The 2014 Rhode Island HIT Survey’s overall response rate was 68.3%, with 2,567 of 3,761 physicians completing the survey. Among the survey respondents, 2,236 (87.1%) had EHRs; and among those hospital-based physicians with EHRs (969), 265 (27.3%) responded to the open-ended question asking how EHRs affected their patient interactions. Compared to hospital-based physicians who did not answer the question, hospital-based physicians who did were more likely to be older and to practice primary care or emergency medicine (Table 1). About 40% (479) of office-based physicians with EHRs (1,267) responded to the open-ended question. Compared to office-based physicians who did not answer the question, office-based physicians who did were also older and more likely to practice primary care.
Major themes
EHRs mean less time to spend with patients because more time is required for documentation
The most common theme among hospital-based physicians, and the second most common theme overall, focused on the additional time spent using a computer for documentation that then takes away from time spent directly interacting with patients.
‘We spend less time at bedside and more time interacting with our computers’. [Hospital-based Respondent]
‘I now spend much less time [with] patients because I know I have hours of data entry to complete’. [Hospital-based Respondent]
Physicians distinguished between time spent on documentation that resulted in less time in the exam room or at the bedside, versus the time spent looking at a computer during the clinical interaction itself. Hospital-based physicians more commonly described less time in the exam room or at the bedside, compared to office-based physicians who commented more about time spent looking at a computer and not the patient.
EHRs reduce the quality of the patient–physician interaction and relationship
The second most common theme among hospital-based physicians was the negative impact of EHRs on the quality of interactions with patients and therefore physicians’ relationships with patients.
‘Negatively [affects interactions]. Interacting with computer rather than my patient. Like having someone at the dinner table texting rather than paying attention’. [Office-based Respondent]
Decreased eye contact while documenting during the clinical encounter emerged as a prominent sub-theme.
‘My nose is now burrowed deep into my computer interface, leaving markedly reduced time to make eye contact and actually interact one on one with my patient’. [Hospital-based Respondent]
We identified as a second sub-theme the perception that using an EHR depersonalizes the interaction and distracts both patient and physician. Comments included words such as intrusive, impersonal, limits, interferes, distracts and disruptive to describe how using an EHR affects patient interaction, and physicians often referred to the EHR as a barrier.
‘I don’t feel connected as I am always looking at the [screen]/typing. The art of medicine and treating is lost in this process’. [Hospital-based Respondent]
‘Detracts from face to face contact with patients. I [a]m looking at a screen to make sure that I’ve checked off all the necessary data points irregardless of whether they have any relationship to the reason the patient is being seen’. [Office-based Respondent]
EHRs have no effect on patient interaction
A smaller proportion of physicians in the hospital setting commented that EHRs have no effect on their interaction with patients. This was the third most commonly observed theme among hospital-based physicians, and two distinct sub-themes emerged. The first sub-theme, more common among hospital-based physicians, was that EHRs truly did not affect their interaction because it was not a major part of their workflow or because they had learned to incorporate EHRs without difficulty.
‘Minimal [effect], as most of my patients are newborn infants. EHR is of some help in communication with parents’. [Hospital-based Respondent]
‘Doesn’t [affect interactions] . . . Medical ass[istan]t in the room acts as a scribe during p[atien]t encounter’. [Office-based Respondent]
While this theme was also the third most common among office-based physicians, a notable difference is that office-based physicians more commonly described that EHRs do not affect patient interactions because physicians have altered their workflow to prevent the EHR from having a negative impact, which emerged as the second sub-theme.
‘I have to do my documentation after seeing the patients because I am not going to type into the computer while they are trying to talk to me’. [Office-based Respondent]
Many of these office-based physicians who described altering their workflow also noted that this approach resulted in longer work days to complete the required documentation:
‘I have tried to keep the [patient]-doctor interaction at the forefront of this work, so I mostly jot notes on paper in the room . . . this means I have hours and hours of work at home, but I can’t and won’t stop putting the patient at the center’. [Office-based Respondent]
EHRs improve access to information, which benefits patient interactions
Hospital-based physicians described how easy access to information has a positive impact on their interactions with patients. This was the fourth most commonly identified theme, and we identified several sub-themes. First, hospital-based physicians commented that viewing problem lists and lab results help them prepare for the clinical encounter and make it more efficient.
‘Helps me with the past medical history before I see the patient which is beneficial in the ED’. [Hospital-based Respondent]
A second sub-theme encompassed how physicians used EHRs to facilitate communication, by allowing the patient and physician to review test results together and by providing ready access to educational materials.
‘I love [showing] Google images to the patients in the office for the purpose of patient education. I save meaningful graphic representatives with which to teach. I use numerous we[b]-based tools . . . [However], for some visits it reduces eye contact’. [Office-based Respondent]
A third sub-theme captured how EHRs improved communication with other physicians, most commonly through access to notes, and how this access facilitated their interaction with patients.
‘Allows me in the ED to look at an old record before I see the patient to learn some history’. [Hospital-based Respondent]
This theme was also the fourth most commonly described among office-based physicians, although differences were noted among the sub-themes. Office-based physicians commented more frequently about using EHRs during the visit to facilitate communication and noted improved communication with patients via patient portals, while they less frequently commented that viewing problem lists and lab results help them feel more prepared for the clinical encounter.
Negative or positive, but non-specific comments about patient interactions
In the remaining quotes (separate from the four main themes), some physicians expressed that using EHRs had an undesirable impact on their interactions, without providing additional detail. Similarly, physicians expressed positive but non-specific statements; this was the least commonly identified. No major differences were found between settings.