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Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication.
This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system.
This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as “multitasking EHR use,” “silent EHR use,” “non-EHR multitasking,” and “focused patient-clinician talk.” Finally, we analyzed communication patterns to develop a conceptual framework.
We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation.
Safety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.
Clinicians in US safety net clinics—federally funded clinics serving socioeconomically disadvantaged populations [
Safety net systems could receive incentives to facilitate electronic health record (EHR) implementation costs by meeting metrics for medication reconciliation for EHR “meaningful use,” defined by the US Centers for Medicare and Medicaid Services (CMS) as “the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider” [
Clinician multitasking—performing two or more tasks simultaneously [
To our knowledge, no study has examined ambulatory safety net communication during medication reconciliation using newer EHRs certified for meaningful use. In a prior study, we found that safety net clinicians spent 30.5% of visits multitasking on EHRs, silently used EHRs 4.6% of visit time, and used 33.1% of visit time for focused patient-clinician talk [
We conducted a mixed-methods study using observations of real-world safety net ambulatory encounters to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions.
We conducted this observational study in five primary and specialty care safety net clinics that had recently transitioned (range 3-16 months, median 9) from a “basic” EHR to a CMS-certified “fully functional” EHR [
“Current medications list” in the patient EHR chart and “current medications” section of visit notes. The active medication list in a patient’s electronic record is automatically imported into a visit note on the day of a visit for clinicians to update. Clinicians can check a box labeled “verified medications,” placing a phrase in the note “medication list reviewed and verified with the patient” and meeting the “meaningful use” CMS metric. At the time of this study, refill data from pharmacy claims was not available.
History of present illness. Clinicians narratively document the patient-reported medication concerns or behaviors.
Assessments and plan. Clinicians may narratively document references to patient concerns or behaviors influencing their decision making.
Treatment and orders. Rather than resolving discrepancies in the current medication list, some clinicians may adjust medications in the treatment section or type instructions for patients.
Eligible patients included English- or Spanish-speaking adults (age >18 years) with at least one of three chronic medical conditions (diabetes, congestive heart failure, or rheumatoid arthritis) who received primary care in the adult internal medicine or family medicine clinic
For participating dyads, we collected the following data from one clinician-patient visit [
Structured previsit and postvisit interviews with patients to collect sociodemographic and medical data. Postvisit patient interviews occurred in person or via telephone. Native Spanish speakers translated and back-translated Spanish interview items into English.
Online questionnaires with providers to collect sociodemographic data.
Visit note written by clinician in the EHR.
Video recording of patient and provider visit.
We used previously validated self-report screening questions to determine patients’ English proficiency and health literacy [
We reviewed the EHR note corresponding to the videotaped interactions for the current medication list, any narrative text in any note section referring to medications, and the medications listed in the treatment section.
From the EHR visit note, we abstracted the number of medications on the EHR list or in the text of the visit note. Primary care providers are expected by national standards and local hospital policy to reconcile all medications, including any over-the-counter or nutritional supplements [
Primary care: all medications, including any over-the-counter or nutritional supplements.
Cardiology: all antihypertensive, diuretic, antiplatelet, lipid-lowering, antiarrhythmic, or pulmonary hypertension medications.
Rheumatology: all immunosuppressant or analgesic medications or medications to mitigate those regimens’ side effects (eg, folic acid with methotrexate or bisphosphonate with prednisone).
Diabetes: all oral or injectable hypoglycemic medications, antihypertensive medications, lipid-lowering medications, and aspirin. We excluded glucose monitoring supplies.
We considered a medication explicitly addressed if the patient or clinician specifically discussed its current or past use. We then summed the number of medications from the EHR medication list that were explicitly addressed during the visit, compared with both the number of relevant medications and the number of total medications.
We abstracted this if notes contained the phrase “medication list reviewed and reconciled with the patient.”
