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Golembiewski EH, Espinoza Suarez NR, Maraboto Escarria AP, Yang AX, Kunneman M, Hassett LC, Montori VM. Video-based observation research: A systematic review of studies in outpatient health care settings. PATIENT EDUCATION AND COUNSELING 2023; 106:42-67. [PMID: 36207219 DOI: 10.1016/j.pec.2022.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 09/13/2022] [Accepted: 09/30/2022] [Indexed: 06/16/2023]
Abstract
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.
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Affiliation(s)
| | - Nataly R Espinoza Suarez
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Department of Family Medicine and Emergency Medicine Laval University Quebec, Canada.
| | - Andrea P Maraboto Escarria
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Department of Obstetrics and Gynecology Hospital Angeles Lomas Mexico City, Mexico.
| | - Andrew X Yang
- Mayo Clinic Alix School of Medicine Rochester, MN, USA.
| | - Marleen Kunneman
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Medical Decision Making, Department of Biomedical Data Sciences Leiden University Medical Center Leiden, the Netherlands.
| | - Leslie C Hassett
- Division of Endocrinology, Diabetes, Metabolism and Nutrition Department of Medicine Mayo Clinic, Rochester, MN, USA.
| | - Victor M Montori
- Knowledge and Evaluation Research (KER) Unit Mayo Clinic Rochester, MN, USA; Mayo Clinic Libraries Mayo Clinic, Rochester, MN, USA.
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Card AJ. The biopsychosociotechnical model: a systems-based framework for human-centered health improvement. Health Syst (Basingstoke) 2022; 12:387-407. [PMID: 38235298 PMCID: PMC10791103 DOI: 10.1080/20476965.2022.2029584] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 01/06/2022] [Indexed: 12/23/2022] Open
Abstract
The biopsychosocial model is among the most influential frameworks for human-centered health improvement but has faced significant criticism- both conceptual and pragmatic. This paper extends and fundamentally re-structures the biopsychosocial model by combining it with sociotechnical systems theory. The resulting biopsychosociotechnical model addresses key critiques of the biopsychosocial model, providing a more "practical theory" for human-centered health improvement. It depicts the determinants of health as complex adaptive system of systems; includes the the artificial world (technology); and provides a roadmap for systems improvement by: differentiating between "health status" and "health and needs assessment", [promoting problem framing]; explaining health as an emergent property of the biopsychosociotechnical context [imposing a systems orientation]; focusing on "interventions" vs. "treatments" to modify the biopsychosociotechnical determinants of health, [expanding the solution space]; calling for a participatory design process [supporting systems awareness and goal-orientation]; and including intervention management to support the full lifecycle of health improvement.
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Affiliation(s)
- Alan J. Card
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, CA, U.S.A
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Abstract
Burnout is a response to sustained job stressors manifesting as a classic triad of emotional exhaustion, depersonalization, and a sense of reduced accomplishment. With 42% of physicians demonstrating some symptoms of burnout, this has already reached epidemic proportions. The COVID-19 pandemic has only worsened this phenomenon.
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Affiliation(s)
- Aarti Chandawarkar
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, OH, United States; Section of Primary Care Pediatrics Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States; Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States.
| | - Juan D Chaparro
- Division of Clinical Informatics, Nationwide Children's Hospital, Columbus, OH, United States; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, United States; Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States
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Lanier C, Dominicé Dao M, Baer D, Haller DM, Sommer J, Junod Perron N. How Do Patients Want Us to Use the Computer During Medical Encounters?-A Discrete Choice Experiment Study. J Gen Intern Med 2021; 36:1875-1882. [PMID: 33904040 PMCID: PMC8298679 DOI: 10.1007/s11606-021-06753-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 03/22/2021] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Cédric Lanier
- Primary Care unit (UIGP), BFM local 4091, Centre Médical Universitaire de Genève, University of Geneva, Geneva, Switzerland.
