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 pre-consultation, 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 (R(2) 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.