place for a minimum of two years, four national experts, and four EMR vendor medical directors. Practices, which ranged in size from solo to large groups, were identified within the 12 randomly selected Community Tracking Study (CTS) markets across the United States. Respondents were asked about their perceptions of EMRs' impact on their interpersonal communication with: 1) patients; 2) clinicians and staff within their office; and 3) physicians in other practices. It was not possible to validate respondents' perceptions with direct measures of actual communication, for example, by audio-recording encounters. Additional details on the methodology, including participant recruitment, data collection, and analysis have been previously published. [18]

Funding Acknowledgement

This study was funded by The Commonwealth Fund.

Thanks as well to the state and local physicians societies, in particular the Massachusetts Medical Society, and the state and local chapters of the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American Society of Clinical Oncologists (ASCO), and the American College of Cardiology (ACC), that helped identify and contact practices in the 12 CTS markets. Special gratitude goes to the numerous anonymous physicians, practice staff, and experts who generously donated their time to be interviewed for this project. Their input was invaluable.

Sources and Further Reading

HealthIT.gov — Office of the National Coordinator for Health IT — Federal resources on electronic health record adoption, meaningful use requirements, and health information technology policy under the HITECH Act.

The Commonwealth Fund — Funder of this research, with extensive publications on health information technology, care coordination, and physician practice improvement.

NEJM: Electronic Health Records in Ambulatory Care — A National Survey of Physicians — Landmark national survey by DesRoches et al. on EHR adoption rates and physician perceptions of electronic records in outpatient settings.

AHRQ Health Information Technology — Agency for Healthcare Research and Quality research on health IT implementation, patient safety, and the impact of electronic records on clinical workflows.

AMA Digital Health Resources — American Medical Association guidance on electronic health records, digital health tools, and their effects on physician workflow and patient communication.