| | - Melissa Dominicé Dao
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Dagmar M Haller
- Primary Care unit (UIGP), BFM local 4091, Centre Médical Universitaire de Genève, University of Geneva, Geneva, Switzerland
| | - Johanna Sommer
- Primary Care unit (UIGP), BFM local 4091, Centre Médical Universitaire de Genève, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod Perron
- Unit of Development and Research in Medical Education (UDREM), University of Geneva, Geneva, Switzerland
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Helou S, Abou-Khalil V, Iacobucci R, El Helou E, Kiyono K. Automatic Classification of Screen Gaze and Dialogue in Doctor-Patient-Computer Interactions: Computational Ethnography Algorithm Development and Validation. J Med Internet Res 2021; 23:e25218. [PMID: 33970117 PMCID: PMC8145082 DOI: 10.2196/25218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/07/2021] [Accepted: 04/14/2021] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Samar Helou
- Global Center for Medical Engineering and Informatics, Osaka University, Osaka, Japan
| | | | - Riccardo Iacobucci
- Department of Urban Management, Graduate School of Engineering, Kyoto University, Kyoto, Japan
| | - Elie El Helou
- Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Ken Kiyono
- Graduate School of Engineering Science, Osaka University, Osaka, Japan
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Asan O, Choudhury A, Somai MM, Crotty BH. Augmenting patient safety through participation by design - An assessment of dual monitors for patients in the outpatient clinic. Int J Med Inform 2020; 146:104345. [PMID: 33260089 DOI: 10.1016/j.ijmedinf.2020.104345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/01/2020] [Accepted: 11/15/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patients and physicians engaging together in the electronic health record (EHR) during clinical visits may provide opportunities to both improve patient understanding and reduce medical errors. OBJECTIVE To assess the potential impact of a patient EHR display intervention on patient quality and safety. We hypothesized that if patients had a dedicated display with an explicit invitation to follow clinicians in the EHR that this would identify several opportunities to engage patients in their care quality and safety. MATERIAL AND METHODS Physician-patient outpatient encounters (24 patients and 8 physicians) were videotaped. Encounters took place in a hospital-based general internal medicine outpatient clinic where physicians and patients had their respective EHR monitors. Following the visits, each patient and physician was interviewed for 30 min to understand their perception of the mirrored-screen setting. RESULTS The following 7 themes were identified (a) curiosity, (b) opportunity to ask questions, (c) error identification, (d) control over medications, (e) awareness, (f) shared understanding & decision-making, (g) data privacy. These themes collectively comprised a conceptual model for how patient engagement in electronic health record use, through a dedicated second screen or an explicitly shared screen, relates to safety and quality opportunities. Therefore, the double EHR screen provides an explicit invitation for patients to join the process to influence safety. CONCLUSION Desired outcomes include real-time error identification and better-shared understanding and decision-making, leading to better downstream follow-through with care plans.
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Affiliation(s)
- Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, 07047, USA.
| | - Avishek Choudhury
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, 07047, USA.
| | - Melek M Somai
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, USA.
| | - Bradley H Crotty
- Collaborative for Healthcare Delivery Science, Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, USA.
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Choudhury A, Crotty B, Asan O. Comparing the Impact of Double and Single Screen Electronic Health Records on Doctor-Patient Non-Verbal Communication. IISE Trans Occup Ergon Hum Factors 2020. [DOI: 10.1080/24725838.2020.1742251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Avishek Choudhury
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
| | - Bradley Crotty
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Onur Asan
- School of Systems and Enterprises, Stevens Institute of Technology, Hoboken, NJ, USA
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Sieck CJ, Pearl N, Bright TJ, Yen PY. A qualitative study of physician perspectives on adaptation to electronic health records. BMC Med Inform Decis Mak 2020; 20:25. [PMID: 32039728 PMCID: PMC7008538 DOI: 10.1186/s12911-020-1030-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 01/20/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Cynthia J Sieck
- Department of Family Medicine, The Ohio State University College of Medicine, Columbus, OH, 43201, USA. .,The Center for the Advancement of Team Science, Analytics, and Systems Thinking, Columbus, OH, USA.
