Provider interaction with the electronic health record: the effects on patient-centered communication in medical encounters

Physicians' and Patients' Expectations From Digital Agents for Consultations: Interview Study Among Physicians and Patients

BACKGROUND

Physicians are currently overwhelmed by administrative tasks and spend very little time in consultations with patients, which hampers health literacy, shared decision-making, and treatment adherence.

OBJECTIVE

This study aims to examine whether digital agents constructed using fast-evolving generative artificial intelligence, such as ChatGPT, have the potential to improve consultations, adherence to treatment, and health literacy. We interviewed patients and physicians to obtain their opinions about 3 digital agents-a silent digital expert, a communicative digital expert, and a digital companion (DC).

METHODS

We conducted in-depth interviews with 25 patients and 22 physicians from a purposeful sample, with the patients having a wide age range and coming from different educational backgrounds and the physicians having different medical specialties. Transcripts of the interviews were deductively coded using MAXQDA (VERBI Software GmbH) and then summarized according to code and interview before being clustered for interpretation.

RESULTS

Statements from patients and physicians were categorized according to three consultation phases: (1) silent and communicative digital experts that are part of the consultation, (2) digital experts that hand over to a DC, and (3) DCs that support patients in the period between consultations. Overall, patients and physicians were open to these forms of digital support but had reservations about all 3 agents.

CONCLUSIONS

Ultimately, we derived 9 requirements for designing digital agents to support consultations, treatment adherence, and health literacy based on the literature and our qualitative findings.

eHealth interventions for psychiatry in Switzerland and Russia: a comparative study

Introduction

During the past decade, the use of digital technology to promote mental health has increased dramatically. Additionally, the consequences of the COVID-19 pandemic, such as travel restrictions and the disruption of face-to-face interactions, have led to an increase in the use of digital technologies. A wide variety of technologies have been developed, including messaging chatbots, virtual reality technologies, direct-to-consumer apps, and even technologies that are fully integrated into clinical care tools.

Methods

The following qualitative study is based on the opinions of mental health specialists in both countries regarding the use of digital health technologies in psychiatry in Switzerland and Russia in 2019-2020. We investigate the state of adoption of digital technologies in the field of mental health, the meaning of such technologies, and the crucial factors in the use of such technologies in psychiatry.

Results

Health care professionals in both Russia and Switzerland are well aware of these technologies. However, the use of digital technology to promote mental health has taken different paths in these two health care settings.

The Effects of Patient-Centered Communication on Patient Engagement, Health-Related Quality of Life, Service Quality Perception and Patient Satisfaction in Patients with Cancer: A Cross-Sectional Study in Türkiye

INTRODUCTION

Patient-centered communication is a type of communication that takes place between the provider and the patient.

OBJECTIVES

It is aimed to reveal the effects of patient-centered communication on patient engagement, health-related quality of life, perception of service quality and patient satisfaction.

METHOD

The study was conducted by applying multiple regression analysis to the data obtained from 312 patients with cancer treated in a training and research hospital affiliated to the Ministry of Health in Diyarbakır, Türkiye.

RESULTS

More than half of the patients were female and had stage 4 cancer. Different types of cancer were detected (breast cancer, cancer of the digestive organs, lymphatic and hematopoietic cancer, cancer of the genital organs, cancer of the respiratory organs, etc.). It can be stated that the average values obtained by patients from patient-centered communication and its sub-dimensions are high. There are positive, moderate and low and significant relationships between the overall patient-centered communication and patient engagement, patient satisfaction, service quality perception and quality of life. It was statistically revealed that patient-centered communication positively affected patient engagement, health-related quality of life, service quality perception, and patient satisfaction.

CONCLUSION

Patient-centered communication positively affects various short and medium-term health outcomes and this study offers suggestions for improving patient-provider communication.

Clinicians' Views on Using Artificial Intelligence in Healthcare: Opportunities, Challenges, and Beyond

INTRODUCTION

The healthcare industry has made significant progress in information technology, which has improved healthcare procedures and brought about advancements in clinical care services. This includes gathering crucial clinical data and implementing intelligent health information management. Artificial Intelligence (AI) has the potential to bolster further existing health information systems, notably electronic health records (EHRs). With AI, EHRs can offer more customized and adaptable roles for patients. This study aims to delve into the current and potential uses of AI and examine the obstacles that come with it.

METHOD

In this study, we employed a qualitative methodology and purposive sampling to select participants. We sought out clinicians who were eager to share their professional insights. Our research involved conducting three focus group interviews, each lasting an hour. The moderator began each session by introducing the study's goals and assuring participants of confidentiality to foster a collaborative environment. The facilitator asked open-ended questions about EHR, including its applications, challenges, and AI-assisted features.

RESULTS

The research conducted by 26 participants has identified five crucial areas of using AI in healthcare delivery. These areas include predictive analysis, clinical decision support systems, data visualization, natural language processing (NLP), patient monitoring, mobile technology, and future and emerging trends. However, the hype surrounding AI and the fact that the technology is still in its early stages pose significant challenges. Technical limitations related to language processing and context-specific reasoning must be addressed. Furthermore, medico-legal challenges arise when AI supports or autonomously delivers healthcare services. Governments must develop strategies to ensure AI's responsible and transparent application in healthcare delivery.

CONCLUSION

AI technology has the potential to revolutionize healthcare through its integration with EHRs and other existing technologies. However, several challenges must be addressed before this potential can be fully realized. The development and testing of complex EHR systems that utilize AI must be approached with care to ensure their accuracy and trustworthiness in decision-making about patient treatment. Additionally, there is a need to navigate medico-legal obligations and ensure that benefits are equitably distributed.

Communicating without words: Measuring nonverbal communication between veterinarians and farmers during routine herd health consultations

Uptake of advice and the ability to facilitate change on-farm are key elements for successful veterinary practice. However, having the necessary clinical skills and knowledge is not enough to achieve this: effective communication skills are essential for veterinarians to realize their advisory role by exploring and understanding the farmer's worldview. Research of verbal aspects of veterinarian communication supports the use of a relationship-centered communication style; we next need to study how veterinarian-farmer nonverbal communication (NVC) can influence interactions and their outcomes, which has been examined in medical and companion animal practice. In this study, we considered which aspects of NVC should be measured, and how, to provide an essential first step toward understanding the significance of NVC for veterinarians working in dairy practice, which should be of interest to researchers, veterinary educators, and practitioners. Eleven video recordings of routine consultations in the UK were analyzed for farmer and veterinarian NVC. The NVC attributes with established links to positive patient and client outcomes from medical and social science studies were chosen, and a methodology developed for their measurement, by adapting measures typically used in NVC research. Each consultation was segmented into intervals defined by the main activity and location on farm: introduction, fertility examination, discussion, and closing. This approach allowed us to analyze the content more consistently, establish which aspects of NVC featured within each interval, and whether the activity and location influenced the observed NVC. We measured 12 NVC attributes, including body orientation, interpersonal distance, head position, and body lean, which have been shown to influence empathy, rapport, and trust: key components of relationship-centered communication. Future research should seek to establish the significance of NVC in effective communication between veterinarian and farmer, building on our findings that show it is possible to measure nonverbal attributes. Veterinarians may benefit from becoming skilled nonverbal communicators and have more effective conversations during routine consultations, motivating farmers to make changes and improve herd health.