We classified visit time as related to medication reconciliation during segments when clinicians or patients demonstrated behaviors to compare patients’ current medication-taking behaviors with the clinicians’ available medication lists or to elicit and respond to patients’ medication-related concerns and beliefs. We did not include discussions of newly prescribed or newly recommended medications. This duration included both verbal statements and nonverbal behaviors. Patient verbal statements included those elicited by clinicians’ questions or volunteered independently. Clinician verbal statements included those elicited by patients’ questions or volunteered independently. Nonverbal behaviors included clinicians’ visual inspections of patient medication bottles or paper medication lists as well as data entry or review using the EHR. We then calculated total visit minutes and proportion of visit time spent on medication reconciliation.
We categorized each segment of medication reconciliation time as mutually exclusive categories to describe whether clinicians conducted EHR-related or non-EHR-related tasks [
We then conducted qualitative analysis to uncover patterns of communication and EHR use during medication reconciliation. We used a grounded theory approach, by which a theory to explain a phenomenon is derived from the data itself [
We recorded 35 visits (17 primary and 18 specialty care) between 25 patients and 25 clinicians.
Five sets of communication patterns with EHR medication reconciliation were observed. Within a given visit, multiple patterns could have been observed.
In the most common pattern, clinicians reviewed and added information in the EHR current medication lists while talking with patients about their medications, as demonstrated in visit S11 (female rheumatologist, female patient, Spanish-concordant; 100% EHR multitasking; 1 minute):
[Clinician sits facing the EHR current medication list, with the patient adjacent to the monitor, facing the clinician.]
Clinician: “So you’re taking Enbrel every week?”
Patient: “Yes.”
Clinician: [clicks box checked, scrolls] “Okay, and you’re still taking hydroxychloroquine—”
Patient: “Yes.”
Clinician: “—once a day.”
Patient: “It’s once now?”
Clinician: [shifts gaze to patient for <1 second, then back to EHR] “You’re taking it twice?”
Patient: “Yeah, it was like that.”
Clinician: [clicks on medication in list, clicks to change frequency] “Okay, okay.”
Patient, clinician, and visit characteristics in a study of electronic health record use in safety net primary and specialty care medication reconciliation.
Characteristics | Value | ||
Age (years), mean (SD) | 56.8 (11.0) | ||
Gender (female), n (%) | 11 (44) | ||
Hispanic | 12 (48) | ||
Asian | 6 (24) | ||
Caucasian | 4 (16) | ||
African-American | 2 (8) | ||
Multiethnic | 1 (4) | ||
Primary language Spanish | 10 (40) | ||
Limited English proficiency | 6 (24) | ||
≤8th grade education | 2 (8) | ||
Some high school or high school graduate/General Education Diploma | 7 (28) | ||
Some college or college graduate | 16 (64) | ||
Limited health literacy, n (%) | 5 (20) | ||
Income (≤US $20,000/year), n (%) | 23 (92) | ||
“Poor” or “fair” quality of life, n (%) | 18 (60) | ||
Age (years), mean (SD) | 44.9 (11.9) | ||
Gender (female), n (%) | 14 (67) | ||
Primary care clinic | 14 (56) | ||
Diabetes clinic | 5 (20) | ||
Cardiology clinic | 3 (12) | ||
Rheumatology clinic | 3 (12) | ||
Physician | 21 (84) | ||
Nurse practitioner or physician assistant | 4 (16) | ||
Years since professional degree, mean (SD) | 15.7 (11.3) | ||
<1 year | 2 (6) | ||
1-5 years | 19 (54) | ||
>5 years | 14 (40) | ||
English | 29 (83) | ||
Spanish | 5 (14) | ||
Spanish interpreter | 1 (3) | ||
Visit length (minutes), median (interquartile range) | 20.6 (16.7-32.2) |
Characteristics of medication reconciliation during safety net primary and specialty care visits (n=35).
Medication reconciliation characteristics | Value | ||
Medication reconciliation duration (minutes), median (IQRa) | 2.1 (1.0-4.4) | ||
Multitasking EHRb use | 47 (26-70) | ||
Silent EHR use | 0 (0-6) | ||
Non-EHR multitasking | 0 (0-13) | ||
Focused patient-clinician talk | 24 (0-39) | ||
Number of total medicationsc, median (IQR) | 13 (9-17) | ||
Number of relevant medicationsc, median (IQR) | 7 (5-12) | ||
Number of relevant medications addressedd, median (IQR) | 2 (1-5) |
aIQR: interquartile range.
bEHR: electronic health record.
cThe total medications included all listed in the patient’s note or discussed during the visit encounter. All medications were categorized as relevant for primary care encounters. For specialty care encounters, relevant medications were related to the clinician’s specialty and those with drug or disease interactions.
dMedications were categorized as “addressed” if the patient or clinician specifically discussed its current use.
