Electronic Medical Records
Conditions
Keywords
Communication, Doctor-patient relations, medical informatics, patient-centered care, medical records systems, computerized
Brief summary
The VHA is a leader in electronic medical records (EMR) use for patient care. It is believed that EMR use by doctors will improve patient-centeredness of visits, and improve clinical care. The proposed study will determine how doctors should use the EMR during patient consultations. We will also develop a training program to improve doctors ability to communicate with patients while using EMR.
Detailed description
Anticipated Impact on Veterans Healthcare: Health information technology (HIT), including electronic medical records (EMR) has the potential to improve the quality and safety of ambulatory care. The VHA is a leader in EMR implementation. It is believed that EMR use by physicians will improve patient-centeredness of visits, and healthcare outcomes. The proposed clinical trial addresses the need for rigorous research on EMR use, patient-centered care, and relevant health outcomes. Both physician-patient communication and EMR use are cross-cutting clinical issues with broad implications for patient care within the VHA. Consequently, the proposed project is directly related to the VHA's mission to use HIT to improve the quality health care for veteran patients. BACKGROUND/RATIONALE EMRs can potentially improve quality and safety of ambulatory care. However, little research systematically documents the effect of EMRs on patient-centered care. Studies of the EMR's effect on patient-provider communication have been observational and had small sample sizes. Overall, these studies reported varied success regarding providers integrating the EMR into office visits, and suggest that further research is needed to evaluate the effectiveness of training providers in patient-centered communication and EMR use. OBJECTIVES The PACE aims were to study how EMR use affects patient-provider communication behaviors, and patient-centered care and related health outcomes; to develop a unique provider training program tailored to patient-centered EMR use; and to evaluate the effect of the training intervention on patient-provider communication, patient-centered care, and provider EMR use. METHODS The study used a quasi-experimental (pre-post intervention design) carried out in three phases: 1. Pre-intervention: A pre-intervention patient-provider visit was conducted for each patient-provider pair. Visits were video recorded and reviewed for verbal and nonverbal patient-provider communication. MORAE software was used to record provider-EMR interaction data, including page views, navigation, and mouse clicks. Data were collected for related outcomes (patient and provider satisfaction). 2. Training: Findings from pre-intervention data guided development of a multifaceted provider training intervention promoting patient-centered EMR appropriation. The training intervention was delivered via a full day training workshop and individual feedback sessions. 3. Post-intervention: A second round of visits was conducted with the same patient-provider pairs and similar data were collected as in pre-intervention. Within group analyses (pre-post) were used to test whether the training intervention resulted in significant improvements in (a) patient-centered EMR use and (b) related outcomes (patient and provider satisfaction). IMPACT PACE findings emphasize the need to address EMR usability by the VHA hi2 (Health Informatics Initiative) and iEHR team.
Interventions
BEHAVIORALPhysician training in patient-centered emr use
This intervention was performed in between the pre-intervention (Baseline) clinic visit and post intervention clinic visit.
Sponsors
VA Office of Research and Development
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Adult (age\>18) male and female patients from participating study providers' practices who have an established a doctor-patient relationship with their provider and require a minimum of 2 primary care clinic visits/year based on historical clinic data.
Exclusion criteria
* Patients with significant communication disability (severe speech and hearing impairment, severe dementia, or a mental health condition resulting in a non-communicative patient); * patients are considered mentally incompetent to provide informed written consent; * a life expectancy of less than 1 year.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | Three patient satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures physician's use of patient center communication; Subscale 2 measures clinical competence and skills; Subscale 3 measures physician interpersonal skills. Four provider satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures quality of physician-patient relation; Subscale 2 measures patient's non-demanding co-operative nature, Subscale 3 measures satisfaction with data collection; Subscale 4 measures satisfaction with use of visit time. Change in patient's satisfaction and change in provider's satisfaction from pre to post-intervention clinic visit was reported for the above subscales. Higher change score indicates better outcome. Mean and standard deviation were reported. |
| Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | Three patient satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures physician's use of patient center communication; Subscale 2 measures clinical competence and skills; Subscale 3 measures physician interpersonal skills. Four provider satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures quality of physician-patient relation; Subscale 2 measures patient's non-demanding co-operative nature, Subscale 3 measures satisfaction with data collection; Subscale 4 measures satisfaction with use of visit time. Change in patient's satisfaction and change in provider's satisfaction from pre to post-intervention clinic visit was reported for the above subscales. Higher change score indicates better outcome. Median and range were reported. |
| Change in Patient Engagement | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | Change in proportion of time spent on physician-patient communication from pre to post-intervention clinic visit was calculated. Positive change indicates increased time spent on patient communication. Mean and standard deviation of outcomes were reported in this table. |
| Change in Total Number of EMR Mouse Click Per Visit (Mean/SD) | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | For EMR use, we assessed the change in total number of mouse click per-visit, positive score indicates increased EMR use. Mean and standard deviation of outcome were reported in this table. |
| Change in Total Number of EMR Mouse Click Per Visit (Median/Range) | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | For EMR use, we assessed the change in total number of mouse click per-visit, positive score indicates increased EMR use. |
| Change in EMR Mouse Click Per Minute Per Visit (Mean/SD) | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | — |
| Change in EMR Mouse Click Per Minute Per Visit (Median/Range) | Baseline clinic visit and post-intervention clinic visit (over a period of 1 year) | For EMR use, we assessed the change in the average number of mouse clicks per minute per-visit, positive score indicates increased EMR use. |
Countries
United States
Participant flow
Recruitment details
The study recruited 23 primary care providers from VA San Diego and its community based outpatient clinics. For each provider we enrolled approximately 6 patients from their out-patient practice. A total of 23 physicians and 126 patients were included in the final analysis.