Trends and differences in perceptions of patient-centered communication among adults in the US

OBJECTIVE

Patient-centered communication (PCC) is a key indicator of healthcare quality and is critical to patient-centered care. The purpose of this study is to examine the trends in PCC over the past decade and determine if differences in PCC by subpopulation remain METHODS: We used nationally representative survey data from the Health Information National Trends Study (HINTS) to examine PCC. We conducted trend and multivariate regression analyses to understand the changes of PCC scores and differences in PCC by key sociodemographic groups.

RESULTS

PCC reported among adults minimally increased with the largest increases in participants involved in making decisions regarding their healthcare. Participants who were non-Hispanic Black, older, had less than a high school education, or rural residents reported more positive perceptions of PCC CONCLUSION: Our findings indicate improvements to PCC over time. These findings also indicate that differences in patients' perceptions of PCC continue to persist and it's possible that personal expectations may influence a person's perception of the quality of PCC experienced PRACTICE IMPLICATIONS: This study highlights the continued need for provider education in patient emotional support and providing patients with the skills and resources to engage in high quality PCC.

Patient-provider communication while using a clinical decision support tool: explaining satisfaction with shared decision making for mammography screening

BACKGROUND

Clinical decision aids may support shared decision-making for screening mammography. To inform shared decision-making between patients and their providers, this study examines how patterns of using an EHR-integrated decision aid and accompanying verbal patient-provider communication predict decision-making satisfaction.

METHODS

For 51 patient visits during which a mammography decision aid was used, linguistic characteristics of patient-provider verbal communication were extracted from transcribed audio recordings and system logs automatically captured uses of the decision aid. Surveys assessed patients' post-visit decisional satisfaction and its subcomponents. Linear mixed effects models assessed how patients' satisfaction with decision making was related to patterns of verbal communication and navigation of the decision aid.

RESULTS

The results indicate that providers' use of quantitative language during the encounter was positively associated with patients' overall satisfaction, feeling informed, and values clarity. Patients' question-asking was negatively associated with overall satisfaction, values clarity, and certainty perception. Where system use data indicated the dyad had cycled through the decision-making process more than once ("looping" back through pages of the decision aid), patients reported improved satisfaction with shared decision making and all subcomponents. Overall satisfaction, perceived support, certainty, and perceived effectiveness of decision-making were lowest when a high number of navigating clicks occurred absent "looping."

CONCLUSIONS

Linguistic features of patient-provider communication and system use data of a decision aid predict patients' satisfaction with shared decision making. Our findings have implications for the design of decision aid tools and clinician training to support more effective shared decision-making for screening mammography.

“What’s the best way to document information concerning psychiatric patients? I just don’t know”—A qualitative study about recording psychiatric patients notes in the era of electronic health records

This paper reports the results of a qualitative study regarding the main attitudes and concerns of Swiss psychiatrists related to the utility, usability and acceptability of EHR and how they address the pitfalls of sharing sensitive information with other parties. A total of 20 semi-structured interviews were carried out. Applied thematic analysis was used to identify themes with regard to participation. Three main themes were identified: 1) strengths of the use of EHR in the clinical context; 2) limitations of EHR; and 3) recommendations on preserving confidentiality in health records. The study shows variable practices of EHR use in psychiatric hospitals in Switzerland and a lack of standards on how to document sensitive information in EHR.

The Impact of Artificial Intelligence on Waiting Time for Medical Care in an Urgent Care Service for COVID-19: Single-Center Prospective Study

Background

To demonstrate the value of implementation of an artificial intelligence solution in health care service, a winning project of the Massachusetts Institute of Technology Hacking Medicine Brazil competition was implemented in an urgent care service for health care professionals at Hospital das Clínicas of the Faculdade de Medicina da Universidade de São Paulo during the COVID-19 pandemic.

Objective

The aim of this study was to determine the impact of implementation of the digital solution in the urgent care service, assessing the reduction of nonvalue-added activities and its effect on the nurses’ time required for screening and the waiting time for patients to receive medical care.

Methods

This was a single-center, comparative, prospective study designed according to the Public Health England guide “Evaluating Digital Products for Health.” A total of 38,042 visits were analyzed over 18 months to determine the impact of implementing the digital solution. Medical care registration, health screening, and waiting time for medical care were compared before and after implementation of the digital solution.

Results

The digital solution automated 92% of medical care registrations. The time for health screening increased by approximately 16% during the implementation and in the first 3 months after the implementation. The waiting time for medical care after automation with the digital solution was reduced by approximately 12 minutes compared with that required for visits without automation. The total time savings in the 12 months after implementation was estimated to be 2508 hours.

Conclusions

The digital solution was able to reduce nonvalue-added activities, without a substantial impact on health screening, and further saved waiting time for medical care in an urgent care service in Brazil during the COVID-19 pandemic.

Interaction Time with Electronic Health Records: A Systematic Review

BACKGROUND

The amount of time that health care clinicians (physicians and nurses) spend interacting with the electronic health record is not well understood.

OBJECTIVE

This study aimed to evaluate the time that health care providers spend interacting with electronic health records (EHR).

METHODS

Data are retrieved from Ovid MEDLINE(R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily, (Ovid) Embase, CINAHL, and SCOPUS.

STUDY ELIGIBILITY CRITERIA

Peer-reviewed studies that describe the use of EHR and include measurement of time either in hours, minutes, or in the percentage of a clinician's workday. Papers were written in English and published between 1990 and 2021.

PARTICIPANTS

All physicians and nurses involved in inpatient and outpatient settings.

STUDY APPRAISAL AND SYNTHESIS METHODS

A narrative synthesis of the results, providing summaries of interaction time with EHR. The studies were rated according to Quality Assessment Tool for Studies with Diverse Designs.

RESULTS

Out of 5,133 de-duplicated references identified through database searching, 18 met inclusion criteria. Most were time-motion studies (50%) that followed by logged-based analysis (44%). Most were conducted in the United States (94%) and examined a clinician workflow in the inpatient settings (83%). The average time was nearly 37% of time of their workday by physicians in both inpatient and outpatient settings and 22% of the workday by nurses in inpatient settings. The studies showed methodological heterogeneity.

CONCLUSION

This systematic review evaluates the time that health care providers spend interacting with EHR. Interaction time with EHR varies depending on clinicians' roles and clinical settings, computer systems, and users' experience. The average time spent by physicians on EHR exceeded one-third of their workday. The finding is a possible indicator that the EHR has room for usability, functionality improvement, and workflow optimization.

How Do Patients Want Us to Use the Computer During Medical Encounters?-A Discrete Choice Experiment Study

BACKGROUND

Primary care physicians (PCPs) now widely use electronic health records (EHRs) during medical encounters. Experts in clinical communication issued recommendations for a patient-centered use of EHRs. However, they have never been validated by patients themselves.

OBJECTIVE

To explore patients' preferences regarding physicians' EHR-related behaviors.

DESIGN

Discrete choice experiment study.

PATIENTS

French-speaking patients waiting for a medical consultation at two outpatient clinics in Geneva, Switzerland.

MAIN MEASURES

We invited patients to watch videos displaying 2 or 3 variations of four specific EHR-related behaviors and asked them to indicate which one they preferred. EHR-related behaviors were (1) typing: continuous/intermittent/handwriting in biomedical or psychosocial focused consultations; (2) maintaining contact while typing: visual/verbal/both; (3) signposting the use of EHR: with/without; (4) position of physicians' hands and bust: on the keyboard and towards the patient/away from the keyboard and towards the patient/on the keyboard and towards the screen.