| | - Nicole Pearl
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Po-Yin Yen
- Institute for Informatics, Washington University School of Medicine, St. Louis, MO, USA.,Goldfarb School of Nursing, Barnes-Jewish College, St. Louis, MO, USA
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Shahin W, Kennedy GA, Stupans I. The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review. Patient Prefer Adherence 2019; 13:1019-1035. [PMID: 31303749 PMCID: PMC6611718 DOI: 10.2147/ppa.s212046] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 06/04/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Patients' adherence to therapeutic regimes may be influenced by subjective beliefs about chronic conditions. One of the challenges for health professionals in enhancing adherence is taking patients' understanding into account when giving health advice and/or providing medical treatment. PURPOSE This review aimed to evaluate the consequent effects of personal and cultural beliefs on medication adherence, in patients with chronic conditions such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease and asthma. METHOD A systematic review methodology was used. PubMed, CINAHL, EMBASE and PsychINFO, databases were searched for relevant articles. The main terms analyzed were illness perceptions, health beliefs, cultural beliefs, chronic conditions and medication adherence. RESULTS From 2,646 articles, 127 were retained for further assessment, and finally 25 met the inclusion criteria. A cross-sectional questionnaire survey research design was conducted in all included articles. Of these most (n=22) targeted hypertension or diabetes mellitus. A number of personal and cultural based factors were identified as being associated with adherence to medication regimes - 40% of articles (n=10) examined perception of illness, 20% (n=5) health literacy, 16% (n=4) cultural beliefs, 12% (n=3) self-efficacy, 16% (n=4) spiritual and religious beliefs, as well as 20% (n=5) illness knowledge. Statistically significant associations between medication adherence and these personal and cultural factors were found in 80% (n=20) of the included studies. However, the direction of associations varied between studies depending on the factor that was examined. CONCLUSION This review has evaluated the impact of personal and cultural factors on medication adherence and highlighted the gaps in literature regarding adherence. Further research is required to fully identify the associations between religious beliefs, control beliefs and illness knowledge and medication adherence.
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Affiliation(s)
- Wejdan Shahin
- School of Health & Biomedical Sciences, RMIT University, Bundoora, Victoria3083, Australia
| | - Gerard A Kennedy
- School of Health & Biomedical Sciences, RMIT University, Bundoora, Victoria3083, Australia
| | - Ieva Stupans
- School of Health & Biomedical Sciences, RMIT University, Bundoora, Victoria3083, Australia
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Asan O, Tyszka J, Crotty B. The electronic health record as a patient engagement tool: mirroring clinicians' screen to create a shared mental model. JAMIA Open 2018; 1:42-48. [PMID: 31984318 PMCID: PMC6952027 DOI: 10.1093/jamiaopen/ooy006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 02/13/2018] [Accepted: 03/14/2018] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Onur Asan
- Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeanne Tyszka
- Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bradley Crotty
- Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Shaarani I, Taleb R, Antoun J. Effect of computer use on physician-patient communication using a validated instrument: Patient perspective. Int J Med Inform 2017; 108:152-157. [PMID: 29132621 DOI: 10.1016/j.ijmedinf.2017.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 10/03/2017] [Accepted: 10/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Physician-patient communication is essential in the physician-patient relationship. Concerns were raised about the impact of the computer on this relationship with the increase in use of electronic medical records (EMR). Most studies addressed the physician's perspective and only few explored the patient's perspective. AIM This study aims to assess the patient's perspective of the effect of the physician's computer use during the clinical encounter on the interpersonal and communication skills of the physician using a validated communication assessment tool (CAT). DESIGN AND SETTINGS This is a cross-sectional survey of three hundred eighty-two patients who visited the family medicine clinics (FMC) at the American University of Beirut Medical Center (AUBMC). MATERIAL AND METHODS At the end of the visit with the physician, the patients were approached by the clinical assistant to fill a paper-based questionnaire privately in the waiting room to measure communication skills of physicians using CAT. RESULTS Nearly two-thirds of the patients (62%) did not consider that using the computer by their physician during the visit would negatively affect the patient-doctor communication. Patients rated their physician with a higher communication score when there was an ongoing relationship between the physician and the patient. Higher communication scores were reported for extensive use of the computer by the physician to check results (p<0.001), to retrieve patient record information (p<0.001) and to educate patients (p<0.001) as compared to less use. CONCLUSIONS Physician-patient communication was not negatively affected by the physician use of the computer as rated by patients. An ongoing relationship with the physician remains a significant predictor of better physician-patient communication even in the presence of the computer.
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Affiliation(s)
- Issam Shaarani
- Department of Clinical Sciences, Beirut Arab University, Beirut, Lebanon
| | - Rim Taleb
- Department of Clinical Sciences, Beirut Arab University, Beirut, Lebanon
| | - Jumana Antoun
- Department of Family Medicine, American University of Beirut, Beirut, Lebanon.
