How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care

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.

Verbal information exchange enhances collective performance through increasing group identification

Information exchange is a key factor in the attainment of collective outcomes and the navigation of social life. In the current study, we investigated whether and how information exchange enhanced collective performance by combining behavioral and neuroimaging approaches from the perspective of multiparticipant neuroscience. To evaluate collective performance, we measured the collaborative problem-solving abilities of triads working on a murder mystery case. We first found that verbal information exchange significantly enhanced collective performance compared to nonverbal exchange. Moreover, both group sharing and group discussion positively contributed to this effect, with group discussion being more essential. Importantly, group identification mediated the positive effect of verbal information exchange on collective performance. This mediation was supported by higher interactive frequency and enhanced within-group neural synchronization (GNS) in the dorsolateral prefrontal cortex (DLPFC). Taken together, we provided a multiparticipant theoretical model to explain how verbal information exchange enhanced collective performance. Our findings deepen the insight into the workings of group decision-making.

Evaluation of Eye Gaze Dynamics During Physician-Patient-Computer Interaction in Federally Qualified Health Centers: Systematic Analysis

BACKGROUND

Understanding the communication between physicians and patients can identify areas where they can improve and build stronger relationships. This led to better patient outcomes including increased engagement, enhanced adherence to treatment plan, and a boost in trust.

OBJECTIVE

This study investigates eye gaze directions of physicians, patients, and computers in naturalistic medical encounters at Federally Qualified Health Centers to understand communication patterns given different patients' diverse backgrounds. The aim is to support the building and designing of health information technologies, which will facilitate the improvement of patient outcomes.

METHODS

Data were obtained from 77 videotaped medical encounters in 2014 from 3 Federally Qualified Health Centers in Chicago, Illinois, that included 11 physicians and 77 patients. Self-reported surveys were collected from physicians and patients. A systematic analysis approach was used to thoroughly examine and analyze the data. The dynamics of eye gazes during interactions between physicians, patients, and computers were evaluated using the lag sequential analysis method. The objective of the study was to identify significant behavior patterns from the 6 predefined patterns initiated by both physicians and patients. The association between eye gaze patterns was examined using the Pearson chi-square test and the Yule Q test.

RESULTS

The results of the lag sequential method showed that 3 out of 6 doctor-initiated gaze patterns were followed by patient-response gaze patterns. Moreover, 4 out of 6 patient-initiated patterns were significantly followed by doctor-response gaze patterns. Unlike the findings in previous studies, doctor-initiated eye gaze behavior patterns were not leading patients' eye gaze. Moreover, patient-initiated eye gaze behavior patterns were significant in certain circumstances, particularly when interacting with physicians.

CONCLUSIONS

This study examined several physician-patient-computer interaction patterns in naturalistic settings using lag sequential analysis. The data indicated a significant influence of the patients' gazes on physicians. The findings revealed that physicians demonstrated a higher tendency to engage with patients by reciprocating the patient's eye gaze when the patient looked at them. However, the reverse pattern was not observed, suggesting a lack of reciprocal gaze from patients toward physicians and a tendency to not direct their gaze toward a specific object. Furthermore, patients exhibited a preference for the computer when physicians directed their eye gaze toward it.

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.

Video-based observation research: A systematic review of studies in outpatient health care settings

OBJECTIVE

To examine the use of video-based observation research in outpatient health care encounter research.

METHODS

We conducted a systematic search of MEDLINE, Scopus, Cochrane and other databases from database inception to October 2020 for reports of studies that used video recording to investigate ambulatory patient-clinician interactions. Two authors independently reviewed all studies for eligibility and extracted information related to study setting and purpose, participant recruitment and consent processes, data collection procedures, method of analysis, and participant sample characteristics.

RESULTS

175 articles were included. Most studies (65%) took place in a primary care or family practice setting. Study objectives were overwhelmingly focused on patient-clinician communication (81%). Reporting of key study elements was inconsistent across included studies.

CONCLUSION

Video recording has been used as a research method in outpatient health care in a limited number and scope of clinical contexts and research domains. In addition, reporting of study design, methodological characteristics, and ethical considerations needs improvement.