KEY RESULTS

Three hundred thirty-six patients participated (response rate 61.4%). They preferred intermittent typing versus handwriting or continuous typing for biomedical issues (32.7%; 95% CI: 26.0-40.2% vs 31.6%; 95% CI: 24.9-39.0% or 14.9%; 95% CI: 10.2-21.1%) and psychosocial issues (38.7%; 95% CI: 31.6-46.3% vs 24.4% 95% CI: 18.4-31.5% or 17.9%; 95% CI; 12.7-24.4%). They favored visual and verbal contact (38.9%; 95% CI: 31.9-46.3%) over verbal (30.3%; 95% CI: 23.9-37.5%) or visual contact only (11.4%; 95% CI: 7.5-17.1%) while the doctor was typing. A majority preferred signposting the use of EHR versus no signposting (58.9%; 95% CI: 53.5-64.0% vs 34.8%; 95% CI: 29.9-40.1%). Finally, half of the patients (49.7%; 95% CI: 42.0-57.4%) favored the position with the physician's bust towards the patient and hands away from the keyboard.

CONCLUSIONS

Our study shows that patients' preferences regarding EHR-related behaviors are in line with most experts' recommendations. Such recommendations should be more consistently integrated into under- and postgraduate communication skills training.

A more practical guide to incorporating health equity domains in implementation determinant frameworks

BACKGROUND

Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance.

METHODS

We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework.

RESULTS

We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures.

CONCLUSION

Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.

Pediatric Workplace Learning Opportunities for Medical Students: Is Scribing a Win-Win?

This study examined if preclerkship medical students would find it educational to scribe in a pediatric setting. Scribing promoted students' learning about pediatric clinical encounters enhanced their competency with electronic health record use, and moderately reduced attending physician documentation burden.

Eye-tracking glasses in face-to-face interactions: Manual versus automated assessment of areas-of-interest

The assessment of gaze behaviour is essential for understanding the psychology of communication. Mobile eye-tracking glasses are useful to measure gaze behaviour during dynamic interactions. Eye-tracking data can be analysed by using manually annotated areas-of-interest. Computer vision algorithms may alternatively be used to reduce the amount of manual effort, but also the subjectivity and complexity of these analyses. Using additional re-identification (Re-ID) algorithms, different participants in the interaction can be distinguished. The aim of this study was to compare the results of manual annotation of mobile eye-tracking data with the results of a computer vision algorithm. We selected the first minute of seven randomly selected eye-tracking videos of consultations between physicians and patients in a Dutch Internal Medicine out-patient clinic. Three human annotators and a computer vision algorithm annotated mobile eye-tracking data, after which interrater reliability was assessed between the areas-of-interest annotated by the annotators and the computer vision algorithm. Additionally, we explored interrater reliability when using lengthy videos and different area-of-interest shapes. In total, we analysed more than 65 min of eye-tracking videos manually and with the algorithm. Overall, the absolute normalized difference between the manual and the algorithm annotations of face-gaze was less than 2%. Our results show high interrater agreements between human annotators and the algorithm with Cohen’s kappa ranging from 0.85 to 0.98. We conclude that computer vision algorithms produce comparable results to those of human annotators. Analyses by the algorithm are not subject to annotator fatigue or subjectivity and can therefore advance eye-tracking analyses.

A Novel Patient Values Tab for the Electronic Health Record: A User-Centered Design Approach

BACKGROUND

The COVID-19 pandemic has shined a harsh light on a critical deficiency in our health care system: our inability to access important information about patients' values, goals, and preferences in the electronic health record (EHR). At Memorial Sloan Kettering Cancer Center (MSK), we have integrated and systematized health-related values discussions led by oncology nurses for newly diagnosed cancer patients as part of routine comprehensive cancer care. Such conversations include not only the patient's wishes for care at the end of life but also more holistic personal values, including sources of strength, concerns, hopes, and their definition of an acceptable quality of life. In addition, health care providers use a structured template to document their discussions of patient goals of care.

OBJECTIVE

To provide ready access to key information about the patient as a person with individual values, goals, and preferences, we undertook the creation of the Patient Values Tab in our center's EHR to display this information in a single, central location. Here, we describe the interprofessional, interdisciplinary, iterative process and user-centered design methodology that we applied to build this novel functionality as well as our initial implementation experience and plans for evaluation.

METHODS

We first convened a working group of experts from multiple departments, including medical oncology, health informatics, information systems, nursing informatics, nursing education, and supportive care, and a user experience designer. We conducted in-depth, semistructured, audiorecorded interviews of over 100 key stakeholders. The working group sought consensus on the tab's main content, homing in on high-priority areas identified by the stakeholders. The core content was mapped to various EHR data sources. We established a set of high-level design principles to guide our process. Our user experience designer then created wireframes of the tab design. The designer conducted usability testing with physicians, nurses, and other health professionals. Data validation testing was conducted.

RESULTS

We have already deployed the Patient Values Tab to a pilot sample of users in the MSK Gastrointestinal Medical Oncology Service, including physicians, advanced practice providers, nurses, and administrative staff. We have early evidence of the positive impact of this EHR innovation. Audit logs show increasing use. Many of the initial user comments have been enthusiastically positive, while others have provided constructive suggestions for additional tab refinements with respect to format and content.

CONCLUSIONS

It is our challenge and obligation to enrich the EHR with information about the patient as a person. Realization of this capability is a pressing public health need requiring the collaboration of technological experts with a broad range of clinical leaders, users, patients, and families to achieve solutions that are both principled and practical. Our new Patient Values Tab represents a step forward in this important direction.

Predictors of Patient-Centered Communication among U.S. Adults: Analysis of the 2017-2018 Health Information National Trends Survey (HINTS)

An essential component of patient-centered care is the communication between patients and their providers, which can affect patients' health outcomes A cancer care model, developed by Epstein and Street, includes a multi-dimensional patient-centered communication (PCC) framework with six functions: foster healing relationships, exchange information, respond to emotions, manage uncertainty, make decisions, and enable patient self-management. Seven domains that describe the functions were included on the Health Information National Trends Survey (HINTS) to assess PCC. We examined the association between sociodemographic and health-related factors and PCC as well as how U.S. adults, by different age groups, ranked different domains of PCC.Nationally representative data (n = 5,738) from 2017 to 2018 HINTS were merged to examine predictors of PCC among U.S. adults. Weighted statistics describe the study sample and prevalence for ratings of PCC domains. A multivariate linear regression model was computed to assess associations among predictors and PCC.Participants rated their communication with doctors in the last year with an overall mean of 80 out of 100. Older age, those reporting excellent health, and those with higher confidence in taking care of one's health predicted better PCC. Individuals who reported being non-Hispanic Asian and having lower household income were associated with poorer communication. Participants' lowest rating of PCC concentrated on providers dealing with their emotional needs.Findings suggest that many patients do not feel that their providers adequately manage, communicate, nor respond to their emotional needs. Future efforts should enhance interpersonal exchanges among sub-populations who report poorer communication with providers during clinical visits.

Development and Optimization of Clinical Informatics Infrastructure to Support Bioinformatics at an Oncology Center

Translational bioinformatics for therapeutic discovery requires the infrastructure of clinical informatics. In this chapter, we describe the clinical informatics components needed for successful implementation of translational research at a cancer center. This chapter is meant to be an introduction to those clinical informatics concepts that are needed for translational research. For a detailed account of clinical informatics, the authors will guide the reader to comprehensive resources. We provide examples of workflows from Moffitt Cancer Center led by Drs. Perkins and Markowitz. This perspective represents an interesting collaboration as Dr. Perkins is the Chief Medical Information Officer and Dr. Markowitz is a translational researcher in Melanoma with an active informatics component to his laboratory to study the mechanisms of resistance to checkpoint blockade and an active member of the clinical informatics team.

