Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation

J Gen Intern Med. 2018 Apr;33(4):423-428. doi: 10.1007/s11606-017-4228-2. Epub 2017 Nov 29.


Background: Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.

Objective: To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence.

Design: Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.

Participants: Thirty-two physicians and 217 patients.

Main measures: Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.

Key results: Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures.

Conclusions: Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.

Publication types

  • Observational Study
  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Communication*
  • Cross-Sectional Studies
  • Diagnosis, Computer-Assisted / instrumentation
  • Diagnosis, Computer-Assisted / psychology*
  • Electronic Health Records* / instrumentation
  • Female
  • Fixation, Ocular*
  • Humans
  • Male
  • Middle Aged
  • Patient Participation / psychology*
  • Physician-Patient Relations*