PRACTICE IMPLICATIONS

Video recording as a method has been relatively underutilized within many clinical and research contexts. This review will serve as a practical resource for health care researchers as they plan and execute future video-based studies.

Professionals as Change Agents or Instruments of Reproduction? Medical Residents’ Reasoning for Not Sharing the Electronic Health Record Screen with Patients

The stability of physicians’ authority over patients despite decades of changes in medicine conflicts with newer institutionalist accounts of professionals as change agents rather than instruments of reproduction. We analyzed whether the cultural scripts that twenty-one residents used to justify their approach to a new change, the electronic health record (EHR), signaled a leveling of the patient-physician hierarchy. Residents are intriguing because their position makes them open to change. Indeed, residents justified using the EHR in ways that level the patient-physician hierarchy, but also offered rationales that sustain it. For the latter, residents described using the EHR to substantiate their expertise, situate themselves as brokers between patients and the technology, and preserve the autonomy of clinicians. Our findings highlight how professionals with little direct experience before a change can selectively apply incumbent scripts to sustain extant structures, while informing newer institutionalist accounts of professionals and the design of EHR systems.

Improving Surgical Excellence: Can Coaching Surgeons Improve Patient Engagement?

INTRODUCTION

Non-technical skills complement technical skills in surgeons to provide best possible care for patients. The former is essential to promote patient engagement. Coaching has been introduced to surgeons as a method to improve non-technical skills. We aimed to investigate the impact of coaching for surgeons on patient engagement in the outpatient consultation setting.

METHODS

This was a single-centre cohort study conducted in South Australia. Consultant surgeons, suitable coaches, and patients were recruited. Coaches underwent further training by a human factors psychologist on being an effective coach. Outpatient consultations were recorded in an audio-visual format and analysed by investigators. Patient talking time, mutual eye gaze between surgeon and patient, and number of questions asked by the patient were measured as outcomes for patient engagement.

RESULTS

182 patients, 12 surgeons, and 4 coaches participated in the study. Each surgeon underwent 3 coaching sessions, 5 to 6 weeks apart. There were 62 pre-coaching patient consultations, 63 patient consultations after one coaching session, and 57 patient consultations after two coaching sessions. The mean talking time of the patient increased significantly after a single coaching session (P < 0.05) without making significant difference to the total consultation time (p = 0.76). Coaching sessions did not have a significant effect on mutual eye gaze or mean number of questions asked by the patient.

CONCLUSION

Coaching of non-technical skills for surgeons appears to objectively improve patient engagement during the outpatient consultation. This would suggest that tailored coaching programs should be developed and delivered to surgeons to improve care delivery.

Physician gaze shifts in patient-physician interactions: functions, accounts and responses

OBJECTIVES

Physician gaze towards patients is fundamental for medical consultations. Physicians' use of Electronic Health Records (EHR) affects their gaze towards patients, and may negatively influence this interaction. We aimed to study conversation patterns during gaze shifts of physicians from the patient towards the EHR.

METHODS

Outpatient consultations (N = 8) were eye-tracked. Interactions around physician gaze shifts towards the computer were transcribed.

RESULTS

We found that physician gaze shifts have different interactional functions, e.g., introducing a topic switch or entering data into the EHR. Furthermore, physicians differ in how they account for their gaze shifts, i.e., both implicitly and explicitly. Third, patients vary in treating the gaze shift as an indication to continue their turn or not.

CONCLUSIONS

Our results suggest that physician gaze shifts vary in function, in how physicians account for them, and in how they influence the conversation. Future research should take into account distinctions when relating gaze to patient outcomes.

PRACTICE IMPLICATIONS

Physicians may be aware of the interactional context of their gaze behaviour. Patients respond differently to various types of gaze shifts. How physicians handle gaze shifts can therefore have different consequences for the interaction.

The Influence of Face Gaze by Physicians on Patient Trust: an Observational Study

BACKGROUND

Physicians' gaze towards their patients may affect patients' trust in them. This is especially relevant considering recent developments, including the increasing use of Electronic Health Records, which affect physicians' gaze behavior. Moreover, socially anxious patients' trust in particular may be affected by the gaze of the physician.