Patient-centered care and the electronic health record: exploring functionality and gaps

OBJECTIVE

Healthcare systems have adopted electronic health records (EHRs) to support clinical care. Providing patient-centered care (PCC) is a goal of many healthcare systems. In this study, we sought to explore how existing EHR systems support PCC; defined as understanding the patient as a whole person, building relational connections between the clinician and patient, and supporting patients in health self-management.

MATERIALS AND METHODS

We assessed availability of EHR functions consistent with providing PCC including patient goals and preferences, integrated care plans, and contextual and patient-generated data. We surveyed and then interviewed technical representatives and expert clinical users of 6 leading EHR systems. Questions focused on the availability of specific data and functions related to PCC (for technical representatives) and the clinical usefulness of PCC functions (for clinicians) in their EHR.

RESULTS

Technical representatives (n = 6) reported that patient communication preferences, personalized indications for medications, and end of life preferences were functions implemented across 6 systems. Clinician users (n = 10) reported moderate usefulness of PCC functions (medians of 2-4 on a 5-pointy -35t scale), suggesting the potential for improvement across systems. Interviews revealed that clinicians do not have a shared conception of PCC. In many cases, data needed to deliver PCC was available in the EHR only in unstructured form. Data systems and functionality to support PCC are under development in these EHRs.

DISCUSSION AND CONCLUSION

There are current gaps in PCC functionality in EHRs and opportunities to support the practice of PCC through EHR redesign.

'Motivational work': a qualitative study of preventive health dialogues in general practice

Background

The aim of this article is to explore preventive health dialogues in general practice in the context of a pilot study of a Danish primary preventive intervention ‘TOF’ (a Danish acronym for ‘Early Detection and Prevention’) carried out in 2016. The intervention consisted of 1) a stratification of patients into one of four groups, 2) a digital support system for both general practitioners and patients, 3) an individual digital health profile for each patient, and 4) targeted preventive services in either general practice or a municipal health center.

Methods

The empirical material in this study was obtained through 10 observations of preventive health dialogues conducted in general practices and 18 semi-structured interviews with patients and general practitioners. We used the concept of ‘motivational work’ as an analytical lens for understanding preventive health dialogues in general practice from the perspectives of both general practitioners and patients.

Results

While the health dialogues in TOF sought to reveal patients’ motivations, understandings, and priorities related to health behavior, we find that the dialogues were treatment-oriented and structured around biomedical facts, numeric standards, and risk factor guidance. Overall, we find that numeric standards and quantification of motivation lessens the dialogue and interaction between General Practitioner and patient and that contextual factors relating to the intervention framework, such as a digital support system, the general practitioners’ perceptions of their professional position as well as the patients’ understanding of prevention —in an interplay—diminished the motivational work carried out in the health dialogues.

Conclusion

The findings show that the influence of different kinds of context adds to the complexity of prevention in the clinical encounter which help to explain why motivational work is difficult in general practice.

Association of Electronic Health Record Use Above Meaningful Use Thresholds With Hospital Quality and Safety Outcomes

IMPORTANCE

By 2018, Medicare spent more than $30 billion to incentivize the adoption of electronic health records (EHRs), based partially on the belief that EHRs would improve health care quality and safety. In a time when most hospitals are well past minimum meaningful use (MU) requirements, examining whether EHR implementation beyond the minimum threshold is associated with increased quality and safety may guide the future focus of EHR development and incentive structures.

OBJECTIVE

To determine whether EHR implementation above MU performance thresholds is associated with changes in hospital patient satisfaction, efficiency, and safety.

DESIGN, SETTING, AND PARTICIPANTS

This quantile regression analysis of cross-sectional data used publicly available data sets from 2362 acute care hospitals in the United States participating in both the MU and Hospital Value-Based Purchasing (HVBP) programs from January 1 to December 31, 2016. Data were analyzed from August 1, 2019, to May 22, 2020.

EXPOSURES

Seven MU program performance measures, including medication and laboratory orders placed through the EHR, online health information availability and access rates, medication reconciliation through the EHR, patient-specific educational resources, and electronic health information exchange.

MAIN OUTCOMES AND MEASURES

The HVBP outcomes included patient satisfaction survey dimensions, Medicare spending per beneficiary, and 5 types of hospital-acquired infections.

RESULTS

Among the 2362 participating hospitals, mixed associations were found between MU measures and HVBP outcomes, all varying by outcome quantile and in some cases by interaction with EHR vendor. Computerized provider order entry (CPOE) for laboratory orders was associated with decreased ratings of every patient satisfaction outcome at middle quantiles (communication with nurses: β = -0.33 [P = .04]; communication with physicians: β = -0.50 [P < .001]; responsiveness of hospital staff: β = -0.57 [P = .03]; care transition performance: β = -0.66 [P < .001]; communication about medicines: β = -0.52 [P = .002]; cleanliness and quietness: β = -0.58 [P = .007]; discharge information: β = -0.48 [P < .001]; and overall rating: β = -0.95 [P < .001]). However, at middle quantiles, CPOE for medication orders was associated with increased ratings for communication with physicians (τ = 0.5; β = 0.54; P = .009), care transition (τ = 0.5; β = 1.24; P < .001), discharge information (τ = 0.5; β = 0.41; P = .01), and overall hospital ratings (τ = 0.5; β = 0.97; P = .02). At high quantiles, electronic health information exchange was associated with improved ratings of communication with nurses (τ = 0.9; β = 0.23; P = .03). Medication reconciliation had positive associations with increased communication with nursing at low quantiles (τ = 0.1; β = 0.60; P < .001), increased discharge information at middle quantiles (τ = 0.5; β = 0.28; P = .03), and responsiveness of hospital staff at middle (τ = 0.5; β = 0.77; P = .001) and high (τ = 0.9; β = 0.84; P = .001) quantiles. Patients accessing their health information online was not associated with any outcomes. Increased use of patient-specific educational resources identified through the EHR was associated with increased ratings of communication with physicians at high quantiles (τ = 0.9; β = 0.20; P = .02) and with decreased spending at low-spending hospitals (τ = 0.1; β = -0.40; P = .008).

CONCLUSIONS AND RELEVANCE

Increasing EHR implementation, as measured by MU criteria, was not straightforwardly associated with increased HVBP measures of patient satisfaction, spending, and safety in this study. These results call for a critical evaluation of the criteria by which EHR implementation is measured and increased attention to how different EHR products may lead to differential outcomes.

Contemporaneous patient and health professional views of patient-centred care: a systematic review

OBJECTIVE

To understand the domains of agreement and disagreement, related to person-centred care, between the patient and healthcare professional during a shared episode of care.

DESIGN

A systematic review following the PRISMA protocol searched PubMed (Medline), CINAHL, PsychInfo and Scopus using keywords for health professionals, patients and patient-centred care. A descriptive-interpretive method was used to identify domains described in the person-centred care framework.

SETTING

Research conducted in all healthcare settings (inpatient, outpatient, community) were included.

PARTICIPANTS

Research which presented the contemporaneous perspectives of a health professional and the person they were providing services to were included.

INTERVENTION(S)

Research regarding the delivery of any type of health service was included.

MAIN OUTCOME MEASURE(S)

The person-centred care framework which includes Structure, Process and Outcome as measures for implementing person-centred care was used to interpret and summarize the data.

