Are better solutions 3 to 5 years away?
This article first appeared April 20, 2018 on Medpage Today.
By Ian Ingram
Patients perceived physicians using electronic medical record (EMRs) during office visits to have poorer communication skills, and be less professional and compassionate compared with those conducting a face-to-face visit and simply using a notepad, a randomized trial found.
And most patients (71%) said they preferred the face-to-face visit, reported Eduardo Bruera, MD, and colleagues from MD Anderson Cancer Center in Houston, Texas in JAMA Oncology.
"The EMR has been found to have many negative effects on physician time and burnout rate," Bruera told MedPage Today. "But negative effects on patients had not been documented before to our knowledge."
Using scripted video vignettes, the study randomized 120 advanced cancer patients in a palliative care clinic at MD Anderson to first view either a video portraying a face-to-face office visit where the physician used a notepad to record notes, then followed by an EMR version where the physician used a stationary computer for typing notes and accessing information while minimizing disruption in eye contact (n=60); the second group saw the same two videos but in the reverse order (n=60).
"The face-to-face encounter with undivided attention from the physician has become less frequent," said Bruera. "Our findings suggest that patients prefer physicians who do not use the EMR as part of the encounter."
The face-to-face visit was better perceived across all study outcomes, with better median scores reported in questionnaires both after initial analysis of the first video and that following viewing of both.
Compassion score, where 0 is best and 50 is worst:
- 9 for face-to-face versus 20 for EMR after viewing the first video only (P<0.001)
- 4 versus 21 after crossover analysis (P<0.001)
Communication skills score, where 14 is poor and 70 is excellent:
- 65 versus 54 after first video (P=0.001)
- 68 versus 53 after crossover analysis (P<0.001)
Professionalism scores, where 4 is poor and 20 is very good:
- 19 versus 14 after first video (P<0.001).
- 20 versus 15 after crossover analysis (P<0.001)
"The result is not surprising," said Robert M. Wachter, MD, of the University of California San Francisco, commenting on the study. "Although it's worth taking a step back and asking why do people perceive things to be so different when the doctor is scribbling on a piece of a paper versus tapping on a computer."
The idea that physicians have to split their attention between the patients and documentation is not a new concept, he said. "It does leave you head scratching a little bit about what it is about this thing called the computer interface that appears to be particularly bothersome to patients."
Searching for improvements, some doctors have resorted to the use of scribes. "An awfully expensive and almost hilarious solution," Wachter told MedPage Today, yet tens of thousands have been hired by hospital and clinics.
In a recent article in Harvard Business Review, Wachter and Jeff Goldsmith, of the University of Virginia, described the advent of scribes as a "medieval" solution. "Only in healthcare, it seems, could we find a way to 'automate' that ended up adding staff and costs!" they wrote.
"New technology is needed," said Bruera, who described current EMR technology as "rudimentary" and seemingly designed solely for billing and regulatory compliance.
Wachter told MedPage Today that one option that has worked to varying degrees is an ergonomic solution where the computer is positioned in a triangle so both patient and doctor can see the record process, but said that the endgame is relatively clear. "I think it's probably 3-5 years away before this no longer is a major problem," he said. "There are a big number of companies working on what are called digital scribes."
He described an Amazon Alexa-like device that would sit in the doctor's office, but have intelligence to handle more than just dictation. More sophisticated functionality could identify that a conversation has shifted to the possibility of breast cancer, say, and begin searching the patient's record on its own to see if they've had genetic testing, a family history of the disease, or mammograms. This automated searching would be determined by thousands of previous doctor-patient interactions to find out what doctors had searched for during similar conversations. "When the conversation has content X, the doctor looks up in the chart for test Y and Z," said Wachter, "and then it can mimic that."
Patients in the study were enrolled from December 1, 2016, to May 30, 2017. Median age of patients was 58 years (44-66); most were white (67%), married (64%), and a majority (54%) were women.
The vignettes followed a format recommended in previous studies for this type of research. A script was developed (identical for both scenarios) and professional actors were hired. An independent review of the two vignettes was done to ensure the expressions and emotional quotients were the same.