1
|
Barnes RK, Woods CJ. Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research. RESEARCH ON LANGUAGE AND SOCIAL INTERACTION 2024; 57:7-37. [PMID: 38707494 PMCID: PMC11067862 DOI: 10.1080/08351813.2024.2305038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.
Collapse
Affiliation(s)
- Rebecca K. Barnes
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, U.K.
| | - Catherine J. Woods
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, U.K.
| |
Collapse
|
2
|
Tranter I, van Driel ML, Mitchell B. Doctor! Did you Google my symptoms? A qualitative study of patient perceptions of doctors' point-of-care information seeking. BMJ Open 2022; 12:e061090. [PMID: 35896298 PMCID: PMC9335025 DOI: 10.1136/bmjopen-2022-061090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore patient perceptions regarding doctors' information seeking during consultations. DESIGN AND SETTING Qualitative interviews with participants from six general practice waiting rooms in South East Queensland, Australia. Participants were asked about their experiences and opinions, and to comment on short videos of simulated consultations in which a doctor sought information. The interviews were analysed through a process of iterative thematic analysis using the framework of Braun and Clarke. PARTICIPANTS The 16 participants were purposively sampled including 5 men and 11 women from a diverse range of educational and age groups. RESULTS How a doctor's need to look up information impacted patient impressions of competence and trust was an overarching theme. The four dominant themes include: the trust a patient has in the doctor before the consultation, whether the doctor is expected to know the answer to a question without searching, has the doctor added value to the consultation by searching and the consultation skills used in the process. CONCLUSIONS Patient trust is fundamental to positive perceptions of general practitioners' information seeking at the point-of-care. Communication is key to building this trust. Understanding the patient's agenda, listening, assessing thoroughly and being honest and transparent about the need to seek information all contribute to a positive experience.
Collapse
Affiliation(s)
- Isaac Tranter
- General Practice Clinical Unit, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
| | - Mieke L van Driel
- General Practice Clinical Unit, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
| | - Ben Mitchell
- General Practice Clinical Unit, The University of Queensland Faculty of Medicine and Biomedical Sciences, Herston, Queensland, Australia
| |
Collapse
|
3
|
Filoche S, Stubbe MH, Grainger R, Robson B, Paringatai K, Wilcox P, Jefferies R, Dowell A. How is family health history discussed in routine primary healthcare? A qualitative study of archived family doctor consultations. BMJ Open 2021; 11:e049058. [PMID: 34610935 PMCID: PMC8493894 DOI: 10.1136/bmjopen-2021-049058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES Family health history underpins genetic medicine. Our study aimed to explore language and patterns of communication relating to family health history observed in interactions between general practitioners (GPs) and their patients within routine primary care consultations. DESIGN Secondary analysis of patient and GP routine consultation data (n=252). PARTICIPANTS Consultations that included 'family health history' were eligible for inclusion (n=58). PRIMARY OUTCOMES A qualitative inductive analysis of the interactions from consultation transcripts. RESULTS 46/58 conversations about family health history were initiated by the GP. Most discussions around family history lasted for between approximately 1 to 2 min. Patients were invited to share family health history through one of two ways: non-specific enquiry (eg, by asking the patient about 'anything that runs in the family'); or specific enquiry where they were asked if they had a 'strong family history' in relation to a particular condition, for example, breast cancer. Patients often responded to either approach with a simple no, but fuller negative responses also occurred regularly and typically included an account of some kind (eg, explaining family relationships/dynamics which impeded or prevented the accessibility of information). CONCLUSIONS Family health history is regarded as a genetic test and is embedded in the sociocultural norms of the patient from whom information is being sought. Our findings highlight that it is more complex than asking simply if 'anything' runs in the family. As the collection of family health history is expected to be more routine, it will be important to also consider it from sociocultural perspectives in order to help mitigate any inequities in how family history is collected, and therefore used (or not) in a person's healthcare. Orientating an enquiry away from 'anything' and asking more specific details about particular conditions may help facilitate the dialogue.