RESULTS

After title and abstract screening against inclusion and exclusion criteria, 15 of 1,406 studies were critically appraised. High levels of contemporaneous agreement were identified for easily accessible, supportive and accommodating environments, where information sharing occurred. Contemporaneous agreement occurred most often between patients and healthcare professionals in the importance of sharing information across all geographical settings, with greatest disagreement of patient involvement in the European and American hospital environments.

CONCLUSIONS

Greater understanding of the context of information sharing and drivers for management preferences may support shared decision-making and increase satisfaction. More information regarding contemporaneous experiences of healthcare episodes is required to further inform patient-centred care practices and optimize health outcomes.

Patients' preferences in selecting family physician in primary health centers: a qualitative-quantitative approach

BACKGROUND

The role of family physicians (FPs) in the metropolitan area is critical in identifying risk factors for disease prevention/control and health promotion in various age groups. Understanding patients' preferences and interests in choosing a FP can be an effective and fundamental step in the success of this program. In this study factors affecting the FP selection by Iranian patients referred to health centers in the most populous areas in the south of Tehran were assessed and ranked.

METHODS

A sequential mixed-method (qualitative-quantitative) triangulation approach was designed with three subject groups of patients, physicians, and health officials. The Framework method was used to analyze interviews transcribed verbatim. After implementing an iterative thematic process, a 26-item quantitative questionnaire with high validity and reliability was drafted to evaluate the different factors. A convenient sampling method was used to select 400 subjects on a population-based scale to quantitatively rank the most critical selection factors as a mean score of items.

RESULTS

The selection factors were divided into six centralized codes, including FPs' ethics, individual, professional and performance factors; patients' underlying disease and individual health, and disease-related factors, office's location and management factors, democracy factors, economic factors, and social factors. After filling out the questionnaires, the most important factors in selecting FP were a specialist degree in family medicine (FM) (4.49 ± 0.70), performing accurate examinations with receiving a detailed medical history (4.43 ± 0.68), and spending enough time to visit patients (4.28 ± 0.75), respectively. However, the parameters such as being a fellow-citizen, being the same gender, and physician's appearance were of the least importance.

CONCLUSION

There is a possibility to screen the most important factors affecting the FP choice through the combination of qualitative and quantitative studies. The first and last patients' priority was physicians' specialty in FM and being a fellow-citizen with them, respectively. The clinical and administrative healthcare systems should schedule the entire implementation process to oversee the doctor's professional commitment and setting the visit times of FP.

An Analysis of the Learning Health System in Its First Decade in Practice: Scoping Review

Background

In the past decade, Lynn Etheredge presented a vision for the Learning Health System (LHS) as an opportunity for increasing the value of health care via rapid learning from data and immediate translation to practice and policy. An LHS is defined in the literature as a system that seeks to continuously generate and apply evidence, innovation, quality, and value in health care.

Objective

This review aimed to examine themes in the literature and rhetoric on the LHS in the past decade to understand efforts to realize the LHS in practice and to identify gaps and opportunities to continue to take the LHS forward.

Methods

We conducted a thematic analysis in 2018 to analyze progress and opportunities over time as compared with the initial Knowledge Gaps and Uncertainties proposed in 2007.

Results

We found that the literature on the LHS has increased over the past decade, with most articles focused on theory and implementation; articles have been increasingly concerned with policy.

Conclusions

There is a need for attention to understanding the ethical and social implications of the LHS and for exploring opportunities to ensure that these implications are salient in implementation, practice, and policy efforts.

Patient satisfaction with the implementation of electronic medical Records in the Western Region, Saudi Arabia, 2018

BACKGROUND

The implementation of the Electronic Medical Record (EMR) system initiated a significant transition in the healthcare system from traditional paper-based medical records to a digital version. Though EMR offers several benefits compared to Paper Medical Records (PMR), patient satisfaction with the EMR has been an area of concern. The objective of this study is to explore patient satisfaction with the EMR compared to the PMR of patients attending five Primary Healthcare Centers in the Western Region of Saudi Arabia.

METHODS

A cross-sectional survey was conducted with patients who attended five Primary Health Care centers (PHCs) in the Western Region during 2018. A sample of 377 participants was invited to complete a self-developed structured questionnaire with multiple choice and Likert Scale questions. The questionnaire was distributed to participants in the PHC waiting areas.

RESULTS

The sample size realized as (n = 377) participants, the majority (65.0%) were female. The overall patient satisfaction was 3.708. Patient satisfaction with the EMR was statistically significant compared to the PMR (3.7241 vs. 3.6919, p < 0.001). Several factors provided evidence of the overall satisfaction with the implementation of the EMR, including an increase in physician attention during the clinical consultation (82.3%), increased explanation of tests and medication (85.8%), increased time spent with the patient during the consultation (80.4%) and increased active listening by the physician (77.3%). Besides, the patients felt confident to ask the physician question related to health during clinical consultation (84.0%).

CONCLUSION

Patient satisfaction during the clinical consultation and overall satisfaction with various PHC services improved with the implementation of EMR.

A qualitative study of physician perspectives on adaptation to electronic health records

Background

Electronic Health Records (EHRs) have the potential to improve many aspects of care and their use has increased in the last decade. Because of this, acceptance and adoption of EHRs is less of a concern than adaptation to use. To understand this issue more deeply, we conducted a qualitative study of physician perspectives on EHR use to identify factors that facilitate adaptation.

Methods

We conducted semi-structured interviews with 9 physicians across a range of inpatient disciplines at a large Academic Medical Center. Interviews were conducted by phone, lasting approximately 30 min, and were transcribed verbatim for analysis. We utilized inductive and deductive methods in our analysis.

Results

We identified 4 major themes related to EHR adaptation: impact of EHR changes on physicians, how physicians managed these changes, factors that facilitated adaptation to using the EHR and adapting to using the EHR in the patient encounter. Within these themes, physicians felt that a positive mindset toward change, providing upgrade training that was tailored to their role, and the opportunity to learn from colleagues were important facilitators of adaptation.

Conclusions

As EHR use moves beyond implementation, physicians continue to be required to adapt to the technology and to its frequent changes. Our study provides actionable findings that allow healthcare systems to focus on factors that facilitate the adaptation process for physicians.

Patient-centered Communication Behaviors on Primetime Television

Previous research suggests that television programming may influence viewers' health-related knowledge, perceptions, and behaviors but has yet to examine patient-provider interactions on the most popular primetime television programs. We aimed to characterize the frequency and nature of patient-centered communication (PCC) behaviors on these programs, as cultivation and social cognitive theories suggest that these depictions may influence viewers' expectations of real-life health-care experiences. We examined 203 patient-provider interactions across 84 episodes of 22 primetime television programs-both medical and non-medical-that aired during the spring of 2016 and spring of 2017. Each interaction was analyzed for the presence of 21 optimal PCC behaviors. This study found that the most frequently observed PCC behaviors focused on the provider making good eye contact and displaying good manners. However, PCC behaviors related to managing patient uncertainty and self-management were rare. Overall, providers in medical programs were significantly more likely to exhibit certain PCC behaviors, such as asking a patient questions, having good manners, and self-disclosing personal information, compared to providers in non-medical programs. Implications of these findings include the potential for such depictions to influence patient expectations of real-life experiences and health outcomes. Future research is needed to examine these potential influences.

Improving the Delivery of Healthcare through Clinical Diagnostic Insights: A Valuation of Laboratory Medicine through "Clinical Lab 2.0"

BACKGROUND

As healthcare payment and reimbursement begin to shift from a fee-for-service to a value-based model, ancillary providers including laboratories must incorporate this into their business strategy. Laboratory medicine, while continuing to support a transactional business model, should expand efforts to include translational data analytics, proving its clinical and economic valuation. Current literature in this area is limited.

