“Effects of exam room EHR use on doctor–patient communication: asystematic literature review” – Triadic and other key terms may have identified additional literature

Christopher Martin Pearce

Department of General Practice, Monash University, Clayton, Australia

Pushpa Kumarapeli

School of Computing and Information Systems, Kingston University-London, Kingston Upon Thames, Surrey, UK

Simon de Lusignan

Department of Health Care Management and Policy, University of Surrey, Guildford, Surrey, UK

Cite this article: Pearce CM, Kumarapeli P, de Lusignan S. Effects of exam room EHR use on doctor–patient communication: a systematic literature review—triadic and other key terms may have identified additional literature. Inform Prim Care 2013;21(1)40–42.

Author address for correspondence:

Pushpa Kumarapeli

School of Computing and Information Systems

Kingston University-London

Kingston Upon Thames

Surrey, KT1 2EE, UK

Email: P.Kumarapeli@kingston.ac.uk


Kazmi’s systemic review1 concludes on the positive influence of the computer use on the biomedical aspect of the consultation interaction, and the adverse effect on the psychosocial dimension. It broaches concerns about the availability of high-quality studies focusing on the doctor–patient interactions. However, there are visible limitations associated with the search strategy employed, which indeed can be considered as a common challenge for reviews in this field of interaction research involving doctor, patient, and computer.

A lesson that has been reemphasized by this paper is the importance of striking a balance between the precision and the sensitivity of a literature search.2 It is important to employ a search strategy that considers the potential biasing factors, while increasing the comprehensiveness.3 While, the set of search terms author has used seem reasonable, there are concerns about their effectiveness, which may have resulted in not reflecting the true breadth of literature out there.


The UK made the earliest, and in many ways most significant contribution to this field. The common theme in the literature is to describe the ‘triadic’ relationship, which views the interaction as a three way, not just the sum of three dyadic interactions. The term ‘Triadic’ was first coined in 1996,4 and based on UK research. The UK has also been the source of two of the largest studies (in terms of consultations) that have laid significant foundations to the literature, one by being the first to provide a comprehensive categorization of behaviours,5 and the second by examining the influence of the other players (in particular different computer systems).6 The other large study is Australian, and further defined frameworks.7


That these studies could be missed in a comprehensive review is not so much puzzling, but an artefact of one of the dilemmas that haunt health informatics in general, and the interaction research specifically, which is the keyword-searching-process that is used in much academic research. This could be attributed to both mechanics and knowledge elements of the search. When using search terms, their synonyms and related terms, care need to be taken to comprehend their position within the literature databases, the way in which indexing of the literature might have been carried out, and the subject headings and keywords used. For example, medical subject headings (MeSH) used in MEDLINE and Emtree headings may represent similar concepts in different terms.8 Use of search terms like ‘professional–patient relations’ or ‘attitude to computer’, or use of facilities provided in databases to use wildcards, or proximity operators, such as ‘near’ (e.g., patient near doctor) could have increased comprehensiveness of the search strategy in this paper. Such mechanical tuning of the search is important when exploring an area like consultation interactions, where the role or position of each ‘actor’ (doctor–patient–computer) could vary based on how they have been defined within each study. Similarly, inclusion of literature associated with out-patient settings could have been supplemented by combining keywords like ‘general practice’ OR ‘family practice’ where the influence of electronic health record (EHR) use on human–human interactions is mostly visible.


The second area of significance highlighted by the review is the need for this research area to move to the next level and report the impact and outcome of this triadic (doctor–patient–computer) relationship. Patient centred medicine has already moved on to look at outcomes,9 it is time for triadic research to do the same. The initial studies where simple, observational studies that attempted to classify,5,10 and later theorise about the triadic relationship.11,12 Subsequently studies reported specific sections of the interaction, such as types of consultations,13 physical layout,14 the beginning,15 the patient viewpoint,16 and the roles of different software systems.6,17 Reviewing this paper has resulted in an international consensus on a framework for reporting studies in this domain, and to move the research on this topic to the next level, exploring outcomes and answering the ‘so what’ question.18


This review has drawn useful conclusions from the search terms used. However, it is limited by its choice of search terms. Future research in this domain should include general practice and terms that identify studies of the triadic doctor–patient–computer interaction.


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15. Pearce C, Kumarpeli P and de Lusignan S. Getting seamless care right from the beginning-integrating computers into the human interaction. Studies in Health Technology and Informatics 2010;155:196–202.

16. Pearce C et al. The patient and the computer in the primary care consultation. Journal of the American Medical Informatics Association: JAMIA 2011;18(2):138–42.

17. Pearce C, Arnold M, Phillips CB, Trumble S and Dwan K. The many faces of the computer: an analysis of clinical software in the primary care consultation. International Journal of Medical Informatics 2012;81(7):475–84. http://dx.doi.org/10.1016/j.ijmedinf.2012.01.004.

18. de Lusignan S et al. Reporting observational studies of the use of information technology in the clinical consultation. A position statement from the IMIA Primary Health Care Informatics Working Group (IMIA PCI WG). Yearbook of Medical Informatics 2011;6(1):39–47.


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