The many faces of the computer: An analysis of clinical software in the primary care consultation

BackgroundAlmost all general practitioners in Australia now use a computer for some part of the consultation, and mostly use one of eight clinical software applications. There has been little research into the impact of clinical software on the clinical consultation. Clinical software broadly functions in two ways: it replaces the paper record of the patient's history of health and clinical contacts within the general practice, and it communicates directly to the doctor in various ways about outstanding clinical actions.AimThis paper draws on Goffman's notion of “face” to explore the way in which the actions, visual presentation, and interactions between general practitioners, patients and the computer can imbue the software with its own “face” in the consultation.MethodsAnalysis of 141 consultations by 20 doctors (13 men, 7 women), who used one of four medical software applications commonly used in Australian general practice. Consultations were videotaped, tagged, analysed using a hermeneutic framework.ResultsAll four software packages replicated constitutive elements of the paper health record, such as medical history, current medications, and the patient's social history, but also introduced other content not present in a paper system. They differed in their use of communicative strategies. This necessitated differing interactions between the software and the doctor. The differences in communicative work of each software package led to their different “faces”, along a gradient from a relatively passive mode that provided context dependent information in an unobtrusive way, to a relatively active mode that interrupted to provide information and to demand responses. We conclude that the more active the mode of presence of the computer in the consultation, the more patients and doctors may have to adapt their communicative styles in response.

► Computers are becoming ever present in health in developed nations and are creating a three-way relationship in the consultation.
► Findings describe the way in which screen presentation and specific requirements for recording affect the consultation.
► Summary screens and prompts are active agents in shaping the consultation.
► Patients and doctors will have to adapt their communicative styles in response to these changes.