INTRODUCTION
The use of an electronic health record (EHR) by a provider during an office visit has been equated to ‘texting while driving’ and thus raises concerns that a provider’s observation, communication, problem solving and development of trusting relationships could be impacted.1 We agree that a person should not be texting while driving, yet what is wrong with texting in a parked car? In the second situation, the driver identified a conflict of attention and chose to stop and do one activity at a time. Can healthcare providers help identify when it is ‘safe’ to ‘text while doctoring’?
To understand the effects of any given factor on the provider during the office visit, we must first review the cognitive tasks that a provider performs. The cognitive tasks accomplished during a medical office visit with an EHR have been described.2 During an office visit, the provider has the important cognitive task of attending to the patient while actively using the EHR. It has been argued that all aspects of health care provider performance require cognitive processes.3 It is evident from these diverse activities that each part of the office visit requires the provider to complete different cognitive tasks.
The role of the EHR in the current work system needs to be clarified. The functionality of the EHR has also been described.4 Based on providers’ interviews, a prediction was made that the EHR would increase the physician’s mental workload and thus make the tasks of simultaneously data entry and engagement in patient centred care more problematic.4
It has been concluded that the introduction of the EHR into the office environment would have intended and unintended consequences on the cognitive and social dimensions of the clinical encounter5. It has been proposed that the performance of cognitive work mediates between the work system design and the patient, the employee, and organizational outcomes.4 Thus, to be effective, the EHR must both enhance the performance of the diverse cognitive tasks performed during an office visit and integrate into the work system design.
The EHRs observed effect on patient–provider communication uncovered common patterns and communication was ‘changed’ due to the computer being in the room with novel ‘time-out’ periods.6 The interviewed patients were unclear about the computer’s function and what their providers were doing on the computer.
Videotaped office visits were also evaluated for determining the effects of the EHR on patient–provider communication.7 The EHR affected visit organization, verbal and nonverbal behavior, computer navigation and mastery, and spatial organization of the room. The clinician’s baseline mastery of communication skills correlated with their effective use of exam room computers (ERCs) and these skills were carried forward and affected the clinician–patient communication positively or negatively depending on provider’s baseline skills.
Three distinct practice ‘styles’ identified through videotaped analysis have been labeled as informational, interpersonal and managerial.8 These styles were distinguished based on the behaviors of the clinicians during real-time clinic visit progress. The author’s found that clinician style determined the use of the ERC over a wide variety of behaviors, including the time spent on looking at the patient, collaborative use of the ERC screen, and types of questions asked by patients.8 Further research using videotape analysis and focus group interviews found that providers’ use and perception of EHRs were influenced by factors grouped into four categories: spatial, relational, educational and structural.5
Communication dynamics were also analyzed using videotapes of primary care physicians and the studied sample spent 24%–42% of the visit time gazing at the computer.9 These findings and others have led to labeling the computer a ‘third party’ in the visit, as the ERC competes with the patient for the clinician’s attention and diminishes patient centredness.5,9,10 In fact, 92% of one study’s participants reported that the use of the EHR disturbed their patient–provider communication.11 This led the authors to suggest adjusting the spatial organization of the office and working on providers’ communication and computer skills.
The literature clearly demonstrates the complexity of the cognitive tasks that the health care provider performs during an outpatient office visit. But how does this impact teaching students or the preceptors enthusiasm for teaching? One study found that nearly half of the faculty reported decreased enthusiasm for teaching following EHR implementation.12
The purpose of our study was to obtain provider/preceptor opinions regarding the effects of the EHR on distinct aspects of the office visit as well as their ability to educate students. We hypothesized that the use of the EHR may be detrimental to some aspects of the office visit and one’s ability to teach, but may be neutral or even enhance other aspects of the visit. In other words, we aimed to attempt to determine when, or if, it is safe to ‘text while doctoring’.