Occasionally this also included interspersed EHR multitasking with non-EHR multitasking, such as looking at pill bottles or paper medication lists to update the EHR current medication list. In encounter P11 (male PCP, male patient, English-concordant; 68% EHR multitasking, 9% silent EHR, 24% focused clinician-patient talk; 2.1 minutes) a clinician used the EHR and pill bottles to check a recently uninsured patient’s medications:
[Clinician sits facing EHR screen. Patient sits adjacent to the screen, facing clinician, and takes pill bottles out of bag.]
Clinician: [holds bottle in hand, looks at label for 1 second] “Are you taking these—” [puts down bottle, looks at EHR current medication list] “—every day or only once in a while?”
Patient: [takes out other pill bottles] “Once in a while.”
Clinician: [begins typing into medication list] “Okay.”
Patient: [shakes bottle] “Uh, I’m down to one here.”
Clinician: [glances at pill bottle for <1 second, then to EHR] “Okay, would you say all of these you’re taking just once in a while?” [looks at bottle for <1 second then to EHR]
Patient: “Mhm. This one’s gone.” [shakes bottle]
Clinician: [looks at bottle for 1 second, back to EHR] “Okay.”
To negotiate medication discrepancies, clinicians often navigated beyond the current medication list, using multiple sections within the note and the entire electronic chart, including past visit notes, notes from other settings, and test results. Clinicians multitasked, navigating and reading EHR sections while eliciting or listening to information from the patient. Clinicians also interspersed EHR multitasking with silent EHR use to concentrate on reviewing information or completing tasks. Patients often offered social talk breaking this silent EHR use and triggering clinician multitasking.
Multitasking, silent electronic health record (EHR) use, and number of medications explicitly addressed during safety net medication reconciliation (N=35). *Primary care encounters are labeled with a “P” and specialty care encounters with an “S.” The number following each line indicates the number of “addressed” medications out of the total number of “relevant” medications. Medications were categorized as “addressed” if the patient or clinician specifically discussed its current use. For primary care encounters, all medications listed in the patient’s note or discussed during the visit encounter were categorized as “relevant.” For specialty care encounters, medications related to the clinician’s specialty or with drug or disease interactions were categorized as “relevant”; the total number of all medications is listed in parentheses for these specialty encounters. † means clinicians clicked on a box labeled “verified medications” to indicate that medication reconciliation was performed.
During visit P1 (female PCP, male patient, English-concordant; 40% EHR multitasking, 3% silent EHR use, 50% focused patient-clinician talk; 3.6 minutes), the clinician spent 3 minutes attempting to verify one medication, using multiple EHR sources of information (the medication list, three past clinician notes from the current and previous EHR), pill bottles, and patient history. Silent EHR use occurred when the clinician reviewed a previous visit note:
[Clinician sits facing EHR screen with hand on mouse. EHR screen is angled toward patient who sits facing clinician. Pill bottles are on the desk.]
Clinician: [looks at pill bottle] “Okay...You’re taking this one, the torsemide?” [shows patient pill bottle while clicking into the EHR current medication list]
Patient: [looks at pill bottle] “Yeah. Once a day.”
Clinician: [scrolling through medication list] “Is that a new one?”
Patient: “No.”
[Clinician looks at pill bottle, then back to medication list.]
Patient: [looking at clinician] “Why? It’s not on my list?”
Clinician: [begins typing in medication list search function] “It’s not, actually.”
Patient: [putting away backpack] “Then maybe I shouldn’t take it. It’s an old one.”
[Clinician looks down at pill bottle for one second, then back to medication list. Clinician exits out of medication list to History of Patient Illnesses section.]
Clinician: [clicking into list of previous clinician notes] “Hold on. When was the last time you saw these cardiac doctors?”