CONTENT

This article is a summary of how laboratory medicine can support value-based healthcare. Population health management is emerging as a method to support value-based healthcare by aggregating patient information, providing data analysis, and contributing to clinical decision support. Key issues to consider with a laboratory-developed population health management model are discussed, including changing reimbursement models, the use of multidisciplinary committees, the role of specialists in data analytics and programming, and barriers to implementation. Examples of data considerations and value are given.

SUMMARY

Laboratory medicine is able to provide meaningful clinical diagnostic insights for population health initiatives that result in improved short- and long-term patient outcomes and drive cost-effective care. Opportunities include data analysis with longitudinal laboratory data, identification of patient-specific targeted interventions, and development of clinical decision support tools. Laboratories will need to leverage the skills and knowledge of their multidisciplinary staff, along with their extensive patient data sets, through innovative analytics to meet these objectives.

Electronic health records, communication, and data sharing: challenges and opportunities for improving the diagnostic process

Background Diagnosis requires that clinicians communicate and share patient information in an efficient manner. Advances in electronic health records (EHRs) and health information technologies have created both challenges and opportunities for such communication. Methods We conducted a multi-method, focused ethnographic study of physicians on general medicine inpatient units in two teaching hospitals. Physician teams were observed during and after morning rounds to understand workflow, data sharing and communication during diagnosis. To validate findings, interviews and focus groups were conducted with physicians. Field notes and interview/focus group transcripts were reviewed and themes identified using content analysis. Results Existing communication technologies and EHR-based data sharing processes were perceived as barriers to diagnosis. In particular, reliance on paging systems and lack of face-to-face communication among clinicians created obstacles to sustained thinking and discussion of diagnostic decision-making. Further, the EHR created data overload and data fragmentation, making integration for diagnosis difficult. To improve diagnosis, physicians recommended replacing pagers with two-way communication devices, restructuring the EHR to facilitate access to key information and improving training on EHR systems. Conclusions As advances in health information technology evolve, challenges in the way clinicians share information during the diagnostic process will rise. To improve diagnosis, changes to both the technology and the way in which we use it may be necessary.

Sexual minority men want provider behavior consistent with attitudes and norms during patient-provider interactions regarding HIV prevention

HIV is a health problem for sexual minority men in the United States. One factor among many that contributes to this HIV disparity is poor patient-provider interactions. We focused on specific provider behavior preferred by sexual minority men during patient-provider interactions about HIV prevention. We interviewed 20 HIV-negative sexual minority men who endorsed 1+ psychosocial HIV risk factor. We used follow up interviews and conventional content analysis. Among our sample, 55% identified as White; 50% as bisexual, (M_age = 28.45). Findings suggested even some providers knowledgeable about sexual minority health provided unhelpful care to sexual minority men (knowledge-behavior discrepancy). Some knowledgeable providers engaged in affirmative, tailored treatment (knowledge-behavior consistency). Specific behaviors of preferred patient-provider interactions regarding HIV prevention are reported. Our recommendations are based on patient perceptions, which is a limit and strength. We identified an important type of unhelpful patient-provider interaction for HIV-negative sexual minority men beyond discriminatory experiences. Patient-provider interaction efforts need to go beyond education to help providers practice skills. With increased focus on cultural competency for sexual minority patients, more providers may advertise their practice as affirmative, yet interactions will likely vary, may require lifelong practice of cultural humility, and impact HIV prevention.

Diabetes Care Editors' Expert Forum 2018: Managing Big Data for Diabetes Research and Care

Technological progress in the past half century has greatly increased our ability to collect, store, and transmit vast quantities of information, giving rise to the term "big data." This term refers to very large data sets that can be analyzed to identify patterns, trends, and associations. In medicine-including diabetes care and research-big data come from three main sources: electronic medical records (EMRs), surveys and registries, and randomized controlled trials (RCTs). These systems have evolved in different ways, each with strengths and limitations. EMRs continuously accumulate information about patients and make it readily accessible but are limited by missing data or data that are not quality assured. Because EMRs vary in structure and management, comparisons of data between health systems may be difficult. Registries and surveys provide data that are consistently collected and representative of broad populations but are limited in scope and may be updated only intermittently. RCT databases excel in the specificity, completeness, and accuracy of their data, but rarely include a fully representative sample of the general population. Also, they are costly to build and seldom maintained after a trial's end. To consider these issues, and the challenges and opportunities they present, the editors of Diabetes Care convened a group of experts in management of diabetes-related data on 21 June 2018, in conjunction with the American Diabetes Association's 78th Scientific Sessions in Orlando, FL. This article summarizes the discussion and conclusions of that forum, offering a vision of benefits that might be realized from prospectively designed and unified data-management systems to support the collective needs of clinical, surveillance, and research activities related to diabetes.

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis

BACKGROUND

Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use.

OBJECTIVE

The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use.

METHODS

We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes.

RESULTS

Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use.

CONCLUSIONS

Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.

Automation to optimise physician treatment of individual patients: examples in psychiatry

There is widespread agreement by health-care providers, medical associations, industry, and governments that automation using digital technology could improve the delivery and quality of care in psychiatry, and reduce costs. Many benefits from technology have already been realised, along with the identification of many challenges. In this Review, we discuss some of the challenges to developing effective automation for psychiatry to optimise physician treatment of individual patients. Using the perspective of automation experts in other industries, three examples of automation in the delivery of routine care are reviewed: (1) effects of electronic medical records on the patient interview; (2) effects of complex systems integration on e-prescribing; and (3) use of clinical decision support to assist with clinical decision making. An increased understanding of the experience of automation from other sectors might allow for more effective deployment of technology in psychiatry.

Effect of computer use on physician-patient communication using interviews: A patient perspective

BACKGROUND

A commonly stated barrier to adoption of electronic medical record (EMR) is fear of a negative impact on physician-patient communication. Systematic reviews have shown that there is limited literature addressing the patients' perspective as compared to the physicians' perspectives.

AIM

This study aims to understand patients' perspective on the effect of EMR on physician-patient communication in an ambulatory setting.

DESIGN AND SETTINGS

This is a qualitative study using semi-structured interviews with 49 patients at a multi-physician family medicine clinic in a large academic medical center in Beirut, Lebanon.

MATERIALS AND METHODS

At the end of the visit with the physicians, the patients were approached by the clinical assistant to conduct an interview concerning the patient-doctor communication in the presence of electronic medical record. The interview was conducted in a private office by an experienced researcher.

RESULTS

Almost all patients reported that computer use during the encounter did not affect the quality of communication with their physician. Five themes emerged from the analysis of the interviews: (1) EMR use in clinic is considered a necessity; (2) EMR use by physicians is efficient in record keeping and information retrieval; (3) physicians balance between using the computer and paying attention to patients; (4) computer use by physicians might affect communication about personal and intimate issues; (5) concomitant computer use while listening to the patient was not considered disturbing.

CONCLUSIONS

Most patients appreciated EMR use by physicians during the clinical encounter and acknowledged its benefits despite the presence of some concerns. Most patients did not consider that EMRs affect communication with physicians negatively especially when used in a balanced manner. Attention rather than eye contact is what mattered the most for patients.

Trends in Use of Electronic Health Records in Pediatric Office Settings

OBJECTIVES

To determine the prevalence and functionalities of electronic health records (EHRs) and pediatricians' perceptions of EHRs.

