Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation

  • Richard L. StreetJr
  • Lin Liu
  • Neil J. Farber
  • Yunan Chen
  • Alan Calvitti
  • Nadir Weibel
  • Mark T. Gabuzda
  • Kristin Bell
  • Barbara Gray
  • Steven Rick
  • Shazia Ashfaq
  • Zia Agha
Original Research



Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.


To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians’ efforts to facilitate patient involvement, and silence.


Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.


Thirty-two physicians and 217 patients.

Main Measures

Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.

Key Results

Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = −0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians’ facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures.


Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient’s thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.



This work was supported by the Agency for Healthcare Research and Quality R01HS021290. This material is the result of work supported with resources of the VA San Diego Healthcare System. The contents do not represent the views of the US Department of Veterans Affairs or the United States Government. Richard Street also is supported by the Houston VA Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Richard L. StreetJr
    • 1
    • 2
    • 3
  • Lin Liu
    • 4
    • 5
  • Neil J. Farber
    • 4
  • Yunan Chen
    • 6
  • Alan Calvitti
    • 5
  • Nadir Weibel
    • 4
  • Mark T. Gabuzda
    • 5
  • Kristin Bell
    • 5
  • Barbara Gray
    • 5
  • Steven Rick
    • 5
  • Shazia Ashfaq
    • 5
  • Zia Agha
    • 4
    • 7
  1. 1.From Department of Communication Texas A&M UniversityCollege StationUSA
  2. 2.Department of MedicineBaylor College of MedicineHoustonUSA
  3. 3.Houston VA Center for Innovations in Quality, Effectiveness and SafetyHoustonUSA
  4. 4.From University of California San DiegoSan DiegoUSA
  5. 5.VA San Diego Healthcare SystemSan DiegoUSA
  6. 6.University of California IrvineIrvineUSA
  7. 7.West HealthSan DiegoUSA

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