Patient: [looking at clinician while clinician scrolls down list of past visits] “Um, like two months ago. Yeah, two months ago.” [Clinician clicks into a cardiology visit note.] “I think I’ve got another appointment coming up.”
Clinician: [scrolls through note, pill bottle still in hand] “Okay, hold on, I’m going to try to read their note here.”
[5 seconds of silence as clinician looks at note. Patient looks down at hands.]
Patient: “How many years did it take for you to become a doctor like you are?”
[2 minutes of EHR multitasking; clinician clicks and scrolls through five different EHR sections while engaging in social talk with the patient.]
Clinician: [scrolls through note] “Okay here’s the deal. I can’t find...umm...” [highlights information in note] “...I cannot find this guy—“ [shakes pill bottle] “—in the notes from cardiology.” [turns to patient] “Okay, so we’re going to stop this, because this medicine acts the same as this one.” [picks up another pill bottle and shows patient] “So we don’t want two medicines doing the same thing. So you’re not going to use that anymore.”
Clinicians demonstrated different ways of interspersing focused patient-clinician talk with multitasking or silent EHR use. For example, clinicians used brief periods of focused talk to address patients’ medication or health concerns arising during medication reconciliation. In visit P2 (female PCP, male patient, Spanish-concordant; 51% EHR multitasking, 10% silent EHR use, 39% focused patient-clinician talk; 8.5 minutes), a clinician stopped multitasking on the EHR to address the patient’s worry about a side effect:
[Clinician sits with body toward the patient while clicking off medications in the EHR current medication list and examining pill bottles for 4 seconds.]
Patient: “For example, the one for the heart, they told me it could have a side effect that feels like arthritis.” [points to chest] “That’s what they told me.”
Clinician: [slightly turns head from screen, looks at patient] “Well, those medications for gout and arthritis aren’t really related to the heart. Don’t worry about that.”
[Patient hands clinician pill bottle. Clinician looks at it for <1 second and looks back to patient.]
Clinician: “And no—I don’t believe—It is true that gout could be a secondary effect of the medicine, but it’s not—” [turns head to EHR, pauses for 1 second] “Well, that’s not true.” [turns head back to patient] “The furosemide, the diuretic, could possibly—”
Patient: [hands clinician another pill bottle] “This one?”
Clinician: “Yeah, this one.”
Patient: “I’ve been taking this one for 25 years.”
Clinician: “But it’s not that the number of years affects the gout, it’s just that in the moment that you’re taking it you have greater risk of gout.”
Patient: [takes out other pill bottles] “Okay.”
Clinician: “Thank you for bringing these, I’m going to review these medications with the list in the computer.” [turns head to EHR screen]
The clinician then interspersed silent EHR use and EHR multitasking using pill bottles, updating the current medication list. While EHR multitasking, the clinician found out from the patient that he was no longer receiving colchicine for gout due to insurance limitations. After completing reconciliation of all pill bottles, the clinician readdressed the patient’s concern through focused talk:
[Clinician’s body oriented toward patient with full eye contact.]
Clinician: “So about the gout...It’s true that this—” [holds up pill bottle] “—has a side effect, and although your gout may be better controlled without this medicine, the rest of your body would be worse off without it—” [laughs] “—because you need this furosemide, and any medicine that removes water affects gout. So, I would like to continue the same with this medication—” [points to pill bottle] “—and I would like to increase—” [picks up other pill bottle] “—this medicine, the allopurinol, to prevent more gout attacks. What do you think of this plan? You agree, too?”
Patients often revealed concerns about their medications and nonmedication topics during medication reconciliation, sometimes without clinician elicitation. Some clinicians responded by continuing to multitask, offering expressions of empathy or exploring patients’ concerns while continuing to use the EHR.
In visit P12 (female PCP, female patient, English-concordant; 76% EHR multitasking, 24% silent EHR; 1.6 minutes), the clinician addresses the patient’s concern verbally while continuing EHR tasks:
[Patient sits in a wheelchair adjacent to EHR monitor, facing the clinician. The clinician is walking toward EHR after sanitizing hands].
Patient: [concerned tone] “I was going to ask you, with my Ativan—” [clinician sits and faces EHR] “—if you can increase it.”