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Lanier C, Dominicé Dao M, Hudelson P, Cerutti B, Junod Perron N. Learning to use electronic health records: can we stay patient-centered? A pre-post intervention study with family medicine residents. BMC FAMILY PRACTICE 2017; 18:69. [PMID: 28549460 PMCID: PMC5446676 DOI: 10.1186/s12875-017-0640-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 05/16/2017] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Cédric Lanier
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, rue Gabrielle Perret-Gentil, CH-1211, Geneva, Switzerland. .,Primary care unit, University of Geneva, Centre Médical Universitaire de Genève, Geneva, Switzerland.
| | - Melissa Dominicé Dao
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, rue Gabrielle Perret-Gentil, CH-1211, Geneva, Switzerland
| | - Patricia Hudelson
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, rue Gabrielle Perret-Gentil, CH-1211, Geneva, Switzerland
| | - Bernard Cerutti
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Noëlle Junod Perron
- Department of Community Medicine, Primary Care and Emergency Medicine, Geneva University Hospitals, rue Gabrielle Perret-Gentil, CH-1211, Geneva, Switzerland
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Patel MR, Vichich J, Lang I, Lin J, Zheng K. Developing an evidence base of best practices for integrating computerized systems into the exam room: a systematic review. J Am Med Inform Assoc 2017; 24:e207-e215. [PMID: 27539198 PMCID: PMC7651892 DOI: 10.1093/jamia/ocw121] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/13/2016] [Accepted: 07/19/2016] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE The introduction of health information technology systems, electronic health records in particular, is changing the nature of how clinicians interact with patients. Lack of knowledge remains on how best to integrate such systems in the exam room. The purpose of this systematic review was to (1) distill "best" behavioral and communication practices recommended in the literature for clinicians when interacting with patients in the presence of computerized systems during a clinical encounter, (2) weigh the evidence of each recommendation, and (3) rank evidence-based recommendations for electronic health record communication training initiatives for clinicians. METHODS We conducted a literature search of 6 databases, resulting in 52 articles included in the analysis. We extracted information such as study setting, research design, sample, findings, and implications. Recommendations were distilled based on consistent support for behavioral and communication practices across studies. RESULTS Eight behavioral and communication practices received strong support of evidence in the literature and included specific aspects of using computerized systems to facilitate conversation and transparency in the exam room, such as spatial (re)organization of the exam room, maintaining nonverbal communication, and specific techniques that integrate the computerized system into the visit and engage the patient. Four practices, although patient-centered, have received insufficient evidence to date. DISCUSSION AND CONCLUSION We developed an evidence base of best practices for clinicians to maintain patient-centered communications in the presence of computerized systems in the exam room. Further work includes development and empirical evaluation of evidence-based guidelines to better integrate computerized systems into clinical care.
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Affiliation(s)
- Minal R Patel
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Jennifer Vichich
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Ian Lang
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI
| | - Jessica Lin
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI
| | - Kai Zheng
- Department of Informatics, Donald Bren School of Information and Computer Sciences, University of California Irvine, Irvine, CA, USA
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Rathert C, Mittler JN, Banerjee S, McDaniel J. Patient-centered communication in the era of electronic health records: What does the evidence say? PATIENT EDUCATION AND COUNSELING 2017; 100:50-64. [PMID: 27477917 DOI: 10.1016/j.pec.2016.07.031] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Cheryl Rathert
- Department of Health Administration, 1008 East Clay St. P.O. Box 980203, Virginia Commonwealth University, Richmond, VA 23298-0203, United States.
| | - Jessica N Mittler
- Department of Health Administration, 1008 East Clay St. P.O. Box 980203, Virginia Commonwealth University, Richmond, VA 23298-0203, United States.
| | - Sudeep Banerjee
- Department of Health Administration, 1008 East Clay St. P.O. Box 980203, Virginia Commonwealth University, Richmond, VA 23298-0203, United States.
| | - Jennifer McDaniel
- Tompkins-McCaw Library for the Health Sciences, 509 North 12th Street, P.O. Box 980582, Virginia Commonwealth University, Richmond, VA 23298-0582, United States.