Collapse
Affiliation(s)
- Sara Filoche
- Department of Obstetrics, Gynaecology and Women's Health, University of Otago, Wellington, New Zealand
| | - Maria H Stubbe
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| | - Rebecca Grainger
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Bridget Robson
- Te Rōpū Rangahau Hauora a Eru Pōmare, Department of Public Health, University of Otago, Wellington, New Zealand
| | - Karyn Paringatai
- Te Tumu, School of Māori, Pacific and Indigenous Studies, University of Otago, Dunedin, New Zealand
| | - Phil Wilcox
- Department of Mathematics and Statistics, University of Otago, Dunedin, New Zealand
| | - Regina Jefferies
- Department of Obstetrics, Gynaecology and Women's Health, University of Otago, Wellington, New Zealand
| | - Anthony Dowell
- Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand
| |
Collapse
|
4
|
Efficient Clinical Counseling for Sickle Cell Disease. J Natl Med Assoc 2021; 113:382-387. [PMID: 33610309 DOI: 10.1016/j.jnma.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 01/22/2021] [Indexed: 11/22/2022]
Abstract
Sickle cell anemia (SCA) is a chronic illness that requires frequent health care visits for preventative management. Adherence to national guidelines such as the National Heart Lung and Blood Institute (NHLBI) Expert Panel Report on the Evidence-Based Management of Sickle Cell Disease can be challenging to both the clinician and the patient. Utilizing effective communication strategies with patients and their families can improve clinician/patient relationships, as well as adherence to national guidelines. Aims of this overview are to review challenges faced in outpatient subspecialty medicine and describe evidence-based techniques for more effective communication for patients with sickle cell anemia.
Collapse
|
5
|
Matthews EB, Bond L, Stanhope V. Understanding Health Talk in Behavioral Health Encounters: A Qualitative Analysis. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2020; 48:551-563. [PMID: 32964333 DOI: 10.1007/s10488-020-01088-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
Although physical and behavioral health conditions commonly cooccur, best practices making behavioral health treatment responsive to clients' health needs are limited. Particularly little is known about how physical health is addressed by clinicians within routine therapeutic treatment. This study describes the frequency and type of health talk occurring within integrated behavioral health sessions, and explores how this talk functions within ongoing therapeutic work. Participants in this study included 51 dyads of clinical social workers (n = 13) and clients (n = 51) receiving therapy within an integrated community health and behavioral health center. Therapy sessions were recorded and transcribed verbatim. Content analysis determined the frequency and content of health talk in sessions. Thematic analysis was used to understand the function of health talk within these visits. Health talk occurred in 92% (n = 47) of sessions. Clients initiated the majority of discussions. Talk about sleep (40%, n = 19), diet/exercise (35%, n = 16), and chronic health conditions (28%, n = 13) were most common. Health talk either complimented or conflicted with therapeutic work, depending on the topic discussed and when it occurred during session. Health talk changed the scope of therapeutic work by integrating care coordination into routine practice. Health talk was pervasive and was frequently initiated by clients, signaling its relevance to clients' recovery. Providers leveraged heath talk to complement their therapeutic work, but these strategies were not universally applied. Care coordination activities were a part of routine therapy. Practice and policy changes that support a more interdisciplinary approach to clinical work are needed.
Collapse
Affiliation(s)
- Elizabeth B Matthews
- Graduate School of Social Service, Fordham University, 113 W 60th St, New York, NY, 10023, USA.
| | - Lynden Bond
- New York University Silver School of Social Work, 1 Washington Plaza, New York, NY, 10003, USA
| | - Victoria Stanhope
- New York University Silver School of Social Work, 1 Washington Plaza, New York, NY, 10003, USA
| |
Collapse
|
6
|
Communication in high risk ante-natal consultations: a direct observational study of interactions between patients and obstetricians. BMC Pregnancy Childbirth 2020; 20:493. [PMID: 32854633 PMCID: PMC7450934 DOI: 10.1186/s12884-020-03015-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/14/2020] [Indexed: 12/22/2022] Open
Abstract
Background Effective communication is crucial to any doctor-patient consultation, not least in pregnancy where the outcome affects more than one person. While higher levels of patient participation and shared decision making are recognised as desirable, there is little agreement on how best to achieve this. Most previous research in this area is based on reported data such as interviews or surveys and there is a need for more fine-grained analysis of authentic interaction. This study aimed to identify the discourse characteristics and patterns that exemplify effective communication practices in a high-risk ante-natal clinic. Methods We video-recorded 20 consultations in a high-risk ante-natal clinic in a large New Zealand city with patients attending for the first time. Post-consultation interviews were conducted with the 20 patients and 13 obstetricians involved. Discourse analysis of the transcripts and videos of the consultations was conducted, in conjunction with thematic analysis of interview transcripts. Results Most patients reported high quality communication and high levels of satisfaction; the detailed consultation analysis revealed a range of features likely to have contributed. On the clinician side, these included clear explanations, acknowledgement of the patient’s experience, consideration of patient wishes, and realistic and honest answers to patient questions. On the patient side, these included a high level of engagement with technical aspects of events and procedures, and appropriate questioning of obstetricians. Conclusions This study has demonstrated the utility of combining direct observation of consultations with data from patient experience interviews to identify specific features of effective communication in routine obstetric ante-natal care. The findings are relevant to improvements needed in obstetric communication identified in the literature, especially in relation to handling psychosocial issues and conveying empathy, and may be useful to inform communication training for obstetricians. The presence of the unborn child may provide an added incentive for parents to develop their own health literacy and to be an active participant in the consultation on behalf of their child. The findings of this study can lay the groundwork for further, more detailed analysis of communication in ante-natal consultations.