OBJECTIVE

We aimed to evaluate if physicians' gaze towards the face of their patient influenced patient trust and to assess if this relation was stronger for socially anxious patients. We furthermore explored the relation between physicians' gaze and patients' perception of physician empathy and patients' distress.

DESIGN

This was an observational study using eye-tracking glasses and questionnaires.

PARTICIPANTS

One hundred patients and 16 residents, who had not met before, participated at an internal medicine out-patient clinic.

MEASURES

Physicians wore eye-tracking glasses during medical consultations to assess their gaze towards patients' faces. Questionnaires were used to assess patient outcomes. Multilevel analyses were conducted to assess the relation between physicians' relative face gaze time and trust, while correcting for patient background characteristics, and including social anxiety as a moderator. Analyses were then repeated with perceived empathy and distress as outcomes.

RESULTS

More face gaze towards patients was associated with lower trust, after correction for gender, age, education level, presence of caregivers, and social anxiety (β=-0.17, P=0.048). There was no moderation effect of social anxiety nor a relation between face gaze and perceived empathy or distress.

CONCLUSIONS

These results challenge the notion that more physician gaze is by definition beneficial for the physician-patient relationship. For example, the extent of conversation about emotional issues might explain our findings, where more emotional talk could be associated with more intense gazing and feelings of discomfort in the patient. To better understand the relation between physician gaze and patient outcomes, future studies should assess bidirectional face gaze during consultations.

Health Literacy in Patients’ Clinical Records of Hospital Settings: A Systematic Review

Introduction

Health literacy (HL) can be defined as the individual's ability to understand and process health information. A low level of HL can be viewed as a stronger predictor of a person's health status than age, education level, and race. Although HL is an important determinant of health, it is often underestimated. This systematic review investigates the evidence on HL assessment in hospital settings.

Methods

PubMed Medline, CINAHL, Scopus, Web of Science and Educational Resources Information Centre databases were searched, with the date last searched being 16 March 2020. The PRISMA guidelines were applied, and the protocol of the study was registered with PROSPERO (CRD42021236029). The quality of the included studies was appraised using the STrengthening the Reporting of OBservational Studies in Epidemiology (STROBE) guidelines for cross-sectional studies.

Results

Five studies reported HL assessments in hospital patients’ clinical records. Four main strategies were used to implement HL routine assessment in hospitals: multidisciplinary teams, stakeholders, training, and monitoring. Different performance measures were used to monitor the feasibility of incorporating HL assessment into electronic health records (EHRs).

Conclusion

This review examined how inpatients’ HL is recorded in hospital settings. HL is poorly measured in a hospital setting. These results guide hospital leadership in involving nurses in HL assessment implementation in hospitals and support nurses in creating a specific performance measure dashboard to monitor effective HL assessments in hospitals.

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.

Engaging cultural humility diffractively

BACKGROUND

Conventional models of cultural humility - even those extending analysis beyond the dyad of healthcare provider-patient to include concentric social influences such as families, communities and institutions that make clinical relationships possible - aren't conceptually or methodologically calibrated to accommodate shifts occurring in contemporary biomedical cultures. More complex methodological frameworks are required that are attuned to how advances in biomedical, communications and information technologies are increasingly transforming the very cultural and material conditions of health care and its delivery structures, and thus how power manifests in clinical encounters.

METHODS

In this paper, we offer a two-pronged intervention in the cultural humility literature. At a first level of analysis, we suggest the need to broaden understandings of culture and associated workings of power to accommodate the effects of biomedicine's technologising turn. A second level of intervention invites experimentation to broaden the availability of methodological tools to analyse and assess the multidimensionality of technologies and their agentic effects in healthcare encounters.

RESULTS

Drawing from new materialism theories, practices of care are approached "diffractively" as contingent and dynamic material-discursive events. Our neo-materialist framework for cultural humility expands analytical sight-lines beyond hierarchical relationships and dichotomies privileging humans (practitioner and/or patient) as sole actants in the clinical exchange. Attended to are the ongoing dynamics of practices entangling big-data driven knowledges and interventions, pharmacological technologies and material instruments and devices, diseases, and the bodies/subjectivities of health care providers and patients. We investigate the implications for clinical assessment if a cultural humility framework is methodologically attuned to the clinical encounter as a discontinuous, discursive-material process producing multiple, contextually emergent data moments and objects for analysis.