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Yang Y, Asan O. Designing Patient-facing Health Information Technologies for the Outpatient Settings: A Literature Review. JOURNAL OF INNOVATION IN HEALTH INFORMATICS 2016; 23:185. [PMID: 27348487 PMCID: PMC6716365 DOI: 10.14236/jhi.v23i1.185] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/15/2015] [Accepted: 11/14/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction The implementation of health information technologies (HITs) has changed the dynamics of doctor–patient communication in outpatient settings. Designing patient-facing HITs provides patients with easy access to healthcare information during the visit and has the potential to enhance the patient-centred care. Objectives The objectives of this study are to systematically review how the designs of patient-facing HITs have been suggested and evaluated, and how they may potentially affect the doctor–patient communication and patient-centred care. Method We conducted an online database search to identify articles published before December 2014 relevant to the objectives of this study. A total of nine papers have been identified and reviewed in this study. Results Designing patient-facing HITs is at an early stage. The current literature has been exploring the impact of HITs on doctor–patient communication dynamics. Based on the findings of these studies, there is an emergent need to design more patient-centred HITs. There are also some papers that focus on the usability evaluation of some preliminary prototypes of the patient-facing HITs. The design styles of patient-facing HITs included sharing the health information with the patients on: (1) a separate patient display, (2) a projector, (3) a portable tablet, (4) a touch-based screen and (5) a shared computer display that can be viewed by both doctors and patients. Each of them had the strengths and limitations to facilitate the patient-centred care, and it is worthwhile to make a comparison of them in order to identify future research directions. Conclusion The designs of patient-facing HITs in outpatient settings are promising in facilitating the doctor-patient communication and patient engagement. However, their effectiveness and usefulness need to be further evaluated and improved from a systems perspective.
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Affiliation(s)
- Yushi Yang
- Medical College of Wisconsin, Clemson University, USA.
| | - Onur Asan
- Medical College of Wisconsin, Clemson University, USA.
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Zhang J, Chen Y, Ashfaq S, Bell K, Calvitti A, Farber NJ, Gabuzda MT, Gray B, Liu L, Rick S, Street RL, Zheng K, Zuest D, Agha Z. Strategizing EHR use to achieve patient-centered care in exam rooms: a qualitative study on primary care providers. J Am Med Inform Assoc 2015; 23:137-43. [PMID: 26568605 DOI: 10.1093/jamia/ocv142] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 08/12/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Electronic health records (EHRs) have great potential to improve quality of care. However, their use may diminish "patient-centeredness" in exam rooms by distracting the healthcare provider from focusing on direct patient interaction. The authors conducted a qualitative interview study to understand the magnitude of this issue, and the strategies that primary care providers devised to mitigate the unintended adverse effect associated with EHR use. METHODS AND MATERIALS Semi-structured interviews were conducted with 21 healthcare providers at 4 Veterans Affairs (VAs) outpatient primary care clinics in San Diego County. Data analysis was performed using the grounded theory approach. RESULTS The results show that providers face demands from both patients and the EHR system. To cope with these demands, and to provide patient-centered care, providers attempt to perform EHR work outside of patient encounters and create templates to streamline documentation work. Providers also attempt to use the EHR to engage patients, establish patient buy-in for EHR use, and multitask between communicating with patients and using the EHR. DISCUSSION AND CONCLUSION This study has uncovered the challenges that primary care providers face in integrating the EHR into their work practice, and the strategies they use to overcome these challenges in order to maintain patient-centered care. These findings illuminate the importance of developing "best" practices to improve patient-centered care in today's highly "wired" health environment. These findings also show that more user-centered EHR design is needed to improve system usability.
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Affiliation(s)
- Jing Zhang
- Department of Biomedical Informatics, University of California, San Diego, San Diego, CA, USA Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA
| | - Yunan Chen
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA Department of Informatics, University of California, Irvine, Irvine, CA, USA
| | - Shazia Ashfaq
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA
| | - Kristin Bell
- Department of Internal Medicine, VA San Diego Health Care System, San Diego, CA, USA Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Alan Calvitti
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA
| | - Neil J Farber
- Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Mark T Gabuzda
- Department of Internal Medicine, VA San Diego Health Care System, San Diego, CA, USA Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Barbara Gray
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA
| | - Lin Liu
- Department of Family Medicine and Public Health, University of California, San Diego, San Diego, CA, USA
| | - Steven Rick
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA
| | - Richard L Street
- Department of Communication, Texas A&M University, College Station, TX, USA
| | - Kai Zheng
- School of Public Health Department of Health Management and Policy, School of Information, University of Michigan, Ann Arbor, MI, USA
| | - Danielle Zuest
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA
| | - Zia Agha
- Health Services Research & Development, VA San Diego Healthcare System, San Diego, CA, USA Department of Medicine, University of California, San Diego, San Diego, CA, USA West Health Institute, La Jolla, CA, USA
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Asan O, Kushner K, Montague E. Exploring Residents' Interactions With Electronic Health Records in Primary Care Encounters. Fam Med 2015; 47:722-726. [PMID: 26473566 PMCID: PMC6716379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Our objective was to explore and compare residents' interaction with electronic health records during primary care encounters and whether those behaviors differ by residency year level. METHODS A field study was conducted in which 38 patient visits with 12 family medicine resident physicians were observed and video recorded in two primary care clinics under the umbrella of a university-based department of family medicine. Videos were then coded for gaze behaviors in which patients' and physicians' gazes at electronic health records and at each other were coded using a pre-established objective coding scheme. RESULTS Third-year residents spent the greatest percentage of visit time looking at EHR screens when compared to first- and second-year residents. Third-year residents also spent significantly more time typing or inputting information into the records during the clinical visit when compared to first- and second-year residents. CONCLUSIONS This study illustrated that patterns for using the EHR and interacting with patients may change over time for residents. These changes may be due to increased EHR proficiency or increased workload that incentivizes using the EHR to retrieve information and to complete charting in front of the patient.