Clinician: [scrolls through History of Patient Illnesses] “Tell me about that. Tell me why you want to increase it.”
Patient: [looking at clinician] “Because...I’m under a lot of stress...”
Clinician: [scrolls through EHR list of visits, clicks into past visit note, inquisitive tone] “Mhm.”
Patient: “And what I was taking; it’s not working for me.”
Clinician: “Mm-hm.” [past visit note loads] “Tell me what else we’re doing to help.” [concerned tone] “I know you’re under a lot of stress.” [scrolls through note] “We’ve talked about, before, worrying about the side effects of the Ativan and I think there may be better medicines for you to take to deal with the stress.”
At times, clinicians did not respond to the patients’ concerns, continuing their multitasking or silent EHR use. In visit P5 (male PCP, female patient, English-concordant; 100% EHR multitasking; 5.6 minutes), the patient describes pain and depression which the clinician does not address during the visit:
[Clinician sits facing EHR screen, hand on mouse. Patient sits adjacent to monitor, facing clinician. Clinician has been EHR multitasking; discussing the patient’s medication-taking behaviors for 1 minute.]
Clinician: “...And, the other ones were the um, medication for your stomach.”
Patient: [looks away from clinician] “Yes, and also the other one is a cough syrup.” [concerned tone] “Yeah, sometimes I have—”
Clinician: [clicks medication in EHR current medication list, flat tone] “Okay.”
Patient: [looks back at clinician] “—tremendous pain.”
Clinician: [gaze on EHR, flat tone] “Okay, and are you still taking the Duloxetine? It’s like an antidepressant.” [glances <1 second at patient then back to EHR]
Patient: [gaze on clinician, concerned tone] “Yes. And when I take that in the morning, it makes me, you know.” [puts hand in a fist]
Clinician: [clicks in EHR current medication list, monotone] “Okay, you take that in the morning.”
Patient: [looking at clinician] “—I stop to cry.”
Clinician: [scrolls in medication list, flat tone] “Uh huh.”
Patient: [looking at clinician] “I stop to cry.”
Clinician: [shifts gaze to patient, flat tone] “You stop to cry?”
Patient: “Yes. When I take that for the uh—” [clinician nods, shifts gaze back to EHR] “—when I stop to take the medication for the depression, I get so sensitive. So sensitive.” [motions hand toward heart] “When I take my two pills in the morning, I am strong.” [laughs]
Clinician: [scrolling in medication list, flat tone] “Okay.”
Patient: “Yeah, I found out because I take notes also for my medication.”
[Clinician nods, maintaining gaze on EHR.]
In two encounters, clinicians with high levels of EHR use engaged patients, through screen sharing, transparent disclosure of EHR tasks, and shifting bodily orientation toward their patients.
In visit P10 (female PCP, male patient, English-concordant; 100% EHR multitasking; 2.2 minutes), the clinician shared her screen to review all nine of the patient’s medications, with the patient sitting next to her reviewing the EHR list actively:
Clinician: [clicks into current medication list] “So your meds...”
Patient: [looks at screen and reads] “Sildenafil, five tablets three times a day. Yes.”
Clinician: [clicks to check off medication] “You’re taking furosemide...”
Patient: [looks at clinician, then screen] “Which one is that?”
Clinician: “That’s the water pill.”
Patient: [looks at screen] “Uh, only if I need it. If I have swollen ankles.”
Clinician: [clicks to pull up text box] “How often are you taking it?”
Patient: [turns head from screen to clinician] “I haven’t taken it in probably 6 months.”
Clinician: [quickly turns toward the patient, makes eye contact, smiles, and turns back to screen] “Wow!” [turns back to the screen and types] “I’m going to leave it on your list but I’m going to put ‘as needed.’ How about that?”
Patient: [looks at screen] “Yeah. ‘As needed’ sounds good.”
In visit P6 (female PCP, male patient, English-concordant; 47% EHR multitasking, 4% silent EHR tasks, 13% non-EHR multitasking, 36% focused patient-clinician talk; 5.6 minutes), the clinician screen shares while multitasking and transparently explains the need to use EHR silently:
[EHR in triangle between clinician and patient. Clinician’s body is angled half toward patient and half toward EHR]
Clinician: [looking directly at patient] “I want to go over your medicines. Did you bring your box thing?”