CONCLUSION

Engaging evaluative inquiry diffractively allows for a different ethical practice of care, one that attends to the forms of patient and health provider accountability and responsibility emerging in the clinical encounter.

Automatic Classification of Screen Gaze and Dialogue in Doctor-Patient-Computer Interactions: Computational Ethnography Algorithm Development and Validation

Background

The study of doctor-patient-computer interactions is a key research area for examining doctor-patient relationships; however, studying these interactions is costly and obtrusive as researchers usually set up complex mechanisms or intrude on consultations to collect, then manually analyze the data.

Objective

We aimed to facilitate human-computer and human-human interaction research in clinics by providing a computational ethnography tool: an unobtrusive automatic classifier of screen gaze and dialogue combinations in doctor-patient-computer interactions.

Methods

The classifier’s input is video taken by doctors using their computers' internal camera and microphone. By estimating the key points of the doctor's face and the presence of voice activity, we estimate the type of interaction that is taking place. The classification output of each video segment is 1 of 4 interaction classes: (1) screen gaze and dialogue, wherein the doctor is gazing at the computer screen while conversing with the patient; (2) dialogue, wherein the doctor is gazing away from the computer screen while conversing with the patient; (3) screen gaze, wherein the doctor is gazing at the computer screen without conversing with the patient; and (4) other, wherein no screen gaze or dialogue are detected. We evaluated the classifier using 30 minutes of video provided by 5 doctors simulating consultations in their clinics both in semi- and fully inclusive layouts.

Results

The classifier achieved an overall accuracy of 0.83, a performance similar to that of a human coder. Similar to the human coder, the classifier was more accurate in fully inclusive layouts than in semi-inclusive layouts.

Conclusions

The proposed classifier can be used by researchers, care providers, designers, medical educators, and others who are interested in exploring and answering questions related to screen gaze and dialogue in doctor-patient-computer interactions.

The Measurement of Eye Contact in Human Interactions: A Scoping Review

Eye contact is a fundamental aspect of nonverbal communication and therefore important for understanding human interaction. Eye contact has been the subject of research in many disciplines, including communication sciences, social psychology, and psychiatry, and a variety of techniques have been used to measure it. The choice of measurement method has consequences for research outcomes and their interpretation. To ensure that research findings align with study aims and populations, it is essential that methodological choices are well substantiated. Therefore, to enhance the effective examination of eye contact, we performed a literature review of the methods used to study eye contact. We searched Medline, PsycINFO and Web of Science for empirical peer-reviewed articles published in English that described quantitative studies on human eye contact and included a methodological description. The identified studies (N = 109) used two approaches to assess eye contact: direct, i.e., assessing eye contact while it is occurring, and indirect, i.e., assessing eye contact retrospectively (e.g., from video recordings). Within these categories, eight specific techniques were distinguished. Variation was found regarding the reciprocity of eye contact between two individuals, the involvement of an assessor and the behavior of participants while being studied. Measures not involving the interactors in assessment of eye contact and have a higher spatial and temporal resolution, such as eye tracking, have gained popularity. Our results show wide methodological diversity regarding the measurement of eye contact. Although studies often define eye contact as gaze towards an exact location, this may not do justice to the subjective character of eye contact. The various methodologies have hardly ever been compared, limiting the ability to compare findings between studies. Future studies should take notice of the controversy surrounding eye contact measures.

Exploring the Effects of Clinical Exam Room Design on Communication, Technology Interaction, and Satisfaction

OBJECTIVE

This article evaluates the effects of technology integration and design features in clinical exam rooms on examination experiences, communication, and satisfaction.

BACKGROUND

Exam room features can affect the delivery of patient-centered care and enhance the level of communication, which has been shown to directly impact clinical outcomes. Although there has been an increasing body of literature examining design and patient-centered care, little research has evaluated the extent to which information sharing and electronic health record (EHR) interaction are impacted.

