McGrath JM (Trinity University and Veterans Evidence-based Research Dissemination Center/ Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX)
Arar NH (Veterans Evidence-based Research Dissemination Center/ Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX)
Pugh JA (Veterans Evidence-based Research Dissemination Center/ Audie L. Murphy Memorial Veterans Hospital, San Antonio, TX)
Although VA hospitals have realized many benefits of adopting the electronic medical record (EMR), some physicians are concerned about the possible negative impact the EMR may have on doctor–patient nonverbal communication. Since doctors access a computer during the medical interview, the EMR may be a distraction, causing interpuptions in speech flow and reduced eye contact, among other nonverbal problems. This study examined nonverbal communication in relation to EMR use during the medical interview.
Six physicians were videotaped during their consultations with 50 different patients at a single setting Veterans Administration Hospital. Using a qualitative, observational approach, two researchers independently reviewed all of the videotapes, took extensive notes and judged whether EMR use was related to the following nonverbal categories: Kinesics, Vocalics, Physical Appearance, Haptics, Proxemics, Chronemics, and Artifacts. A percent agreement score was calculated and then observers compared their notes, cross-checked for inconsistencies and identified themes in the analysis. Additional comparisons were made by separating the interviews into high EMR use and low EMR use groups, where high EMR use was defined as interviews in which physicians used the EMR for more than 10% of the interaction time.
The initial percent agreement score was .86, and after cross-check and subsequent discussion, pausing was grouped with chronemics to achieve 100% agreement between observers. The following categories of nonverbal behavior were associated with EMR use: Kinesics (physical orientation, gaze and gestures); Proxemics (distance between doctor, patient and EMR); Chronemics (time using the EMR, pausing); and Artifacts (EMR location and office set up). EMR use caused doctors to lose eye contact with their patients and required physicians to be more physically oriented toward their computers than their patients. Physical orientation varied according to the EMR’s location in the office and physician and patient seating arrangement. Although some ineffective or detrimental nonverbal behaviors seemed inherent with EMR use, such behaviors varied according to degree. For example, three different office spatial designs were identified and named “open,” “closed” and “blocked.” The “open” arrangement put physicians in a position to establish better eye contact and physical orientation than did the alternative “closed” and “blocked” office configurations. Physicians who accessed the EMR and took “breakpoints” (short periods of no computer use and sustained eye contact with patients) used more nonverbal cues than physicians who tended to talk with their patients while continuously working on the computer. These nonverbal cues (head nods, eye contact, gestures, verbal regulators), sometimes referred to as back channel communication, encourage elaboration and facilitate understanding. Long pauses in conversational turn taking associated with EMR use had an unexpected, positive impact on doctor-patient communication. High EMR use physicians had patients who asked more questions and participated more in the medical interview than did low EMR use physicians.
Based on their findings, the authors recommend and illustrate how to set up the EMR in such a way that is most conducive to effective doctor-patient interaction, and they point out EMR location pitfalls that can be easily avoided. For example, the “open” arrangement helps minimize changes in physical orientation toward patients, positions physicians at an optimal angle for effective interpersonal communication and may help facilitate patient questions and understanding by making it easier for patients to access the computer screen if needed. The authors also describe the important functions of gaze in the medical interview and suggest how breakpoints can help reduce information loss that may be associated with EMR use. Nonverbal phenomena (slow turn- taking and reduced eye contact) that are typically associated with less effective interpersonal communication were related to an increase in positive verbal exchange.
Effective communication will require a delicate balance between attention to the EMR and face-to-face interaction with patients. To help facilitate this goal in VA hospitals, immediate changes regarding office set up and physician education are recommended.