JMIR Publications

ABSTRACT

Background:

This mixed-methods study investigated the impact of computer use on physician performance during clinical simulations. Standardized patient scenarios used in family practice certification examinations were adapted to include use of the electronic health record (EHR).

Objective:

The goal was to compare the impact of EHR use during simulated virtual patient encounters on resident physician and staff physician patient-centeredness (PC) and overall clinical performance, as well as to measure the cognitive load (CL) imposed by EHR use.

Methods:

Sixteen participants each completed 2 video telemedicine simulations with standardized patients (SPs). One simulation case included limited past medical history for the SP in the EHR (PMHx case), while the other did not (NoHx case). Participants’ self-perceived CL was measured using the raw National Aeronautics and Space Administration Task Load Index (NASA-TLX). Video recordings were analyzed for participant PC and overall clinical performance. In addition to interacting with the EHR, multiple participants also conducted internet searches. Proportion of time that participants spent interacting with the computer, either using the EHR or searching the internet, was calculated, and signs of physician stress/CL were assessed through qualitative video analysis.

Results:

Participant interpretations of instructions for use of the EHR during simulated virtual encounters varied widely. For example, participants clicked on only the Progress Notes section of the EHR in 11 of 32 encounters. Staff physicians (n = 6) scored higher on PC compared to resident physicians (n = 10) for both cases. Median physician-examiner assigned PC score was 6.0 (IQR 4.0 – 8.0) for resident physicians versus 12.5 (IQR 9.0 – 16.0) for staff physicians for the PMHx case (P = .03). Median PC score was 16.5 (IQR 12.0 – 17.8) for residents versus 21.0 (IQR 18.5 – 22.8) for staff physicians for the NoHx case (P = .02). Physician overall CL as measured by the raw NASA-TLX was not significantly correlated with computer use. For residents only, there were significant correlations between computer use and the mental demand domain of the NASA-TLX for the PMHx case (Kendall’s tau-b = 0.64, P = .009), and between computer use and the time pressure domain of the NASA-TLX for the NoHx case (tau-b = 0.60, P = .02).

Conclusions:

Use of the computer during video telemedicine appointments may negatively impact physician PC and overall clinical performance. Increased clinical experience helps to counter this negative impact of computer use. A need for formal instruction in effective use of the EHR during virtual encounters was identified. This instruction could allow physicians to chart contemporaneously while communicating effectively with patients. Consideration should be given to adding use of the EHR to physician certification examinations, with clear instructions regarding which tasks must be completed in the EHR during interaction with SPs.