A total of 9348 patients seen by 28 faculty and 81 resident internal medicine physicians between August and October 2013 were identified and 384 were randomly selected to include on our call list. After attempting to contact all 384 patients up to six times, we reached 193 (50 %, 193/384) on the phone (i.e., excluded unable to consent, non-English speaking, did not answer, deceased etc.; Figure 1). Of these patients, 110 (57 %, 110/193) consented and 108 (98 %, 108/110) patient interviews were completed.
Of 108 patients interviewed, 51 (47 %, 51/108) were seen by 28 unique faculty members and 57 (53 %, 57/108) were seen by 45 unique residents. Average patient age was 61 (range 21–92), 67 % (72/108) were female and 67 % (72/108) were African American. Patients seen by faculty were older than resident patients (mean age 66 vs. 56, p < 0.05), but had similar proportions of female [67 % (34/51) vs. 67 % (38/57), p = 1.0] and African American patients [65 % (33/51) vs. 68 % (39/57), p = 0.68].
Non-responders did not differ in average age [mean 57.8 (range 20–99), p > 0.05] and had similar proportions of female (61 %, p > 0.05) and African-American patients (67 %, p > 0.05) compared to responders.
Qualitative analysis: Positive and Negative Experiences Related to Physician Computer Use
Patients identified 21 pairs of positive and negative experiences related to physician computer use. Positive and negative experiences were categorized into two major themes: (1) Clinical Functions of EMR and (2) Communication Functions of EMR. Within the two major themes, we identified six subthemes: (1a) Clinical Care (i.e., clinical efficiency), (1b) Documentation (i.e., proper record keeping and access), (1c) Information Access, (1d) Educational Resource, (2a) Patient Engagement and (2b) Physical Focus (i.e., body positioning) (Online Appendix 2). Representative patient quotes are provided in Table 1.
Overall, 85 % (979/1154) of total codes reflected positive perceptions of EMR use with the majority of these falling under the “Clinical Care” subtheme (218). Patients liked that the EMR increased their doctor’s clinical efficiency, allowed them to review other physicians’ notes and promoted teamwork and communication between doctors; “They refer to each other’s notes and communicate about what’s going on with me. It makes me comfortable with the care I’m getting.” The second most commonly reported positive experience with the EMR related to the “Patient Engagement” subtheme (212). Patients liked that their doctors used the EMR to promote patient engagement and discussion and used visuals (i.e., pictures and graphs) to explain their care. They also liked when their doctors were transparent in their use of the EMR, explaining what they were doing on the computer, resulting in a perception of increased quality of care.
Patients also identified negative experiences related to EMR use in the clinic setting. While only 15 % (175/1154) of total patient perceptions were negative, the most common were within the “Physical Focus” subtheme (71), with patients reporting perceptions of unbalanced focus (i.e., physicians more focused on computer than patient) (45), poor eye contact (12) and poor screen positioning (12); “I just want my doctor’s undivided attention …the computer takes them away from focusing on you.” The second-most reported negative experience related to “Patient Engagement” (44), and patients disliked when physicians did not use the computer to facilitate discussion (19) or failed to explain what they were doing on the computer (7), resulting in perceptions of decreased quality of care (15). Member checks with five patients confirmed the positive and negative perceptions described above.
Quantitative Analysis: Patient Satisfaction Data
While most patients (69 %, 75/108) liked when their doctors used the computer during the visit, nearly one-third (29 %, 31/108) were ambivalent and had variable experiences. Similarly, while 59 % (63/107) reported that computer use had a positive effect on their relationship with their doctor, 39 % (42/107) were unsure or found variability in the experience (Table 2).
Overall, the large majority of patients (90 %, 95/106) were satisfied with physicians’ computer use in the clinic setting. Most patients reported their doctor’s computer use helped them to better understand medical conditions and treatments (81 %, 85/105) and made it easier for them to communicate during the visit (75 %, 78/104). The majority of patients (88 %, 90/102) reported their doctors stopped using the computer and were fully focused on them when they discussed sensitive topics. Only 8 % (8/106) of patients agreed that the computer was disruptive and prevented their doctor from focusing on them.
Patients also reported negative perceptions of computer use. Less than half of patients (47 %, 47/100) reported that their doctor positioned the screen to allow them to see the screen and were concerned with this lack of transparency. Moreover, while only 8 % (8/103) of patients cited poor eye contact with their physicians, 26 % (27/103) reported that they at least sometimes felt their doctors looked more at the screen than at them.
In comparing faculty and resident patient responses to the satisfaction questionnaire, the only significant difference was for overall satisfaction with the doctor’s use of the computer in the clinic room, with faculty patients reporting higher satisfaction when compared with resident patients (mean [SD] 4.62 [0.60] vs. 4.27 [0.86], p = 0.02). When comparing overall satisfaction of patients <60 years old (n = 41) to those ≥60 (n = 66), there was no significant difference in their responses (p > 0.05 for all).