Collapse
|
7
|
Matthews EB. Whose System is it Anyway? How Clients and Providers Evaluate the Impact of Session EHR Use on Communication in Mental Health Treatment. Community Ment Health J 2020; 56:540-548. [PMID: 31802323 DOI: 10.1007/s10597-019-00511-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
Electronic health records are common in mental health settings. While providers often express concern that in-session computing will damage client-provider communication, some work suggests that clients do not share this worry. As the majority of this research has been conducted in medical settings, less is known about how clients evaluate in session computing in mental health treatment, and whether this pattern of discordance persists in this setting. This study describes and compares the perceived impact of in-session computing on communication in mental health treatment from the clients and provider perspective, and examined sources of variation in client ratings. Thirteen providers and 53 clients participated in this study, representing 53 unique client-provider dyads. Results suggest that providers perceived in-session computing as more harmful to communication than clients. Client ratings varied by race, age and visit type but were not influenced by how often the computer was used during session.
Collapse
Affiliation(s)
- Elizabeth B Matthews
- Graduate School of Social Service, Fordham University, 113 W. 60th St, New York, NY, 10023, USA.
| |
Collapse
|
8
|
Zamani Z, Harper EC. Exploring the Effects of Clinical Exam Room Design on Communication, Technology Interaction, and Satisfaction. HERD-HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 2019; 12:99-115. [PMID: 30719926 DOI: 10.1177/1937586719826055] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
|
9
|
Wolfe L, Chisolm MS, Bohsali F. Clinically Excellent Use of the Electronic Health Record: Review. JMIR Hum Factors 2018; 5:e10426. [PMID: 30291099 PMCID: PMC6231887 DOI: 10.2196/10426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/27/2018] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Leah Wolfe
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Margaret Smith Chisolm
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Fuad Bohsali
- Department of Medicine, School of Medicine, Duke University, Durham, NC, United States
| |
Collapse
|
10
|
Henderson J, Barnett S, Ghosh A, Pollack AJ, Hodgkins A, Win KT, Miller GC, Bonney A. Validation of electronic medical data: Identifying diabetes prevalence in general practice. Health Inf Manag 2018; 48:3-11. [PMID: 30278786 DOI: 10.1177/1833358318798123] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Electronic medical records are increasingly used for research with limited external validation of their data. OBJECTIVE: This study investigates the validity of electronic medical data (EMD) for estimating diabetes prevalence in general practitioner (GP) patients by comparing EMD with national Bettering the Evaluation and Care of Health (BEACH) data. METHOD: A "decision tree" was created using inclusion/exclusion of pre-agreed variables to determine the probability of diabetes in absence of diagnostic label, including diagnoses (coded/free-text diabetes, polycystic ovarian syndrome, impaired glucose tolerance, impaired fasting glucose), diabetic annual cycle of care (DACC), glycated haemoglobin (HbA1c) > 6.5%, and prescription (metformin, other diabetes medications). Via SQL query, cases were identified in EMD of five Illawarra and Southern Practice Network practices (30,007 active patients; from 2 years to January 2015). Patient-based Supplementary Analysis of Nominated Data (SAND) sub-studies from BEACH investigating diabetes prevalence (1172 GPs; 35,162 patients; November 2012 to February 2015) were comparison data. SAND results were adjusted for number of GP encounters per year, per patient, and then age-sex standardised to match age-sex distribution of EMD patients. Cluster-adjusted 95% confidence intervals (CIs) were calculated for both datasets. RESULTS: EMD diabetes prevalence (T1 and/or T2) was 6.5% (95% CI: 4.1-8.9). Following age-sex standardisation, SAND prevalence, not significantly different, was 6.7% (95% CI: 6.3-7.1). Extracting only coded diagnosis missed 13.0% of probable cases, subsequently identified through the presence of metformin/other diabetes medications (*without other indicator variables) (6.1%), free-text diabetes label (3.8%), HbA1c result* (1.6%), DACC* (1.3%), and diabetes medications* (0.2%). DISCUSSION: While complex, proxy variables can improve usefulness of EMD for research. Without their consideration, EMD results should be interpreted with caution. CONCLUSION: Enforceable, transparent data linkages in EMRs would resolve many problems with identification of diagnoses. Ongoing data quality improvement remains essential.