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Affiliation(s)
- Onur Asan
- Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin
| | - Kenneth Kushner
- Department of Family Medicine, University of Wisconsin-Madison
| | - Enid Montague
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University
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Hillen MA, de Haes HCJM, van Tienhoven G, Bijker N, van Laarhoven HWM, Vermeulen DM, Smets EMA. All eyes on the patient: the influence of oncologists' nonverbal communication on breast cancer patients' trust. Breast Cancer Res Treat 2015; 153:161-71. [PMID: 26227472 PMCID: PMC4536267 DOI: 10.1007/s10549-015-3486-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 11/24/2022]
Abstract
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 (rs = .31, p < .001) and caring (rs = .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.
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Affiliation(s)
- Marij A Hillen
- Department of Medical Psychology, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE, Amsterdam, The Netherlands,
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Asan O, Montague E. Using video-based observation research methods in primary care health encounters to evaluate complex interactions. INFORMATICS IN PRIMARY CARE 2015; 21:161-70. [PMID: 25479346 DOI: 10.14236/jhi.v21i4.72] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this paper is to describe the use of video-based observation research methods in primary care environment and highlight important methodological considerations and provide practical guidance for primary care and human factors researchers conducting video studies to understand patient-clinician interaction in primary care settings. METHODS We reviewed studies in the literature which used video methods in health care research, and we also used our own experience based on the video studies we conducted in primary care settings. RESULTS This paper highlighted the benefits of using video techniques, such as multi-channel recording and video coding, and compared "unmanned" video recording with the traditional observation method in primary care research. We proposed a list that can be followed step by step to conduct an effective video study in a primary care setting for a given problem. This paper also described obstacles, researchers should anticipate when using video recording methods in future studies. CONCLUSION With the new technological improvements, video-based observation research is becoming a promising method in primary care and HFE research. Video recording has been under-utilised as a data collection tool because of confidentiality and privacy issues. However, it has many benefits as opposed to traditional observations, and recent studies using video recording methods have introduced new research areas and approaches.
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Affiliation(s)
- Onur Asan
- Division of General Internal Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Enid Montague
- Division of General Internal Medicine and Geriatrics Feinberg School of Medicine, Northwestern University, 750 North Lake Shore Drive, Chicago, IL 60611, USA.
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Asan O, Carayon P, Beasley JW, Montague E. Work system factors influencing physicians' screen sharing behaviors in primary care encounters. Int J Med Inform 2015; 84:791-8. [PMID: 26049312 DOI: 10.1016/j.ijmedinf.2015.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 05/01/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE While the use of electronic health records (EHRs) in primary care has increased dramatically, its potential benefits need to be considered in light of potential negative impacts on physician-patient interactions and the increase in physician cognitive workload. This study aims to understand work system factors contributing to physicians' use of the EHR as a communication tool during primary-care encounters. METHODS We interviewed 14 primary care physicians on their use of EHRs as a communication tool in patient visits. A qualitative content analysis guided by the work system model identified factors influencing physicians' decisions to share or not share the computer screen with their patients. RESULTS The analysis revealed 26 factors that influenced physicians' decisions to share the screen, most related to the "task" (reviewing lab records), "tools and technology" (using algorithm calculators for risk prediction), or "individual" (patient interest) elements of the work system. The analysis revealed 15 factors that influenced physicians' decisions not to share the screen, most related to the "individual" (patient's acute pain), "organization" (insufficient time), or "task" (documenting embarrassing information) elements of the work system. CONCLUSION Eleven physicians made individual decisions to share or not to share the screen in a particular visit based on work-system related factors. Three doctors always shared the screen, based on the idea that it is polite and builds trust. However, several physicians also reported that it was time consuming and caused unnecessary distractions. Understanding these factors is essential to effective EHR redesign and training for improving physician-patient communication.