Patient: “I did not bring it.”
Clinician: “OK” [glances at EHR med list, then back to patient] “Would you recognize the names?”
Patient: “Yeah! Yeah!”
Clinician: “OK let’s look through them.” [turns screen to share with patient] “Now I’m going to show you this thing. Can you see it?”
Clinician: [looking at screen with patient] “The furosemide—how are you taking that one?” [turns gaze to patient]
Patient: “I’m taking the one 80 pill in the morning and then at night.”
Clinician: “And how late do you take the second one?”
Patient: “The second one I take it around dinner time.”
Clinician: “OK good, because you don’t want to be up all night peeing...”
Patient: “Yeah...”
[They troubleshoot timing of the diuretic medication with focused talk]
Based on this analysis, we developed a conceptual diagram representing the multitasking clinician balancing the cognitive and emotional demands posed by incoming information from multiple sources, attempting to synthesize and act on this information through EHR and communication tasks, and adopting strategies that may help mitigate the risks of this multitasking (
Because most clinicians multitask during medication reconciliation (pattern 1), this complex process is represented by solid black arrows demonstrating the input and output of information (1) between the clinician and the EHR, (2) between the clinician and the patient, and (3) between the clinician and the patient’s medication bottles or paper medication lists. To complete medication reconciliation, the clinician searches across the EHR chart to find, read, and process complex information entered by multiple members of clinical care teams (pattern 2). Meanwhile, clinicians navigate into multiple sections of the visit note to enter data relevant to medication reconciliation (pattern 2). At the same time, the clinician hears and processes complex patient histories about patients’ medication-taking behaviors and concerns, mixed with overt and subtle clues that offer empathic opportunities.
The clinician usually responds by eliciting more information and providing counseling, expressing concerns over medication discrepancies and suboptimal adherence (patterns 3 or 4). Sometimes, the clinician takes advantage of empathic opportunities to offer support and affirmation (patterns 3 and 5). Sometimes, the clinician does not recognize the empathic opportunities—potentially distracted by EHR tasks—or chooses to let the opportunities pass to continue completing medication reconciliation tasks (pattern 4).
The multitasking clinician has risks for error on two fronts, represented by the yellow diamonds. The clinician may make errors in EHR entry, ordering, and comprehension or errors in patient-clinician communication. Of note, communication errors may lead not only to risks to the patient-clinician relationship, but also errors in diagnosis and management if clues about patient symptoms or behaviors are not caught and addressed.
Consciously or unconsciously, clinicians may mitigate these errors by focusing on one interaction at a time. To mitigate the risk of EHR-related errors, clinicians may take periods of silence to focus solely on the EHR, investigating medication discrepancies with more complex and dynamic EHR use. To mitigate the risk of communication errors and relational damage, clinicians may cease EHR multitasking to focused patient-clinician talk.
This diagram’s focus is on the multitasking clinician. However, on rare occasions, patients actively engaged with the EHR use by watching their clinicians use the EHR or after receiving explicit invitation by clinicians to join the process. Potentially, this relationship-centered EHR use offers a third option for risk mitigation, allowing clinicians to feel more comfortable using the EHR with the patients at their side.
Conceptual diagram: multitasking clinicians balancing the demands and risks of electronic health records (EHRs) and communication tasks during medication reconciliation.
In this safety net study, patient-clinician visits exhibited interesting variations in the depth of medication reconciliation discussion and the patterns of EHR use to support that discussion. The absolute number and proportion of total medications addressed bore little relationship with the length of time, and rather than occurring in a “medication reconciliation block,” these discussions were interspersed with other content, including biomedical, psychosocial, and social talk. Overall, clinicians asked simple closed or open-ended questions about the patient’s medication-taking behaviors overall, with deeper investigation about only a subset of medications. Some clinicians employed the more detailed, patient-centered interviewing recommended for learning about a patient’s medication beliefs and burdens, but not about each medication on a given list. Of note, the longest medication reconciliation discussion lasted almost 10 minutes, addressing all four of the most relevant medications to that specialist, while leaving untouched the 10 other medications on the patient’s list. In a cross-sectional analysis, one cannot determine if the depth and length of these medication reconciliation discussions were affected by EHR use or the clinician’s pre-EHR approach to medication reconciliation, uninfluenced by the meaningful use requirement. Given that many relationships were more than 5 years, some clinicians may know some of this information from past visits. However, our results suggest that a comprehensive, patient-centered medication reconciliation interview with medically and psychosocially complex patients may be time-consuming for a safety net primary care or specialty clinician to conduct on their own.
