Multitasking and Silent Electronic Health Record Use in Ambulatory Visits

Electronic health record (EHR) implementation may affect time allocation during patient visits.¹ Clinicians may use EHRs in silence, risking lower patient satisfaction,² or by multitasking while talking with patients. Concurrent multitasking (performing ≥2 tasks simultaneously) is associated with increased error risk and time to complete tasks.³ We studied time allocation and transitions into and out of silent EHR use in clinics after EHR implementation.

This observational study (2013-2015) included 5 primary and specialty safety-net clinics transitioning from basic to fully-functional EHR. Eligible study participants had been enrolled in a study about basic EHR use and communication, which included 47 English- and/or Spanish-speaking adults with chronic conditions and 39 physicians and nurse practitioners.⁴ This analysis includes 25 clinicians and 25 patients with visits after a fully-functional EHR was implemented. Research assistants video recorded visits 3 to 16 months (median, 9) after the implementation of the EHR. After visits, patients rated recent quality of care (poor to excellent). All participants provided written informed consent and received $5 to $20 gift cards for each study procedure. The University of California, San Francisco, institutional review board approved the study.

Two researchers (N.R. and G.Y.M.) coded visits using mutually exclusive categories (Figure): multitasking EHR use (while clinician or patient spoke); silent EHR use (≥3-second silence); non-EHR multitasking; silent non-EHR tasks; education with EHR; education with paper; physical examination; and focused patient-clinician talk. For each category, we calculated total proportion of visit time and sample medians (interquartile ranges).

We qualitatively coded EHR tasks conducted silently and communication transitioning into and out of silent EHR use. We compared patients rating care as “excellent” after visits above and below median multitasking EHR use, using generalized estimating equations regression.

Among 35 visits between 25 patients and 25 clinicians, 17% were in Spanish and 40% of relationships were longer than 5 years (Table). Median visit length was 20.6 minutes.

The Table shows visit time proportions. Multitasking EHR use comprised 30.5% of visit time, silent EHR 4.6%, multitasking non-EHR tasks 4.3%, and focused patient-clinician talk 33.1%. The Figure shows that multitasking time exceeded silent EHR use.

Patients rated care “excellent” after 66.7% of low-multitasking EHR use visits and 76.5% of high-multitasking EHR visits (P = .65).

Silent EHR use (n = 193 instances) occurred while clinicians viewed (39.4%) or entered (24.4%) information, prescribed (13.5%), reconciled medications (8.3%), arranged appointments (5.2%), ordered tests or referrals (5.2%), and sought or typed patient education (3.1%). The median silent EHR use lasted 16.2 seconds, shortest for viewing information (4.6) and longest for patient education (34.0).

Qualitative analysis revealed that clinicians demonstrated various transitions into silent EHR use. Sometimes clinicians signaled a need to focus (“Give me a minute, I want to review in the computer what we’ve done before.”). Other times, clinicians shifted into silence without warning (“There aren’t specific treatments...but they’re going to...uh...uh...uh...”).

Patients often broke silent EHR use with small talk (“So, how is your family?”), or by introducing concerns (“Oh yea, what did the x-ray show about my shoulder?”).

Clinicians mostly multitasked with EHRs. Transitions to silent EHR use could be ambiguous. Patients sometimes broke EHR silences for social and medical reasons.

Multitasking increases risk for errors³ in EHR tasks and communication (eg, missing patient concerns). Risks are affected by the cognitive complexity of the information, EHR usability, documentation support and teamwork, and clinician-patient dynamics.^3,5 Certain EHR (eg, prescribing high-risk medications) and communication tasks (eg, depression assessment) may require focus.

Safety net patients could benefit from silence, since clinician talk typically dominates visits and imposes literacy burdens.⁶ However, clinicians must attend to emerging patient concerns and decide whether to address those concerns, defer them to complete EHR tasks safely, or attempt to complete both, despite multitasking risks.³

Limitations include sample size, single setting, timeframe after implementation, and lack of clinical outcomes. Study strengths are inclusion of a diverse provider and patient population.

Studies should explore strategies for negotiating multitasking and silent EHR use, engaging patients “actively” during silent EHR use, and ensuring clinicians detect emerging patient concerns.

Corresponding Author: Neda Ratanawongsa, MD, MPH, Division of General Internal Medicine, University of California, San Francisco, UCSF Center for Vulnerable Populations at Zuckerberg San Francisco General Hospital and Trauma Center, 1001 Potrero Ave, Box 1364, San Francisco, CA 94143 (neda.ratanawongsa@ucsf.edu).

Accepted for Publication: April 30, 2017.

Published Online: July 3, 2017. doi:10.1001/jamainternmed.2017.2668

Author Contributions: Dr Ratanawongsa had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ratanawongsa, Matta, Koenig, Barton, Yu, Schillinger.

Acquisition, analysis, or interpretation of data: Ratanawongsa, Matta, Lyles, Koenig, Barton, Yu.

Drafting of the manuscript: Ratanawongsa, Matta.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Ratanawongsa, Lyles.

Obtained funding: Ratanawongsa.

Administrative, technical, or material support: Matta, Barton, Yu.

Study supervision: Ratanawongsa, Schillinger.

Conflict of Interest Disclosures: None were reported.

Funding/Support: Research was supported by the Agency for Healthcare Research and Quality Grants 1K08HS022561, P30HS023558, and K99HS022408; National Institute of Arthritis and Musculoskeletal and Skin Diseases 1K23AR064372; and the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) under Award Number KL2TR000143. Dr Schillinger is supported by the Health Delivery Systems Center for Diabetes Translational Research funded through the National Institute of Diabetes and Digestive and Kidney Diseases grant 1P30-DK092924. The contents herein are solely the responsibility of the authors and do not necessarily represent the official views of AHRQ or the NIH. Drs Ratanawongsa and Barton were fellows supported by the Pfizer Medical Academic Partnership Fellowship in Health Literacy.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of AHRQ or the NIH.

Meeting Presentations: Preliminary data from this manuscript were presented at The Patient, the Practitioner, and the Computer Conference; Providence, Rhode Island; March 18, 2017; and the Annual Meeting of the Society of General Internal Medicine; Washington, DC; April 20, 2017.