Communicating about medications during primary care outpatient visits: The role of electronic medical records

Nedal H. Arar, Lonnie Wen, John McGrath, Rebecca Steinbach, Jacqueline A. Pugh

Research output: Contribution to journalArticlepeer-review

41 Scopus citations


Objectives: To assess the role of electronic medical records (EMR) in facilitating the content and process of patient-provider exchanges about medications during outpatient primary care visits. Methods: Fifty encounters with six physicians using the EMR were videotaped, transcribed and content-analysed by applying conversation analysis and ethnomethodology techniques. The analysis focused on three aspects of medication communication: (1) process of care: practices by patients and physicians to implement medication decisions; (2) themes: medication topics that consistently emerge; and (3) names: ways patients and physicians refer to medications. In-depth analysis of 20 encounters examined the extent to which either or both parties initiated, expanded and concluded medication discussions. Results: On average 21.2 (range: 8-35; SD=7.4) distinct exchanges per encounter were observed. Of those, 33% were related to medication. Of the 350 medication-related exchanges throughout the encounters, 56% were categorised as routine medication discussion such as ordering and/or refilling medications. Mailing issues were the next most common medication-related exchanges (10.6%), followed by partial adherence (8.9%), self-regulation (7.4%), alternative therapy/over-the-counter medication (6.6%), side effects (6%) and formulary issues (4.6%). Patients and providers used three ways to name medications: generic/scientific name (42%); physical description (39.7%) and brand name (18.3%). Forty-one percent of exchanges included initiation by one or both parties but no further discussion of the issue; 42% included initiation and expansion by both parties but not conclusion; only 17% of exchanges contained complete medication exchanges (initiation, expansion and conclusion) by both parties. Conclusions: EMR facilitated content and process of communication regarding medications during outpatient encounters, especially among patients taking multiple medications and patients who used physical descriptions to identify their medications. EMR use stimulated medication exchanges, leading to further expansion about the topic. However, fewer than one-fifth of exchanges ended with clear conclusions by both parties regarding prescribed medication regimens.

Original languageEnglish (US)
Pages (from-to)13-21
Number of pages9
JournalInformatics in Primary Care
Issue number1
StatePublished - 2005
Externally publishedYes


  • Adherence
  • Electronic medical records
  • Medications
  • Patient-provider communications

ASJC Scopus subject areas

  • Leadership and Management
  • Health Informatics
  • Family Practice


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