Patient-Physician Interaction Issues: Impact of Using a PDA During a Primary Care Encounter Lisa Weiss, M.D. Brian F. Pendleton, Ph.D. Susan Labuda Schrop, M.S. LuAnne Stockton, B.A., B.S. Northeastern Ohio Universities Colleges of Medicine and Pharmacy Department of Family Medicine Rootstown, Ohio Conference on Practice Improvement December 2008

Presentation Objectives Discuss the effects of electronic devices on patient-physician interactions Identify the importance of basic communication skills in patient-physician interactions Discuss recommendations for personal digital assistant (PDA) use in patient-physician encounters

Background Electronic medical devices are increasingly being used in medical practice to manage information Physician use of a PDA is increasing (45% - 87% dependent on the setting) Physicians report that PDAs Improve access to medication information Improve practice efficiency Influence clinical decision making and patient management options

Background (cont’d) Electronic medical devices (i.e., PDAs) are likely to continue to play a prominent role in the delivery of health care It is important to determine the impact of the use of electronic devices on the patient-physician relationship, and if they do have a negative impact, what solutions can be implemented to overcome any barriers

Goal of the Study Develop strategies for patient-physician interactions that minimize the pitfalls and maximize the benefits of physicians’ use of electronic medical devices in the examination room

Objectives of the Study Determine patients’ perceptions of physician use of a PDA in the examination room Compare patients’ perceptions in a variety of primary care practice types Determine if the type of practice and demographic characteristics of the physician and the patient affect patients’ perceptions

Methods: Participating Sites Six community hospital-based family medicine residency training programs Three community-based practices for the medically underserved Three community-based private family medicine practices

Methods: Study Sample Inclusion criteria: Exclusion criteria: Non-random convenience sample Adults ≥ 18 years of age Patients at one of the study sites Witnessed their physician use a PDA during their encounter Exclusion criteria: Patients who appeared to be acutely ill, cognitively impaired, or could not read or speak English Patients whose physician never used a PDA in front of the patients

Methods: Survey Content Has your doctor ever used a handheld computer in the exam room? Did your doctor use a handheld computer today in the exam room? Did your doctor explain what he/she was doing with the handheld? How surprised were you that your doctor used a handheld? How did the handheld affect your confidence in your doctor?

Methods: Survey Content (cont’d) How did the handheld make you feel about your doctor? How comfortable were you with your doctor using a handheld? If you were uncomfortable, why? How did the handheld affect your communication with your doctor? How did the handheld change your relationship with your doctor?

Methods: Survey Content (cont’d) How smart do you think your doctor is because of using a handheld? How did the handheld affect your satisfaction with the visit? Demographics: Patient: age, gender, race, insurance status, education Physician: gender

Methods: Data Analysis SAS was used to conduct: Descriptive and univariate analysis of all items on the survey Logistic regression analyses to identify the predictors of scores on the Likert-scaled items

Results: Response Rate 562 patients were asked to participate 196 agreed but were excluded because their physician never used a PDA in their presence 284 of the remaining 366 patients (78%) agreed to participate Refusal rate was 30% at the private practices, 21% at the residency programs, and 14% at the underserved clinics. There were only 3 eligible patients who did not know that the PDA was a handheld computer.

Results: Patient Demographic Profile Age: 44.3 years (mean) Gender: 78% women Race: 76% white Education: 11% less than high school 32% high school graduate 57% more than high school Insurance status: 31% private 31% Medicaid 15% Medicare 23% no-charge or sliding scale Age: SD = 17; range = 18-88 The average number of female patients at the sites was 66%. Race analyses were limited to white/black due to insufficient sample size for other races. Education breakdown: more than high school: 8% technical school graduate; 30% 13-14 years; 15% 15-16 years; 4% 17-18 years

Results: Site and Physician Profile Responders by type of site: 67% from residency practices 24% from private practices 10% from practices for the medically underserved Physician gender: 73% male 64 patients observed their physician using a PDA for the first time during the index visit Physician/patient gender pairings: 54% female patient/male physician 24% female patient/female physician 19% male patient/male physician 3% male patient/female physician 102 patients observed their physician using a PDA both on the index visit and on at least one prior occasion 118 patients did not observe physician PDA use during the index visit, but had done so during at least one prior occasion

Results: Patient Reactions Patient Perceptions of Physician PDA Use Item Scale Patient Reaction Surprise 1=extremely; 5= not at all 4.2 Confidence 1=much less; 5= much more 3.5 Comfort 1=much less; 5=much more Effect on communication 1=much worse; 5=much better 3.4 Change of relationship 1=much less personal; 5=much more 3.2 Doctor is smart Feelings about doctor 1=many more bad; 5=many more good 3.6 Satisfaction with the visit When the physician used a PDA, patients generally rated their interactions positively on all dimensions. Logistic regression model provided at end of slides.

Results (cont’d) Male physicians were two times as likely as female physicians to explain their use of the PDA to the patient Physicians in community-based private practices and practices for the medically underserved were more than three times as likely to explain PDA use to their patients than residency-based physicians Medicaid patients were nearly two and a half times more likely than patients with other types of insurance to receive an explanation of PDA use There were no significant effects by patient gender or race.

Results (cont’d) Physician communication was rated more positively by the patient if an explanation of PDA use was provided If the doctor explained what he/she was doing with the PDA, patients*: Felt better about their doctor Were more comfortable with their doctor Felt there was better communication Felt their relationship with their doctor changed for the better *controlling for patient age, gender, insurance status, race, and education, and type of site

Recommendations All physicians need to explain to patients what they are doing when using a PDA in the exam room. Female physicians need to attend more to explaining their PDA use to patients. Residents need to encouraged to explain PDA use to their patients.

Questions ?

Results: Logistic Regression Model Variable Odds Ratio 95% Lower C.I. 95% Upper C.I. Probability Patient gender 1.36 0.695 2.643 0.373 Patient race 1.73 0.888 3.352 0.108 Patient age 0.99 0.971 1.006 0.197 Male physician 1.86 1.013 3.470 0.045 Private site 3.17 1.519 6.604 0.002 Underserved site 3.52 1.258 9.861 0.017 Medicaid 2.54 1.206 5.362 0.014 Patient observations * 2.24 1.237 4.046 0.008 Communication 2.19 1.345 3.487 0.001 Patients who observed physician PDA use both during the index visit and at least one previous visit.