Safety net patients experience barriers to patient-clinician communication and have higher medication reconciliation needs [
Meanwhile, multitasking EHR use comprised almost half of medication reconciliation time, a higher proportion of time than in the visits as a whole [
Clinical multitasking predated EHRs, with clinicians reviewing paper charts or patient pill bottles while interviewing patients. EHRs have the potential to reduce errors overall [
Our study suggests that clinician multitasking is associated with important risks of errors in communication, which pose not only dangers to the relationship but also the accurate diagnosis and management of the patient’s medical and psychosocial needs. As seen in pattern 4, sometimes patients express medication and nonmedication concerns that would require deeper exploration. These concerns may signal suboptimal adherence, an undiagnosed or undertreated medical or psychosocial condition, and a need for empathy and reassurance from the clinician.
As the conceptual diagram depicts, multitasking clinicians using an EHR for medication reconciliation must cope with the cognitive and emotional burdens of this work while managing many other tasks. When patients disclose nonadherence or offer their concerns about medications or other topics, through overt or more subtle clues, clinicians have a series of cognitively challenging tasks. First, they must recognize the cues, which may be more challenging during EHR multitasking when their gaze and attention is not focused on the patient. Second, if they recognize the clues, clinicians must choose whether to respond through further exploration at that time (with focused talk or continued multitasking) or by deferring the exploration until after completing their medication reconciliation tasks. If clinicians respond at the time, they risk making a mistake, both in the EHR tasks and in their communication. If they do not respond at the time, they risk missing important patient engagement opportunities, to the detriment of both patient satisfaction and patient care. This study offered examples of all those patterns and the transitions across them, but this study cannot reveal how many of the clinicians’ choices were intentional to mitigate risk or subconscious. We also do not know what these patients would have preferred and what they felt about their clinicians’ communication and EHR use behaviors in those moments.
Finally, a few clinicians in this sample exemplified behaviors of harnessing EHRs to further relationship-centered communication [
This analysis also adds to the growing literature about newer generation EHRs in the United States under the meaningful use incentives programs, particularly in a safety net primary and specialty care setting. This study adds to the call for clinicians, health systems, and policymakers to redefine medication reconciliation to acknowledge the multiple levels of medication reconciliation that incorporates the patient’s full perspective, including eliciting opportunities to describe and reduce the physical, emotional, and economic burdens of medication regimens [
This study’s limitations should be considered. First, our results may be affected by volunteer bias among clinicians or patients. Second, the sampled visits occurred early after EHR implementation and may not represent medication reconciliation after clinicians spent more time using the EHR, although other researchers have found that early EHR and communication behaviors may be similar to those measured later after implementation [
In summary, the multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.
Codes associated with conceptual diagram: multitasking clinicians balancing the demands and risks of EHR and communication tasks during medication reconciliation.
Centers for Medicare and Medicaid Services
electronic health record
interquartile range
primary care physician
Research reported in this publication was supported by grants from the Agency for Healthcare Research and Quality (AHRQ; 1K08HS022561, P30HS023558, and R00HS022408). DS is supported by the Health Delivery Systems Center for Diabetes Translational Research funded through grant 2P30-DK092924 from the National Institute of Diabetes and Digestive and Kidney Diseases. The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of AHRQ or National Institutes of Health.
NR had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: GYM, DS, and NR; acquisition, analysis, or interpretation of data: GYM, ECK, CRL, DS, and NR; drafting of the manuscript: GYM and NR; critical revision of the manuscript for important intellectual content: GYM, ECK, CRL, DS, and NR; statistical analysis: GYM; obtained funding: NR; administrative, technical, or material support: GYM; study supervision: NR.
None declared.