METHOD

The research randomly allocated 22 patients, 28 caregivers, and 59 clinicians to simulated clinical encounters in four exam room mock-ups with semi-inclusive, exclusive, and inclusive layouts (128 sessions in 32 scenarios). Video recordings of the simulations were coded for clinician gazing, talking, and EHR-interaction behaviors. Participants also completed surveys and answered open-ended questions after experiencing each scenario (N = 362).

RESULTS

Semi-inclusive rooms with a triangular arrangement of consultation table, sharable screens, exam table, and caregiver chair were highly preferred as they supported conversation, gazing, and information sharing. The inclusive layout had higher durations of EHR interactions and enhanced viewing and sharing of EHR information. However, this layout was criticized for the lack of clinician-shared information. The exclusive layouts impeded information sharing, eye contact, and constrained simultaneous data entry and eye contact for clinicians. The distance and orientation between chair, exam table, curtain, and door were important for protecting patient and family comfort and privacy.

CONCLUSION

Characteristics and configurations of design qualities and strategies have a key role on examination experiences, communication, and satisfaction.

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.

Patient Acceptance of Remote Scribing Powered by Google Glass in Outpatient Dermatology: Cross-Sectional Study

BACKGROUND

The ubiquitous use of electronic health records (EHRs) during medical office visits using a computer monitor and keyboard can be distracting and can disrupt patient-health care provider (HCP) nonverbal eye contact cues, which are integral to effective communication. Provider use of a remote medical scribe with face-mounted technology (FMT), such as Google Glass, may preserve patient-HCP communication dynamics in health care settings by allowing providers to maintain direct eye contact with their patients while still having access to the patient's relevant EHR information. The medical scribe is able to chart patient encounters in real-time working in an offsite location, document the visit directly into EHR, and free HCP to focus only on the patient.

OBJECTIVE

The purpose of this study was to examine patient perceptions of their interactions with an HCP who used FMT with a remote medical scribe during office visits. This includes an examination of any association between patient privacy and trust in their HCP when FMT is used in the medical office setting.

METHODS

For this descriptive, cross-sectional study, a convenience sample of patients was recruited from an outpatient dermatology clinic in Northern California. Participants provided demographic data and completed a 12-item questionnaire to assess their familiarity, comfort, privacy, and perceptions following routine office visits with an HCP where FMT was used to document the clinical encounter. Data were analyzed using appropriate descriptive and inferential statistics.

RESULTS

Over half of the 170 study participants were female (102/170, 59.4%), 60.0% were Caucasian (102/170), 24.1% were Asian (41/170), and 88.8% were college-educated (151/170). Age ranged between 18 and 90 years (mean 50.5, SD 17.4). The majority of participants (118/170, 69.4%) were familiar with FMT, not concerned with privacy issues (132/170, 77.6%), and stated that the use of FMT did not affect their trust in their HCP (139/170, 81.8%). Moreover, participants comfortable with the use of FMT were less likely to be concerned about privacy (P<.001) and participants who trusted their HCP were less likely to be concerned about their HCP using Google Glass (P<.009). Almost one-third of them self-identified as early technology adopters (49/170, 28.8%) and 87% (148/170) preferred their HCP using FMT if it delivered better care.

CONCLUSIONS

Our study findings support the patient acceptance of Google Glass use for outpatient dermatology visits. Future research should explore the use of FMT in other areas of health care and strive to include a socioeconomically diverse patient population in study samples.

Laboratory testing in primary care: A systematic review of health IT impacts

INTRODUCTION

Laboratory testing in primary care is a fundamental process that supports patient management and care. Any breakdown in the process may alter clinical information gathering and decision-making activities and can lead to medical errors and potential adverse outcomes for patients. Various information technologies are being used in primary care with the goal to support the process, maximize patient benefits and reduce medical errors. However, the overall impact of health information technologies on laboratory testing processes has not been evaluated.

OBJECTIVES

To synthesize the positive and negative impacts resulting from the use of health information technology in each phase of the laboratory 'total testing process' in primary care.

