Ventres W et al. 2005 "Clinician style and examination room computers: a video ethnography."

Ventres W, Kooienga S, Marlin R, et al. Clinician style and examination room computers: a video ethnography. Fam Med 2005;37(4):276-281.
"Background and Objectives: The use of computers in medical examination rooms is growing. Advocates of this technology suggest that all family physicians should have and use examination room computers (ERCs) within the near future. This study explored how family physicians incorporate the use of ERCs in their interactions with patients.
Methods: This qualitative study involved five family physicians, one family nurse practitioner, and a convenience sample of 29 patients. Data included videotaped visits, clinician interviews, and videotape reviews. The setting was an urban family practice with a 7-year history of viewing electronic medical records. The main outcome measures were themes emergent from videotaped data.
Results: We identified three distinct practice styles that shaped the use of the ERC: informational, interpersonal, and managerial styles. Clinicians with an informational style are guided by their attention to gathering data as prompted by the computer screen. Clinicians with an interpersonal style focus their attention and body language on patients. Clinicians with a managerial style bridge informational and interpersonal styles by alternating their attention in defined intervals between patients and the computer.
Conclusions: Family physicians have varying practice styles that affect the way they use examination room computers during visits with patients."
To "[explore] how family physicians incorporate the use of [examination room computers] in their interactions with patients."
Tools Used
Type Clinic
Primary care
Type Specific
Family practice
Other Information
The clinic was in a large city in the Northwest United States. The clinic had 15 exam rooms.
Type of Health IT
Electronic health records (EHR)
Workflow-Related Findings
"Clinicians with [a managerial] style alternated their attention in defined intervals between patients and the computer to balance the needs for information gathering and establishing rapport with the patient. At some times, these dueling foci interrupted the flow of visits." "The distinct intervals included ... computer-focused documentation of patients' recent histories, ... face-to-face discussions of care, [and entering] post-physical examination documentation." "When [these] clinicians focused on patients, they used a conversational tone. However, while at the computer, these clinicians were guided by information they typed into the [computer]. Their gaze and body language then focused on the computer, and they delayed responses to patients' questions until finished typing or looking at the screen. Managerial clinicians usually turned away from the computer if their patients began discussions that appeared important. Often the end of these interludes was signaled by clinicians' returning to the [computer] to enter data." "Clinicians with [this] style generally did not use the mobility of the computer."
Compared to the informational style of interaction, clinicians with the interpersonal style "spent more time facing patients during the visit, had [more] eye contact, and followed a more conversational pace. These clinicians sat or stood away from the computer or, if positioned at the computer, oriented themselves toward patients for most of the visit. They incorporated more nonmedical conversation and used little or no computer-guided questioning." They "spent less time entering data in front of patients" and "rarely entered computer documentation in the examination room. [The] clinician's use of the [computer] increased only toward the end of visits to type in relevant prescriptions, referrals, or letters." Clinicians "used the mobility of the computer screen to a greater extent to accommodate the location of patients and often turned the screen to review records in collaboration with patients."
Physicians with the informational style of interaction with the examination room computer spent "the major part of [the] visits positioned at the computer, taking patients' histories, reviewing records, or prescribing medications. The clinicians rarely turned the screen to show it to patients but rather asked verification questions of patients about information read from the screen." "There were periods during which these clinicians faced their patients while positioned away from the computer or giving recommendations regarding specific issues. Yet, they were more likely to use computer-guided questioning, and their attention was focused on details of information. There were frequent periods of silence during which the clinicians reviewed patient records on the screen or asked questions without averting their gaze from the [computer]."
Study Design
Only postintervention (no control group)
Study Participants
Six clinicians were studied over a six week period; four or five clinical visits were videotaped for each clinician.