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Affiliation(s)
- Onur Asan
- Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.
| | - Pascale Carayon
- Center for Productivity and Productivity Improvement, Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - John W Beasley
- School of Medicine and Public Health, Department of Family Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Enid Montague
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Asan O, Young HN, Chewning B, Montague E. How physician electronic health record screen sharing affects patient and doctor non-verbal communication in primary care. PATIENT EDUCATION AND COUNSELING 2015; 98:310-6. [PMID: 25534022 PMCID: PMC4319541 DOI: 10.1016/j.pec.2014.11.024] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 11/21/2014] [Accepted: 11/30/2014] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Use of electronic health records (EHRs) in primary-care exam rooms changes the dynamics of patient-physician interaction. This study examines and compares doctor-patient non-verbal communication (eye-gaze patterns) during primary care encounters for three different screen/information sharing groups: (1) active information sharing, (2) passive information sharing, and (3) technology withdrawal. METHODS Researchers video recorded 100 primary-care visits and coded the direction and duration of doctor and patient gaze. Descriptive statistics compared the length of gaze patterns as a percentage of visit length. Lag sequential analysis determined whether physician eye-gaze influenced patient eye gaze, and vice versa, and examined variations across groups. RESULTS Significant differences were found in duration of gaze across groups. Lag sequential analysis found significant associations between several gaze patterns. Some, such as DGP-PGD ("doctor gaze patient" followed by "patient gaze doctor") were significant for all groups. Others, such DGT-PGU ("doctor gaze technology" followed by "patient gaze unknown") were unique to one group. CONCLUSION Some technology use styles (active information sharing) seem to create more patient engagement, while others (passive information sharing) lead to patient disengagement. PRACTICE IMPLICATIONS Doctors can engage patients in communication by using EHRs in the visits. EHR training and design should facilitate this.
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Affiliation(s)
- Onur Asan
- Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, USA.
| | - Henry N Young
- College of Pharmacy, University of Georgia, Athens, USA
| | - Betty Chewning
- School of Pharmacy, University of Wisconsin-Madison, Madison, USA
| | - Enid Montague
- Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, USA
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Asan O, D Smith P, Montague E. More screen time, less face time - implications for EHR design. J Eval Clin Pract 2014; 20:896-901. [PMID: 24835678 PMCID: PMC4237676 DOI: 10.1111/jep.12182] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2014] [Indexed: 12/01/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Understanding the impact of health information technology on doctor-patient interaction is vital to designing better electronic health records (EHRs). This article quantitatively examines and compares clinically experienced physicians' interactions with patients using paper or EHRs in ambulatory primary care settings. METHODS Clinical encounters using paper or EHRs were recorded with high-resolution video cameras to capture physicians' interactions with the health records and patients. All videos were coded using quantified video coding methodology to understand how physicians interacted with EHRs and patients through measuring eye gaze durations. Statistical analysis was conducted to compare the results of the paper and EHR visits. RESULTS Eight experienced family medicine physicians and 80 patients participated in the study. A total of 80 visits, 40 with paper and 40 with EHRs were recorded. The proportion of time physicians spent gazing at medical records during EHR visits was significantly more than in paper chart visits (35.2 versus 22.1%, P = 0.001). A significantly smaller proportion of physician time was spent gazing at the patient when using an EHR compared with when using a paper chart (52.6 versus 45.6%, P = 0.041). CONCLUSIONS For this group of family medicine physicians, more time was spent looking at the EHR screen than paper records and a little less time looking at the patient. These findings may negatively affect the patient perception of the visit with the physician and have implications for the design of future EHRs.
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Affiliation(s)
- Onur Asan
- Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med 2014; 12:573-6. [PMID: 25384822 PMCID: PMC4226781 DOI: 10.1370/afm.1713] [Citation(s) in RCA: 1894] [Impact Index Per Article: 189.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The Triple Aim-enhancing patient experience, improving population health, and reducing costs-is widely accepted as a compass to optimize health system performance. Yet physicians and other members of the health care workforce report widespread burnout and dissatisfaction. Burnout is associated with lower patient satisfaction, reduced health outcomes, and it may increase costs. Burnout thus imperils the Triple Aim. This article recommends that the Triple Aim be expanded to a Quadruple Aim, adding the goal of improving the work life of health care providers, including clinicians and staff.