METHODS

We conducted a systematic review. Databases including Medline, PubMed, CINAHL, Web of Science and Google Scholar were searched. Studies eligible for inclusion reported empirical data on: 1) the use of a specific IT system, 2) the impacts of the systems to support the laboratory testing process, and were conducted in 3) primary care settings (including ambulatory care and primary care offices). Our final sample consisted of 22 empirical studies which were mapped to a framework that outlines the phases of the laboratory total testing process, focusing on phases where medical errors may occur.

RESULTS

Health information technology systems support several phases of the laboratory testing process, from ordering the test to following-up with patients. This is a growing field of research with most studies focusing on the use of information technology during the final phases of the laboratory total testing process. The findings were largely positive. Positive impacts included easier access to test results by primary care providers, reduced turnaround times, and increased prescribed tests based on best practice guidelines. Negative impacts were reported in several studies: paper-based processes employed in parallel to the electronic process increased the potential for medical errors due to clinicians' cognitive overload; systems deemed not reliable or user-friendly hampered clinicians' performance; and organizational issues arose when results tracking relied on the prescribers' memory.

DISCUSSION

The potential of health information technology lies not only in the exchange of health information, but also in knowledge sharing among clinicians. This review has underscored the important role played by cognitive factors, which are critical in the clinician's decision-making, the selection of the most appropriate tests, correct interpretation of the results and efficient interventions.

CONCLUSIONS

By providing the right information, at the right time to the right clinician, many IT solutions adequately support the laboratory testing process and help primary care clinicians make better decisions. However, several technological and organizational barriers require more attention to fully support the highly fragmented and error-prone process of laboratory testing.

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.

Promoting patient participation in healthcare interactions through communication skills training: A systematic review

OBJECTIVE

To present literature on training patients in the use of effective communication skills.

METHODS

Systematic searches were conducted in six databases. References were screened for inclusion through several phases. Extracted data included intervention study design, sample characteristics, content and structure of training programs, outcomes assessed, and findings reported.

RESULTS

A total of 32 unique intervention studies were included. Most targeted primary care or cancer patients and used a randomized controlled study design. Interventions used a variety of training formats and modes of delivering educational material. Reported findings suggest that communication training is an effective approach to increase patients' total level of active participation in healthcare interactions and that some communication behaviors may be more amenable to training (e.g., expressing concerns). Trained patients do not have longer visits and tend to receive more information from their providers. Most studies have found no relationship between communication training and improved health, psychosocial wellbeing, or treatment-related outcomes.

CONCLUSIONS

Findings reinforce the importance and potential benefits of patient communication training.

PRACTICE IMPLICATIONS

Additional research is warranted to determine the most efficacious training programs with the strongest potential for dissemination.

Learning to use electronic health records: can we stay patient-centered? A pre-post intervention study with family medicine residents

Background

The Electronic Health Record (EHR) is now widely used in clinical encounters. Because its use can negatively impact the physician-patient relationship, several recommendations on the “patient-centered” use of the EHR have been published. However, the impact of training to improve EHR use during clinical encounters is not well known. The aim of this study was to assess the impact of training on residents’ EHR-related communication skills and explore whether they varied according to the content of the consultation.

Methods

We conducted a pre-post intervention study at the Primary Care Division of the Geneva University Hospitals, Switzerland. Residents were invited to attend a 3-month training course that included 2 large group sessions and 2–4 individualized coaching sessions based on videotaped encounters. Outcomes were: 1) residents’ perceptions regarding the use of EHR, measured through a self-administered questionnaire and 2) objective use of the EHR during the first 10 min of patient encounters. Changes in practice were measured pre and post intervention using the Roter interaction analysis system (RIAS) and EHR specific items.

Results

Seventeen out of 27 residents took part in the study. Participants used EHR in about 30% of consultations. After training, they were less likely to consider EHR to be a barrier to the physician-patient relationship, and felt more comfortable using the EHR. After training, participants increased the use of signposting when using the EHR (pre: 0.77, SD 1.69; post: 1.80, SD3.35; p 0.035) and decreased EHR use when psychosocial issues appeared (pre: 24.5% and post: 9.76%, p < 0.001).

