Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: Multi-channel video study

Background and objective: Electronic patient record (EPR) systems are widely used. This study explores the context and use of systems to provide insights into improving their use in clinical practice. Methods: We used video to observe 163 consultations by 16 clinicians using four EPR brands. We made a visual study of the consultation room and coded interactions between clinician, patient, and computer. Few patients (6.9%, n=12) declined to participate. Results: Patients looked at the computer twice as much (47.6 s vs 20.6 s, p<0.001) when it was within their gaze. A quarter of consultations were interrupted (27.6%, n=45); and in half the clinician left the room (12.3%, n=20). The core consultation takes about 87% of the total session time; 5% of time is spent preconsultation, reading the record and calling the patient in; and 8% of time is spent post-consultation, largely entering notes. Consultations with more than one person and where prescribing took place were longer (R2 adj=22.5%, p<0.001). The core consultation can be divided into 61% of direct clinician-patient interaction, of which 15% is examination, 25% computer use with no patient involvement, and 14% simultaneous clinician-computer-patient interplay. The proportions of computer use are similar between consultations (mean=40.6%, SD=13.7%). There was more data coding in problem-orientated EPR systems, though clinicians often used vague codes. Conclusions: The EPR system is used for a consistent proportion of the consultation and should be designed to facilitate multi-tasking. Clinicians who want to promote screen sharing should change their consulting room layout.