Participants by arm
| Arm | Count |
|---|---|
| PACE Study Patients The proposed study will use a quasi-experimental (pre-post intervention design) carried out in three phases.
Physician training in patient-centered emr use: physician training in patient-centered EMR use (PACE) will be developed. The conceptual model of patient-centered communication will provide the underlying framework for the training aimed at improving physicians interviewing and communication skills. | 126 |
| PACE Study Providers 23 providers participated in the study. However, final analysis was based on 126 clinic visits. | 23 |
| Total | 149 |
Withdrawals & dropouts
| Period | Reason | FG000 | FG001 |
|---|---|---|---|
| Overall Study | Death | 3 | 0 |
| Overall Study | Lost to Follow-up | 8 | 0 |
| Overall Study | No show | 9 | 0 |
| Overall Study | Patient changed provider | 3 | 0 |
| Overall Study | Provider dropped out of study | 14 | 4 |
| Overall Study | Relocated | 3 | 0 |
| Overall Study | Withdrawal by Subject | 9 | 0 |
Baseline characteristics
| Characteristic | PACE Study Patients | PACE Study Providers | Total |
|---|---|---|---|
| Age, Continuous | 60.5 years STANDARD_DEVIATION 13.4 | NA years | NA years |
| Region of Enrollment United States | 126 participants | 23 participants | 149 participants |
| Sex: Female, Male Female | 4 Participants | 17 Participants | 21 Participants |
| Sex: Female, Male Male | 122 Participants | 6 Participants | 128 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | — / — |
| other Total, other adverse events | 0 / 0 |
| serious Total, serious adverse events | 0 / 0 |
Outcome results
Primary
Change in EMR Mouse Click Per Minute Per Visit (Mean/SD)
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (n=56 for the outcomes reported below) only and mixed model method was used to analyze the subjects (n=119) using all available data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| PACE Study | Change in EMR Mouse Click Per Minute Per Visit (Mean/SD) | -0.089 EMR mouse clicks per minute per visit | Standard Deviation 3.11 |
Comparison: The null hypothesis states that there is no significant change in outcome from pre-intervention clinical visit (baseline) to post-intervention clinic visit.p-value: <0.05Mixed Models Analysis
Comparison: The null hypothesis states that there is no significant change in outcome from pre-intervention clinical visit (baseline) to post-intervention clinic visit.p-value: <0.05Wilcoxon signed rank test
Primary
Change in EMR Mouse Click Per Minute Per Visit (Median/Range)
For EMR use, we assessed the change in the average number of mouse clicks per minute per-visit, positive score indicates increased EMR use.
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (n=56 for the outcomes reported below) only and mixed model method was used to analyze the subjects (n=119) using all available data.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| PACE Study | Change in EMR Mouse Click Per Minute Per Visit (Median/Range) | 0.005 EMR mouse clicks per minute per visit |
Primary
Change in Patient Engagement
Change in proportion of time spent on physician-patient communication from pre to post-intervention clinic visit was calculated. Positive change indicates increased time spent on patient communication. Mean and standard deviation of outcomes were reported in this table.
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (n=72 for the outcomes reported below) only and mixed model method was used to analyze the subjects (n=125) using all available data.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| PACE Study | Change in Patient Engagement | Time spent on patient and companion | 2.9 percentage of total visit time | Standard Deviation 15.2 |
| PACE Study | Change in Patient Engagement | Time spent on physical exam | -1.4 percentage of total visit time | Standard Deviation 14.7 |
| PACE Study | Change in Patient Engagement | Time spent on EMR | -1.6 percentage of total visit time | Standard Deviation 16.6 |
Comparison: The null hypothesis is that there is no significant change in patient engagement from pre to post visit.p-value: >0.05Mixed Models Analysis
Comparison: The null hypothesis is that there is no significant change in patient engagement from pre to post visit.p-value: >0.05Wilcoxon signed rank test
Primary
Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD)
Three patient satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures physician's use of patient center communication; Subscale 2 measures clinical competence and skills; Subscale 3 measures physician interpersonal skills. Four provider satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures quality of physician-patient relation; Subscale 2 measures patient's non-demanding co-operative nature, Subscale 3 measures satisfaction with data collection; Subscale 4 measures satisfaction with use of visit time. Change in patient's satisfaction and change in provider's satisfaction from pre to post-intervention clinic visit was reported for the above subscales. Higher change score indicates better outcome. Mean and standard deviation were reported.
