EHRs cause behaviour changes in doctors, says study

A study published in the Annals of Family Medicine has revealed that family doctors who use electronic health records instead of paper while in surgery are developing very different consulting styles.

Researchers at Oregon Health and Science University and Multnomah County Health Department, in Portland, interviewed patients, GPs and nurse practitioners, and viewed videotapes of consultations.

They identified three different practice styles; interpersonal, where doctors sat away from the computer and listened to their patients, or turned the computer around to show the patient what they were typing; ‘informationally-focused’, where they simply concentrated on the computer; and managerial, where doctors gave equal attention to patient and PC.

"Whether physicians perceived the EHR as important in developing the meaning of the encounter influenced how they used it," says the study. "Those who saw the EHR as a means for collaboration were more likely to share the screen with their patients than those who used it more narrowly as a medical record."

However, the technology itself acted to change some of the relationships between clinician and patient. For instance, templates used in the electronic health records worked well for certain illnesses, such as respiratory tract infections, but less so for "patients’ narratives or emotional issues" and complex complaints.

One clinician quoted in the study said: "My use of the EHR is limited by the encounter type I’m having. If a patient is coming to me with depression, I leave the computer alone because I think it’s kind of cold."

Another said: "If I feel like my typing is interfering with my relationship with a patient, I stop typing – only then I’ve got a lot of typing to do later on."

Some also felt that while electronic health records were useful because they were concise, they left no room for patient narrative or background. "There was a subtle cookie-cutter effect to EHR-generated notes," said the researchers.

Clinicians’ own use and familiarity with computer systems also impacted on relationships with patients. "The simple ability to type was noted overwhelmingly as crucial to using the EHR effectively with patients," explained the study. One nurse practitioner said that if you had to ‘hunt and peck’ to type, the EHR became a lot less useful.

"Many mistakenly see the EHR as an updated version of the paper chart, but behind the superficial resemblance of tabs, notes and flow sheets is a complicated system of functions (and correspondingly, of human notions) that play into its application in the medical setting," the study concludes.

In the light of their findings, the authors of the study have also created a list of top tips for using electronic health records. These recommend the use of mobile computer monitors that both doctors and patients can see, telling the patients what you are doing as you type and reserving the use of templates for note taking, not structuring interviews with patients.

The full text of the study can be downloaded from (link). The top tips for using EHRs with patients are available at (link).