Collapse
|
11
|
Keystrokes, Mouse Clicks, and Gazing at the Computer: How Physician Interaction with the EHR Affects Patient Participation. J Gen Intern Med 2018; 33:423-428. [PMID: 29188544 PMCID: PMC5880755 DOI: 10.1007/s11606-017-4228-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/12/2017] [Accepted: 10/25/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Evidence is mixed regarding how physicians' use of the electronic health record (EHR) affects communication in medical encounters. OBJECTIVE To investigate whether the different ways physicians interact with the computer (mouse clicks, key strokes, and gaze) vary in their effects on patient participation in the consultation, physicians' efforts to facilitate patient involvement, and silence. DESIGN Cross-sectional, observational study of video and event recordings of primary care and specialty consultations. PARTICIPANTS Thirty-two physicians and 217 patients. MAIN MEASURES Predictor variables included measures of physician interaction with the EHR (mouse clicks, key strokes, gaze). Outcome measures included active patient participation (asking questions, stating preferences, expressing concerns), physician facilitation of patient involvement (partnership-building and supportive talk), and silence. KEY RESULTS Patients were less active participants in consultations in which physicians engaged in more keyboard activity (b = -0.002, SE = 0.001, p = 0.02). More physician gaze at the computer was associated with more silence in the encounter (b = 0.21, SE = 0.09, p = 0.02). Physicians' facilitative communication, which predicted more active patient participation (b = 0.65, SE = 0.14, p < 0.001), was not related to EHR activity measures. CONCLUSIONS Patients may be more reluctant to actively participate in medical encounters when physicians are more physically engaged with the computer (e.g., keyboard activity) than when their behavior is less demonstrative (e.g., gazing at EHR). Using easy to deploy communication tactics (e.g., asking about a patient's thoughts and concerns, social conversation) while working on the computer can help physicians engage patients as well as maintain conversational flow.
Collapse
|
12
|
Evolving roles and structures of triadic engagement in healthcare. JOURNAL OF SERVICE MANAGEMENT 2017. [DOI: 10.1108/josm-09-2016-0249] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this paper is to focus on the changing nature of healthcare service encounters by studying the phenomenon of triadic engagement incorporating interactions between patients, local and virtual networks and healthcare professionals.
Design/methodology/approach
An 18-month longitudinal ethnographic study documents interactions in naturally occurring healthcare consultations. Professionals (n=13) and patients (n=24) within primary and secondary care units were recruited. Analysis of observations, field notes and interviews provides an integrated picture of triadic engagement.
Findings
Triadic engagement is conceptualised against a two-level framework. First, the structure of triadic consultations is identified in terms of the human voice, virtual voice and networked voice. These are related to: companions’ contributions to discussions and the virtual network impact. Second, evolving roles are mapped to three phases of transformation: enhancement; empowerment; emancipation. Triadic engagement varied across conditions.
Research limitations/implications
These changing roles and structures evidence an increasing emphasis on the responsible consumer and patients/companions to utilise information/support in making health-related decisions. The nature and role of third voices requires clear delineation.
Practical implications
Structures of consultations should be rethought around the diversity of patient/companion behaviours and expectations as patients undertake self-service activities. Implications for policy and practice are: the parallel set of local/virtual informational and service activities; a network orientation to healthcare; tailoring of support resources/guides for professionals and third parties to inform support practices.
Originality/value
Contributions are made to understanding triadic engagement and forwarding the agenda on patient-centred care. Longitudinal illumination of consultations is offered through an exceptional level of access to observe consultations.
Collapse
|
13
|
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] [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.