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (ranges from 63 to 73 for the outcomes reported below) only and mixed model method was used to analyze the subjects (ranges from 108 to126) using all available data.
| Arm | Measure | Group | Value (MEAN) | Dispersion |
|---|---|---|---|---|
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Patient satisfaction/visit | -0.033 units on a scale | Standard Deviation 0.454 |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Patient satisfacton/clinical skill | 0.032 units on a scale | Standard Deviation 0.69 |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Patient satisfaction/interpersonal skill | -0.018 units on a scale | Standard Deviation 0.386 |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Provider satisfaction/physician-patient relation | 0.077 units on a scale | Standard Deviation 0.538 |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Provider satisfaction/patient's cooperation | 0.0101 units on a scale | Standard Deviation 0.869 |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Provider satisfaction/data collection | 0.095 units on a scale | Standard Deviation 0.686 |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Mean/SD) | Provider satisfaction/use of time | -0.035 units on a scale | Standard Deviation 0.827 |
Comparison: The null hypothesis states that there is no significant change in outcome from pre-intervention clinical visit (baseline) to post-intervention clinic visit.p-value: >0.05Mixed Models Analysis
Comparison: The null hypothesis states that there is no significant change in outcome from pre-intervention clinical visit (baseline) to post-intervention clinic visit.p-value: >0.05Wilcoxon signed rank test
Primary
Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range)
Three patient satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures physician's use of patient center communication; Subscale 2 measures clinical competence and skills; Subscale 3 measures physician interpersonal skills. Four provider satisfaction subscales were analyzed (range 1-5 for all subscales, 1=not satisfied at all, 5=very satisfied). Subscale 1 measures quality of physician-patient relation; Subscale 2 measures patient's non-demanding co-operative nature, Subscale 3 measures satisfaction with data collection; Subscale 4 measures satisfaction with use of visit time. Change in patient's satisfaction and change in provider's satisfaction from pre to post-intervention clinic visit was reported for the above subscales. Higher change score indicates better outcome. Median and range were reported.
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (ranges from 63 to 73 for the outcomes reported below) only and mixed model method was used to analyze the subjects (ranges from 108 to126) using all available data.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Patient satisfaction/visit | 0 units on a scale |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Patient satisfaction/clinic skill | 0 units on a scale |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Patient satisfaction/interpersonal skill | 0 units on a scale |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Provider satisfaction/physician-patient relation | 0 units on a scale |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Provider satisfaction/patient's cooperation | 0 units on a scale |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Provider satisfaction/data collection | 0 units on a scale |
| PACE Study | Change in Patient's Satisfaction, Change in Provider's Satisfaction (Median/Range) | Provider satisfaction/use of time | 0 units on a scale |
Comparison: The null hypothesis is that there is no significant change in outcome from pre to post visit.p-value: >0.05Mixed Models Analysis
Comparison: The null hypothesis is that there is no significant change in outcome from pre to post visit.p-value: >0.05Wicoxon signed rank test
Primary
Change in Total Number of EMR Mouse Click Per Visit (Mean/SD)
For EMR use, we assessed the change in total number of mouse click per-visit, positive score indicates increased EMR use. Mean and standard deviation of outcome were reported in this table.
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (n= 60 for the outcomes reported below) only and mixed model method was used to analyze the subjects (n=119) using all available data.
| Arm | Measure | Value (MEAN) | Dispersion |
|---|---|---|---|
| PACE Study | Change in Total Number of EMR Mouse Click Per Visit (Mean/SD) | -1.22 EMR mouse clicks per visit | Standard Deviation 155 |
Comparison: The null hypothesis states that there is no significant change in outcome from pre-intervention clinical visit (baseline) to post-intervention clinic visit.p-value: <0.05Mixed Models Analysis
Comparison: The null hypothesis states that there is no significant change in outcome from pre-intervention clinical visit (baseline) to post-intervention clinic visit.p-value: <0.05Wilcoxon signed rank test
Primary
Change in Total Number of EMR Mouse Click Per Visit (Median/Range)
For EMR use, we assessed the change in total number of mouse click per-visit, positive score indicates increased EMR use.
Time frame: Baseline clinic visit and post-intervention clinic visit (over a period of 1 year)
Population: Wilcoxon signed rank test was used to analyzed the subjects using complete data (n=60 for the outcomes reported below) only and mixed model method was used to analyze the subjects (n=119) using all available data.
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| PACE Study | Change in Total Number of EMR Mouse Click Per Visit (Median/Range) | -2 EMR mouse clicks per visit |
Comparison: The null hypothesis is that there is no significant change in outcome from pre to post visit.p-value: <0.05Mixed Models Analysis
Comparison: The null hypothesis is that there is no significant change in outcome from pre to post visit.p-value: <0.05Wilcoxon signed rank test