CONTINUING EDUCATION ANCC 2.5 CONTACT HOURS Patient Satisfaction With Electronic Health Record Use by Primary Care Nurse Practitioners Katie L. Mysen, DNP,APRN, FNP-BC, Barbara Penprase, PhD, RN, CNE, ANEF, Ronald Piscotty, PhD, RN-BC make it more difficult to focus on relationship-oriented as- pects of communication such as exploring psychosocial and The purpose of this research study was to determine if sat- emotional issues and nonverbal aspects of communication isfaction and communication between the patient and the 4 nurse practitioner are affected by allowing patients to view such as eye contact. Communication between the healthcare their electronic health records during the history portion of provider and the patient has been shown to have a positive the primary care office visit compared with patients who relationship on patient outcomes such as satisfaction and do not view their records. A cross-sectional, experimental de- adherence to treatment.5 There is a perception among sign was utilized for this study. The intervention group was healthcare providers that therapeutic communication suf- shown several components of the electronic health record fers when introducing the computer into the relationship during the history portion of the nurse practitioner assess- between the patient and the provider, negatively affecting pa- ’ ment. This group s scores on a patient satisfaction survey tient satisfaction. were compared with those of the control group, who were Strategies for overcoming the communication concerns not shown the electronic health record. The study findings associated with EHR use may include taking breaks from suggest that the introduction of the electronic health record does not affect patients’ satisfaction related to the office working on the computer to focus on the patient, considering “ ” visit by the nurse practitioner. the spatial arrangement of the room to make it more open, positioning the nurse practitioner closer to the patient to KEY WORDS: Communication, Electronic health record, allow more eye contact, and allowing patients to view their Nurse practitioner, Patient satisfaction own records on the computer.4 While these strategies have been suggested in the literature, there is little specific research to ascertain whether implementation of these approaches to he electronic health record (EHR) is an important tool communication actually improves patient satisfaction with in improving quality and lowering costs of healthcare in the interaction. T the United States. There are many advantages to the implementation and use of EHRs by primary care nurse LITERATURE REVIEW practitioners including electronic prescribing of medication A review of the literature related to the effect of the EHR on 1 and improved patient safety. Electronic health records pro- patient satisfaction and patient-provider communication vide built-in evidence-based decision support to assist nurse during implementation of the EHR in primary care was per- 1 practitioners in providing high-quality care. Electronic health formed from 2005 to 2014. Few research studies focused records also allow nurse practitioners greater access to re- on this topic were found, and of these the findings varied re- search findings, real-time data review, and improved patient lated to patient satisfaction and communication and the use data collection at the point of care, which promote patient of EHR. 2 safety, efficiency, and evidence-based healthcare. A correlational path analysis study by Tejero6 investi- Despite the established benefits, there are a variety of bar- gated the association between the nurse-patient relationship riers to the adoption of the EHR including cost, time to learn and patient satisfaction. The Nurse Patient Bonding Instru- new functions, lost productivity during implementation, com- ment was used to measure interactions between nurse and pa- 3 plexity of EHR functions, and system issues. Furthermore, tient. Results of this study indicate that nurse-patient bonding the introduction of the EHR into the examination room may directly affects patient satisfaction. Frankel et al7 evaluated the impact of EHRs in the examination room on the communica- Author Affiliations: Oakland University, Rochester, MI (Dr Mysen); School of Nursing, Oakland University, Rochester (Dr Penprase); and College of Nursing, Wayne State University, Detroit tion between the clinician and the patient. The clinicians (Dr Piscotty), MI. included physicians, nurse practitioners, and one physician’s The authors have disclosed that they have no significant relationship with, or financial interest in, assistant. The research team identified basic communica- any commercial companies pertaining to this article. Corresponding author: Katie L. Mysen, DNP, APRN, FNP-BC, Oakland University, 2200 North tion concepts from the Four Habits Communication Model Squirrel Roak, Rochester, MI 48309 ([email protected]). (4HCM). The 4HCM is used to teach communication skills 116 CIN: Computers, Informatics, Nursing March 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. to clinicians at Kaiser Permanente.8 The 4HCM includes practitioner office visit while the EHR is used have been investing in the beginning, eliciting the patient’s perspective, completed, supporting the need for further research in this demonstrating empathy, and investing in the end.8 The re- area. The purpose of this study is to determine whether sat- sults of the study of Frankel et al7 indicated that the introduc- isfaction and communication between the patient and the tion of the EHR into the examination room amplified the nurse practitioner are different in patients who view their baseline communication skills of the clinician. Introducing EHR during the history portion of the primary care office the EHR into the examination room affected clinician- visit compared with those who do not view their records dur- patient communication by changing the verbal, visual, and ing the visit. postural connection between patients and clinicians. Duffy 9 et al studied the impact of EHRs on nurse-patient interac- METHODS tion to determine whether nurses using EHRs had less eye Design contact or communicated less with patients than did nurses Institutional review board approval was obtained from a lo- using paper documentation. The results of this study indi- cal university for this research as an exempt study. A cross- cated that the nurses using the EHR did have less eye con- sectional, experimental design was utilized. Participants tact with their patients than nurses documenting on paper. were given an informational letter explaining the purpose of Furthermore, there were longer periods of silence between the study when they checked in for their appointments. The ac- nurses using the EHR and patients. The results also indi- tual encounter with the patient was the same for both the con- cated increased patient satisfaction with the nurses who doc- trol and intervention groups, except that one group was shown umented on paper.9 their EHR information, and the other group was not. The in- Nagy and Kanter10 performed an experimental study in tervention group was shown several components of their which patient satisfaction surveys were administered to ran- EHR during the history portion of the nurse practitioner as- domly selected patients who had recent interactions with sessment. These components included medication and allergy physicians. The surveys were divided into three categories rela- lists for verification, laboratory results, and vital signs, whereas tive to when the physicians “went live” with the EHR. The cat- the control group did not view this information. After the in- egoriesincludedpre1to3months,post1to3months,and tervention, the participants were asked to complete a satisfac- post 4 to 6 months in which the patient interacted with the phy- tion survey. Completion of the satisfaction survey implied sician after the implementation of the EHR. consent to participate in the study. Nagy and Kanter10 found no significant difference be- tween the scores on the patient satisfaction surveys from any Sample and Setting of the three groups. The authors concluded that the introduc- The setting for the study was a primary care clinic in Southeast tion of EHR in the examination room had neither a negative Michigan. The practice provides primary healthcare services 4 nor a positive effect on patient satisfaction. McGrath et al for patients of all ages, different races, and from a variety performed a qualitative, observational study that examined of socioeconomic backgrounds. Two full-time physicians and nonverbal communication when using the EHR during the one part-time nurse practitioner provide services. On aver- medical interview. The researchers observed that the partic- age, the nurse practitioner sees 104 to 120 patients per month. ipants in the study had reduced eye contact when using the For the purposes of this study, the population included pa- computer. The researchers also observed a decrease in ges- tients scheduled with the nurse practitioner attending the tures between the patient and the physician and an increase clinic during the data collection phase of the study. Minors in the amount and length of pauses during interactions. younger than 18 years, subjects who were unable to read Furthermore, the observers described some of the physicians and write English, and those who were cognitively impaired “ ” “ ” as fixated on or glued to the EHR, which may have had were excluded