Conclusions

This study suggests that training can improve residents’ EHR-related communication skills, especially in situations where patients bring up sensitive psychosocial issues. Future research should focus on patients’ perceptions of the relevance and usefulness of such skills.

Electronic health record use among cancer patients: Insights from the Health Information National Trends Survey

Over 90% of US hospitals provide patients with access to e-copy of their health records, but the utilization of electronic health records by the US consumers remains low. Guided by the comprehensive information-seeking model, this study used data from the National Cancer Institute’s Health Information National Trends Survey 4 (Cycle 4) and examined the factors that explain the level of electronic health record use by cancer patients. Consistent with the model, individual information-seeking factors and perceptions of security and utility were associated with the frequency of electronic health record access. Specifically, higher income, prior online information seeking, interest in accessing health information online, and normative beliefs were predictive of electronic health record access. Conversely, poorer general health status and lack of health care provider encouragement to use electronic health records were associated with lower utilization rates. The current findings provide theory-based evidence that contributes to the understanding of the explanatory factors of electronic health record use and suggest future directions for research and practice.

Physician activity during outpatient visits and subjective workload

We describe methods for capturing and analyzing EHR use and clinical workflow of physicians during outpatient encounters and relating activity to physicians' self-reported workload. We collected temporally-resolved activity data including audio, video, EHR activity, and eye-gaze along with post-visit assessments of workload. These data are then analyzed through a combination of manual content analysis and computational techniques to temporally align streams, providing a range of process measures of EHR usage, clinical workflow, and physician-patient communication. Data was collected from primary care and specialty clinics at the Veterans Administration San Diego Healthcare System and UCSD Health, who use Electronic Health Record (EHR) platforms, CPRS and Epic, respectively. Grouping visit activity by physician, site, specialty, and patient status enables rank-ordering activity factors by their correlation to physicians' subjective work-load as captured by NASA Task Load Index survey. We developed a coding scheme that enabled us to compare timing studies between CPRS and Epic and extract patient and visit complexity profiles. We identified similar patterns of EHR use and navigation at the 2 sites despite differences in functions, user interfaces and consequent coded representations. Both sites displayed similar proportions of EHR function use and navigation, and distribution of visit length, proportion of time physicians attended to EHRs (gaze), and subjective work-load as measured by the task load survey. We found that visit activity was highly variable across individual physicians, and the observed activity metrics ranged widely as correlates to subjective workload. We discuss implications of our study for methodology, clinical workflow and EHR redesign.

Patient-centered communication in the era of electronic health records: What does the evidence say?

OBJECTIVE

Patient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known.

METHOD

A comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis.

RESULTS

Results indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management.

CONCLUSION

More rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care.

PRACTICE IMPLICATIONS

Training alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians' and patients' abilities to effectively communicate.

Providers' perceived facilitators and barriers to EHR screen sharing in outpatient settings

As health care becomes more patient-centered, some scholars and policy makers propose shifting use of electronic health records (EHRs) to a tool to educate and engage patients. Physician-patient screen sharing may provide a way to achieve this. However, the barriers and facilitators that physicians experience with screen sharing are unknown. In this study, we explored providers' facilitators and barriers to using EHR as a primary care communication tool. We conducted an interview study with 14 primary care providers to discover their views on screen sharing. We used the work system model as a conceptual framework to classify emergent factors. Content analysis yielded 28 facilitators and 56 barriers to patient-centered screen sharing in primary care. We linked these to work system elements. We outline suggestions for more patient-centered EHR systems, and for provider communication training. Finally, we consider the role screen sharing might play in the development of physician-patient situation awareness.

Capturing the patients' voices: Planning for patient-centered electronic health record use

OBJECTIVES

To understand (1) the perceptions of patients regarding use of EHR during clinic visits, (2) the impact of the presence of EHR on patient interactions with physicians, and (3) the ways in which EHR usage might increase patient engagement.

METHODS

We conducted semi-structured interviews of a convenience sample of patients of internal medicine resident doctors from three primary care clinics. Interviews were audio-recorded and transcribed verbatim. We used thematic analysis to identify themes from the transcripts. Informed consent was obtained from each participant.