STUDY DESIGN

An 8-page self-administered questionnaire sent to 1619 randomly selected nonretired US American Academy of Pediatrics members in 2016 was completed by 709 (43.8%). Responses were compared with surveys in 2009 and 2012.

RESULTS

The percent of pediatricians who were using EHRs increased from 58% in 2009 and 79% in 2012 to 94% in 2016. Those with fully functional EHRs, including pediatric functionality, more than doubled from 8.2% in 2012 to 16.9% in 2016 (P = .01). Fully functional EHRs lacking pediatric functionality increased slightly from 7.8% to 11.1% (P = .3), and the percentage of pediatricians with basic EHRs remained stable (30.4% to 31.0%; P < .3). The percentage of pediatricians who lacked basic EHR functionality or who reported no EHR decreased (from 53.6% to 41.0%; P < .001). On average, pediatricians spent 3.4 hours per day documenting care.

CONCLUSIONS

Although the adoption of EHRs has increased, >80% of pediatricians are working with EHRs that lack optimal functionality and 41% of pediatricians are not using EHRs with even basic functionality. EHRs lacking pediatric functionality impact the health of children through increased medical errors, missed diagnoses, lack of adherence to guidelines, and reduced availability of child-specific information. The pediatric certification outlined in the 21st Century Cures Act may result in improved EHR products for pediatricians.

Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports

AIMS AND OBJECTIVES

To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process.

BACKGROUND

The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122-1131).

DESIGN

The project was a mixed-method, two-phase study that collected data from two sites.

METHODS

In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice.

RESULTS

Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration.

CONCLUSIONS

We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation.

RELEVANCE TO CLINICAL PRACTICE

Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases.

What factors influence the use of electronic health records during the first 10 minutes of the clinical encounter?

Purpose

The use of electronic health records (EHRs) by physicians during the consultation is common and can be problematic. Factors influencing the use of EHRs during clinical encounters include physician and patient characteristics, consultation type as well as spatial organization of the room and type of EHR template. Their relative importance is however not well known. This study aimed to explore to what extent several physician, patient and consultation factors were associated with EHR use during the first 10 minutes of primary care consultations.

Methods

We examined EHR use of 17 residents in 142 videotaped consultations at the Primary Care Division of the Geneva University Hospitals, Switzerland. We conducted univariable and multivariable analyses with patient, physician and consultation variables to predict EHR use: sex and age of the patient; physician’s sex, age, postgraduate experience and EHR-use self-perception; and language, type of consultation (new/follow-up) and content of the consultation using the Roter interaction analysis system (RIAS), the main variable being the percentage of utterances in relation to EHR use during the first 10 minutes.

Results

Male physicians (residents) and those with less clinical experience and conducting a new consultation or addressing biomedical content were positively correlated with EHR use (+5.3% for male physicians, P=0.101; +0.6% per year of experience, P=0.021; +6.0% for new consultation, P=0.097; +0.4% per 1% of biomedical content increase; P=0.018).

Conclusion

Only a small number of physician, patient and consultation factors appear to have an impact on the use of EHR during primary care consultations, and this impact remains modest. Given the influence of EHR use on physician–patient relationship, further research should explore what other factors are implicated in EHR use and whether they can be changed or improved.

Clinically Excellent Use of the Electronic Health Record: Review

BACKGROUND

The transition to the electronic health record (EHR) has brought forth a rapid cultural shift in the world of medicine, presenting both new challenges as well as opportunities for improving health care. As clinicians work to adapt to the changes imposed by the EHR, identification of best practices around the clinically excellent use of the EHR is needed.

OBJECTIVE

Using the domains of clinical excellence previously defined by the Johns Hopkins Miller Coulson Academy of Clinical Excellence, this review aims to identify best practices around the clinically excellent use of the EHR.

METHODS

The authors searched the PubMed database, using keywords related to clinical excellence domains and the EHR, to capture the English-language, peer-reviewed literature published between January 1, 2000, and August 2, 2016. One author independently reviewed each article and extracted relevant data.

RESULTS

The search identified 606 titles, with the majority (393/606, 64.9%) in the domain of communication and interpersonal skills. Twenty-eight of the 606 (4.6%) titles were excluded from full-text review, primarily due to lack of availability of the full-text article. The remaining 578 full-text articles reviewed were related to clinical excellence generally (3/578, 0.5%) or the specific domains of communication and interpersonal skills (380/578, 65.7%), diagnostic acumen (31/578, 5.4%), skillful negotiation of the health care system (4/578, 0.7%), scholarly approach to clinical practice (41/578, 7.1%), professionalism and humanism (2/578, 0.4%), knowledge (97/578, 16.8%), and passion for clinical medicine (20/578, 3.5%).

CONCLUSIONS

Results suggest that as familiarity and expertise are developed, clinicians are leveraging the EHR to provide clinically excellent care. Best practices identified included deliberate physical configuration of the clinical space to involve sharing the screen with patients and limiting EHR use during difficult and emotional topics. Promising horizons for the EHR include the ability to augment participation in pragmatic trials, identify adverse drug effects, correlate genomic data to clinical outcomes, and follow data-driven guidelines. Clinician and patient satisfaction with the EHR has generally improved with time, and hopefully continued clinician, and patient input will lead to a system that satisfies all.

Evaluating hospital websites in Kuwait to improve consumer engagement and access to health information: a cross-sectional analytical study

BACKGROUND

Current advances in information and communication technology have made accessing and obtaining health-related information easier than ever before. Today, many hospital websites use a patient-centric approach to promote engagement and encourage learning for better health-related decision making. However, little is known about the current state of hospital websites in the State of Kuwait. This study aims to evaluate hospital websites in Kuwait and offer recommendations to improve patient engagement and access to health information.

METHODS

This study employs a cross-sectional analytical approach to evaluate hospital websites in Kuwait in 2017. The websites of hospitals that provide in-patient services were identified through a structured search. Only active websites that were available in either English or Arabic were considered. The evaluation of the websites involved a combination of automated and expert- based evaluation methods and was performed across four dimensions: Accessibility, Usability, Presence, and Content.

RESULTS

Nine hospitals met the inclusion criteria. Most of the websites fell short in all four dimensions. None of the websites passed the accessibility guidelines. The usability of websites varied between hospitals. Overall, the majority of hospitals in Kuwait have rudimentary online presence and their websites require careful reassessment with respect to design, content, and user experience. The websites focus primarily on promoting services provided by the hospital rather than engaging and communicating with patients or providing evidence-based information.

CONCLUSIONS

Healthcare organization and website developers should follow best-practices to improve their websites taking into consideration the quality, readability, objectivity, coverage and currency of the information as well as the design of their websites. Hospitals should leverage social media to gain outreach and better engagement with consumers. The websites should be offered in additional languages commonly spoken by people living in Kuwait. Efforts should be made to ensure that health information on hospital websites are evidence-based and checked by healthcare professionals.

A computer template to enhance patient-centredness in multimorbidity reviews: a qualitative evaluation in primary care

Background

Computer templates for review of single long-term conditions are commonly used to record care processes, but they may inhibit communication and prevent patients from discussing their wider concerns.

Aim

To evaluate the effect on patient-centredness of a novel computer template used in multimorbidity reviews.

Design and setting

A qualitative process evaluation of a randomised controlled trial in 33 GP practices in England and Scotland examining the implementation of a patient-centred complex intervention intended to improve management of multimorbidity. A purpose-designed computer template combining long-term condition reviews was used to support the patient-centred intervention.

