ENVIRONMENTAL FACTORS ASSOCIATED WITH PRIMARY CARE PHYSICIANS' USE OF PATIENT-CENTERED COMMUNICATION

Purpose: Little is known about the impact of environmental factors such as electronic medical records (EMRs), health risk appraisals (HRAs), and written patient reminders, on clinicians’ use of patient-centered communication. Controlling for physician and patient personal influences, we evaluate environmental influences on physicians’ patient-centered communication. 

Method: Observational study of N=485 periodic health examinations to N=64 primary care physicians. Physician characteristics were obtained from administrative records and patient characteristics from a pre-visit survey.  Research assistants completed observation checklist that recorded: time physician was present in examination room; physicians’ use of EMR and HRA; and patients’ use of written discussion topic reminders. Two physician office visit communication behaviors were obtained via audio-recordings: self-initiated partnership building and supportive talk.(Street, 2001) Three research assistants coded recordings by listening while reading transcripts. Inter-rater reliability was assessed with Cohen’s kappa and was 0.66 for physician partnership building and 0.74 for physician supportive talk.  A structural equation model, that considered the hierarchical structure of the data, was fit to estimate the association of personal and environmental factors on physician use of self-initiated partnership building and supportive talk. 

Result: Mean patient age was 59 years, 65% women, and 28% black; mean physician age was 50 years, 57% women, 14% black and 68% general internists; 81% of visits used the EMR, 13% an HRA, and 11% a patient written reminder. Physicians engaged in more supportive talk with patients reporting depressive symptoms and when HRAs were used, and less when patients brought written reminders. Physicians used more partnership building with more educated and black patients, and less when patients brought written reminders or had been seen recently. Visits with older physicians included more supportive talk, while those with black physicians used less partnership building. No other factors, including race and gender concordance, patient decision-making preference, EMR use, or how long after the scheduled time the appointment started were significantly associated with physicians’ use of patient-centered communication. 

Conclusion: While patient-centered communication was associated with personal influences, environmental influences also played a role: HRAs had a positive and patient written reminders a negative influence on patient-centered communication. The impact of commonly present environmental factors on the quality of office visit communication needs to be continually monitored for both positive and negative consequences.