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Affiliation(s)
- Thomas Bodenheimer
- Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California San Francisco, San Francisco, California
| | - Christine Sinsky
- Medical Associates Clinic and Health Plan, Dubuque, Iowa American Medical Association, Chicago, Illinois
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Schoenthaler A, Montague E, Manwell LB, Brown R, Schwartz MD, Linzer M. Patient-physician racial/ethnic concordance and blood pressure control: the role of trust and medication adherence. ETHNICITY & HEALTH 2014; 19:565-78. [PMID: 24266617 PMCID: PMC4031314 DOI: 10.1080/13557858.2013.857764] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
OBJECTIVES To examine the associations between racial/ethnic concordance and blood pressure (BP) control, and to determine whether patient trust and medication adherence mediate these associations. DESIGN Cross-sectional study of 723 hypertensive African-American and white patients receiving care from 205 white and African-American providers at 119 primary care clinics, from 2001 to 2005. Racial/ethnic concordance was characterized as dyads where both the patient and physician were of the same race/ethnicity; discordance occurred in dyads where the patient was African-American and the physician was white. Patient perceptions of trust and medication adherence were assessed with self-report measures. The BP readings were abstracted from patients' medical charts using standardized procedures. RESULTS Six hundred thirty-seven patients were in race/ethnic-concordant relationships; 86 were in race/ethnic-discordant relationships. Concordance had no association with BP control. White patients in race/ethnic-concordant relationships were more likely to report better adherence than African-American patients in race/ethnic-discordant relationships (OR: 1.27, 95% CI: 1.01, 1.61, p = 0.04). Little difference in adherence was found for African-American patients in race/ethnic-concordant vs. discordant relationships. Increasing trust was associated with significantly better adherence (OR: 1.17, 95% CI: 1.04, 1.31, p < 0.01) and a trend toward better BP control among all patients (OR: 1.26, 95% CI: 0.97, 1.63, p = 0.07). CONCLUSIONS Patient trust may influence medication adherence and BP control regardless of patient-physician racial/ethnic composition.
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Affiliation(s)
| | | | - Linda Baier Manwell
- University of Wisconsin School of Medicine & Public Health, Madison, United States
| | - Roger Brown
- University of Wisconsin-Madison, Madison, United States
| | | | - Mark Linzer
- Hennepin County Medical Center, Minneapolis, United States
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Asan O, Xu J, Montague E. Dynamic Comparison of Physicians' Interaction Style with Electronic Health Records in Primary Care Settings. JOURNAL OF GENERAL PRACTICE (LOS ANGELES, CALIF.) 2013; 2. [PMID: 25411656 PMCID: PMC4233672 DOI: 10.4172/2329-9126.1000137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Researchers have been increasingly interested in the influence of computers on physician-patient communication in consultation rooms because of the substantial growth in the use of Electronic Health Records (EHRs) in the U.S. Previous research showed that physicians have different ways of interacting with patients and EHRs; and these styles may relate to different patterns of nonverbal interaction between the physicians and patients and influence the outcomes of the clinical visit. The purpose of this study was to identify the differences of eye gaze patterns in three EHR interaction styles: the technology-centered style, the human-centered style, and the mixed interaction style. 100 primary care visits with different interaction styles were videotaped. Eye gaze behaviors were coded and described as frequencies and durations of gaze. The dynamic eye gaze patterns of the physicians and patients, in terms of how their gaze behaviors were sequentially associated, were analyzed using lag-sequential analysis. The results indicated that technology-centered group had significantly shorter amount of mutual gaze than other two groups (p=0.032; p=0.015, respectively). In addition, in technology centered style, the physicians were more likely to shift their gaze to the computer when the patients gazed at them; and when the physicians gazed at the computers, the patients were more likely to gaze somewhere else which might be an indicator of disengagement. The study implied that EHRs should be designed in a way that facilitates a positive interaction between the physicians and patients, such as maintaining mutual gaze. Training should also be provided to the physicians for establishing effective and positive interaction styles.
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Affiliation(s)
- Onur Asan
- Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jie Xu
- Industrial and System Engineering, University of Wisconsin-Madison, Madison, USA
| | - Enid Montague
- Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago IL, USA
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Dental care providers' and patients' perceptions of the effect of health information technology in the dental care setting. J Am Dent Assoc 2013; 144:1022-9. [DOI: 10.14219/jada.archive.2013.0229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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