Method

Twenty-eight reviews using the intervention computer template and nine usual-care reviews were observed and recorded. Sixteen patient interviews, four patient focus groups, and 23 clinician interviews were also conducted in eight of the 12 intervention practices. Transcripts were thematically analysed based on predefined core components of patient-centredness and template use.

Results

Disrupted communication was more evident in intervention reviews because the template was unfamiliar, but the first template question about patients’ important health issues successfully elicited wide-ranging health concerns. Patients welcomed the more holistic, comprehensive reviews, and some unmet healthcare needs were identified. Most clinicians valued identifying patients’ agendas, but some felt it diverted attention from care of long-term conditions. Goal-setting was GP-led rather than collaborative.

Conclusion

Including patient-centred questions in long-term condition review templates appears to improve patients’ perceptions about the patient-centredness of reviews, despite template demands on a clinician’s attention. Adding an initial question in standardised reviews about the patient’s main concerns should be considered.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care

BACKGROUND

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.

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Clinical Excellence in Endocrinology

CONTEXT

Clinical endocrinology is a field driven largely by numerical parameters. To achieve outstanding patient care, however, the clinical endocrinologist must employ a range of skills which can collectively be called "clinical excellence." While there is extensive published guidance regarding appropriate medical management and outcomes for endocrine patients, there has been no consensus definition of excellence in the field, nor any recommendation as to how excellence can be achieved.

EVIDENCE ACQUISITION

Literature review, review of websites of professional societies, clinical organizations, and government agencies.

EVIDENCE SYNTHESIS AND RECOMMENDATIONS

After review of endocrine clinical outcomes guidelines and published descriptions of clinical excellence generally, key aspects of clinical excellence in endocrinology were derived: the ability to work in teams, communication and interpersonal skills, skillful negotiation of the health care system, and a strong knowledge base and scholarly approach. Examples of how these skills drive superior outcomes for patients are discussed.

CONCLUSIONS

Clinical excellence in endocrinology is necessary to optimize care for endocrine patients. A definition of clinical excellence should be adopted by professional societies and medical institutions and its importance in patient care recognized and emphasized. Efforts should be undertaken in the context of endocrine fellowship training and faculty development to foster the skills inherent in clinical excellence.

The electronic health record as a patient engagement tool: mirroring clinicians' screen to create a shared mental model

Objective

Electronic health records (EHRs) in physician offices can both enhance and detract from the patient experience. Best practices have emerged focusing on screen sharing. We sought to determine if adding a second monitor, mirroring the EHR for patients, would be welcome and useful for patients and clinicians.

Materials and Methods

This mixed-method study was conducted in a general medicine clinic from March to June 2016. Clinicians and patients met in a specially equipped exam room with a patient-facing monitor. Visits were video-recorded to assess time spent viewing the EHR and followed by interviews, which were transcribed and analyzed using established qualitative methods.

Results

Eight clinicians and 24 patients participated. Main themes included the second screen serving as a catalyst for patient engagement, augmenting the clinic visit in a meaningful way, improving transparency of the care process and documentation, and providing a substantially different experience for patients than a shared single screen. Concerns and suggestions for improvement were also reported. Quantitative results showed high patient engagement times with the EHR (25% of the visit length) compared to reports in previous studies. The median satisfaction score was 5 out of 5 for patients and 3.3 out of 5 for clinicians.

Discussion and Conclusion

Providing patient access to the EHRs with this design was linked with several benefits including improved patient engagement, education, transparency, comprehension, and trust. Future studies should explore how best to display information in such screens for patients and identify impact on care, safety, and quality.

Predictors of physicians' stress related to information systems: a nine-year follow-up survey study

Background

Among the important stress factors for physicians nowadays are poorly functioning, time consuming and inadequate information systems. The present study examined the predictors of physicians’ stress related to information systems (SRIS) among Finnish physicians. The examined predictors were cognitive workload, staffing problems, time pressure, problems in teamwork and job satisfaction, adjusted for baseline levels of SRIS, age, gender and employment sector.

Methods

The study has a follow-up design with two survey data collection waves, one in 2006 and one in 2015, based on a random sample of Finnish physicians was used. The present study used a sample that included 1109 physicians (61.9% women; mean age in 2015 was 54.5; range 34–72) who provided data on the SRIS in both waves. The effects of a) predictor variable levels in 2006 on SRIS in 2015 and b) the change in the predictor variables from 2006 to 2015 on SRIS in 2015 were analysed with linear regression analyses.

Results

Regression analyses showed that the higher level of cognitive workload in 2006 significantly predicted higher level of SRIS in 2015 (β = 0.08). The reciprocity of this association was tested with cross-lagged structural equation model analyses which showed that the direction of the association was from cognitive workload to SRIS, not from SRIS to cognitive workload. Moreover, increases in time pressure (β = 0.16) and problems in teamwork (β = 0.10) were associated with higher levels of SRIS in 2015, whereas job satisfaction increase was associated with lower SRIS (β = − 0.06).

Conclusions

According to our results, physicians’ cognitive workload may have long-lasting negative ramifications in regard to how stressful physicians experience their health information systems to be. Thus, organisations should pay attention to physicians workload if they wish physicians to master all the systems they need to use. It is also important to provide physicians with enough time and collegial support in their system-related problems, and in learning new systems and system updates.

Technological appropriations as workarounds

Purpose

The purpose of this paper is to further adaptive structuration theory (AST) by associating technological appropriations with health information technology workarounds. The author argues that appropriating electronic health record (EHR) technology ironically – in a way other than it is designed to be used – and divergently across an organization results in enhanced perceptions of EHR technology and its implementation.

Design/methodology/approach

Data were collected from 345 healthcare employees in a single healthcare organization that was switching to EHRs from paper records. Two major constructs of AST – unfaithfulness and dissension in appropriation – were operationalized and analyzed using multivariate regressions to test the relationship between the type of appropriation and perceptions of EHR technology’s relative advantage and implementation success.

Findings

Results reveal that both ironic (unfaithful) technological appropriation and dissension in technological appropriation across the organization predicted employees’ perceptions of EHR’s relative advantage and perceptions of EHR implementation success. Furthermore, physicians are the least likely to perceive EHR’s relative advantage or EHR implementation success. These results exemplify that EHR workarounds are taking place and reaffirm AST’s principle that employees evolve technology to better suit their working environments and preferences.

Originality/value

The survey and scales used in this study further demonstrate that there are meaningful statistical measures to accompany the qualitative methods frequently used in the AST literature. In addition, this paper expands AST research by exploring the positive outcomes that follow ironic and divergent technology appropriations.

Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation

BACKGROUND

Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters.

OBJECTIVE

To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence.

DESIGN

Cross-sectional, observational study of video and event recordings of primary care and specialty consultations.

PARTICIPANTS

Thirty-two physicians and 217 patients.

MAIN MEASURES

Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence.

KEY RESULTS

Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures.

CONCLUSIONS

Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.

Importance of Patient-Provider Communication to Adherence in Adolescents with Type 1 Diabetes

Effective communication between pediatric diabetes patients and their providers has the potential to enhance patient satisfaction and health outcomes, as well as improve diabetes-related self-management. In this review, we highlight the importance of communication between patients and providers, focusing on the effect of communication on adherence in the high-risk population of adolescents with type 1 diabetes. We synthesize the literature describing patient-provider communication in pediatric populations and provide implications for practice that focus on the most relevant, modifiable factors for improving self-management in adolescents with type 1 diabetes.