RESULTS

We interviewed 32 patients; 37.5% male. Our analysis revealed three primary themes: (1) the views and beliefs of patients on the use of EHR in clinics, (2) patients' perception of the communication skills of residents, and (3) patients' perceptions about information sharing, patient engagement, and health education related to the EHR. An invitation to patients to view the screen as the physician interprets its content increases patient satisfaction and understanding. Residents' possessed skills in communication is not impeded when using EHR.

CONCLUSION

Patients generally express a positive or neutral perception of EHR use during clinic visits. Using information voiced by patients, we can teach health providers EHR strategies that are likely to engage patients in the visit and engender their trust.

Electronic Health Records: Then, Now, and in the Future

OBJECTIVES

Describe the state of Electronic Health Records (EHRs) in 1992 and their evolution by 2015 and where EHRs are expected to be in 25 years. Further to discuss the expectations for EHRs in 1992 and explore which of them were realized and what events accelerated or disrupted/derailed how EHRs evolved.

METHODS

Literature search based on "Electronic Health Record", "Medical Record", and "Medical Chart" using Medline, Google, Wikipedia Medical, and Cochrane Libraries resulted in an initial review of 2,356 abstracts and other information in papers and books. Additional papers and books were identified through the review of references cited in the initial review.

RESULTS

By 1992, hardware had become more affordable, powerful, and compact and the use of personal computers, local area networks, and the Internet provided faster and easier access to medical information. EHRs were initially developed and used at academic medical facilities but since most have been replaced by large vendor EHRs. While EHR use has increased and clinicians are being prepared to practice in an EHR-mediated world, technical issues have been overshadowed by procedural, professional, social, political, and especially ethical issues as well as the need for compliance with standards and information security. There have been enormous advancements that have taken place, but many of the early expectations for EHRs have not been realized and current EHRs still do not meet the needs of today's rapidly changing healthcare environment.

CONCLUSION

The current use of EHRs initiated by new technology would have been hard to foresee. Current and new EHR technology will help to provide international standards for interoperable applications that use health, social, economic, behavioral, and environmental data to communicate, interpret, and act intelligently upon complex healthcare information to foster precision medicine and a learning health system.

Reflections on Physician-Patient Interactions in the EHR Era

Physician-patient communication is becoming increasingly complicated with the growing use of electronic health records (EHRs). While the EHR has shown benefits in some aspects of medical care, these improvements are often at the expense of patient-centered communication. Below are some reflections on this topic, as well as techniques to improve the clinician-patient interaction in the EHR era.

All eyes on the patient: the influence of oncologists' nonverbal communication on breast cancer patients' trust

Trust in the oncologist is crucial for breast cancer patients. It reduces worry, enhances decision making, and stimulates adherence. Optimal nonverbal communication by the oncologist, particularly eye contact, body posture, and smiling, presumably benefits patients’ trust. We were the first to experimentally examine (1) how the oncologist’s nonverbal behavior influences trust, and (2) individual differences in breast cancer patients’ trust. Analogue patients (APs) viewed one out of eight versions of a video vignette displaying a consultation about chemotherapy treatment. All eight versions varied only in the oncologist’s amount of eye contact (consistent vs. inconsistent), body posture (forward leaning vs. varying), and smiling (occasional smiling vs. no smiling). Primary outcome was trust in the observed oncologist (Trust in Oncologist Scale). 214 APs participated. Consistent eye contact led to stronger trust (β = −.13, p = .04). This effect was largely explained by lower educated patients, for whom the effect of consistent eye contact was stronger than for higher educated patients (β = .18, p = .01). A forward leaning body posture did not influence trust, nor did smiling. However, if the oncologist smiled more, he was perceived as more friendly (r_s = .31, p < .001) and caring (r_s = .18, p = .01). Older (β = .17, p = .01) and lower educated APs (β = −.25, p < .001) were more trusting. Trust was weaker for more avoidantly attached APs (β = −.16, p = .03). We experimentally demonstrated the importance of maintaining consistent eye contact for breast cancer patients’ trust, especially among lower educated patients. These findings need to be translated into training for oncologists in how to optimize their nonverbal communication with breast cancer patients while simultaneously managing increased time pressure and computer use during the consultation.