Collapse
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
| |
Collapse
|
14
|
Bennett EA, Kolko RP, Chia L, Elliott JP, Kalarchian MA. Treatment of Obesity Among Youth With Intellectual and Developmental Disabilities: An Emerging Role for Telenursing. West J Nurs Res 2017; 39:1008-1027. [PMID: 28349744 DOI: 10.1177/0193945917697664] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Childhood obesity is a serious health issue, associated with medical comorbidity and psychosocial impairment that can persist into adulthood. In the United States, youth with intellectual and developmental disabilities are more likely to be obese than youth without disabilities. A large body of evidence supports the efficacy of family-based treatment of childhood obesity, including diet, physical activity, and behavior modification, but few interventions have been developed and evaluated specifically for this population. We highlight studies on treatment of obesity among youth with intellectual and developmental disabilities, including both residential/educational settings as well as outpatient/hospital settings. All interventions were delivered in-person, and further development of promising approaches and delivery via telenursing may increase access by youth and families. Nursing scientists can assume an important role in overcoming barriers to care for this vulnerable and underserved population.
Collapse
|
15
|
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.
Collapse
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.
| |
Collapse
|
16
|
Lee WW, Alkureishi MA, Ukabiala O, Venable LR, Ngooi SS, Staisiunas DD, Wroblewski KE, Arora VM. Patient Perceptions of Electronic Medical Record Use by Faculty and Resident Physicians: A Mixed Methods Study. J Gen Intern Med 2016; 31:1315-1322. [PMID: 27400921 PMCID: PMC5071284 DOI: 10.1007/s11606-016-3774-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 01/27/2016] [Accepted: 06/08/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND While concerns remain regarding Electronic Medical Records (EMR) use impeding doctor-patient communication, resident and faculty patient perspectives post-widespread EMR adoption remain largely unexplored. OBJECTIVE We aimed to describe patient perspectives of outpatient resident and faculty EMR use and identify positive and negative EMR use examples to promote optimal utilization. DESIGN This was a prospective mixed-methods study. PARTICIPANTS Internal medicine faculty and resident patients at the University of Chicago's primary care clinic participated in the study. APPROACH In 2013, one year after EMR implementation, telephone interviews were conducted with patients using open-ended and Likert style questions to elicit positive and negative perceptions of EMR use by physicians. Interview transcripts were analyzed qualitatively to develop a coding classification. Satisfaction with physician EMR use was examined using bivariate statistics. RESULTS In total, 108 interviews were completed and analyzed. Two major themes were noted: (1) Clinical Functions of EMR and (2) Communication Functions of EMR; as well as six subthemes: (1a) Clinical Care (i.e., clinical efficiency), (1b) Documentation (i.e., proper record keeping and access), (1c) Information Access, (1d) Educational Resource, (2a) Patient Engagement and (2b) Physical Focus (i.e., body positioning). Overall, 85 % (979/1154) of patient perceptions of EMR use were positive, with the majority within the "Clinical Care" subtheme (n = 218). Of negative perceptions, 66 % (115/175) related to the "Communication Functions" theme, and the majority of those related to the "Physical Focus" subtheme (n = 71). The majority of patients (90 %, 95/106) were satisfied with physician EMR use: 59 % (63/107) reported the computer had a positive effect on their relationship and only 7 % (8/108) reported the EMR made it harder to talk with their doctors. CONCLUSIONS Despite concerns regarding EMRs impeding doctor-patient communication, patients reported largely positive perceptions of the EMR with many patients reporting high levels of satisfaction. Future work should focus on improving doctors "physical focus" when using the EMR to redirect towards the patient.
Collapse
Affiliation(s)
- Wei Wei Lee
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue MC 3051, L325B, Chicago, IL, 60637, USA.
| | | | - Obioma Ukabiala
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Laura Ruth Venable
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue MC 3051, L325B, Chicago, IL, 60637, USA
| | - Samantha S Ngooi
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue MC 3051, L325B, Chicago, IL, 60637, USA
| | - Daina D Staisiunas
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue MC 3051, L325B, Chicago, IL, 60637, USA
| | | | - Vineet M Arora
- Department of Medicine, University of Chicago, 5841 S. Maryland Avenue MC 3051, L325B, Chicago, IL, 60637, USA
| |
Collapse
|
17
|
Van der Merwe JW, Rugunanan M, Ras J, Röscher EM, Henderson BD, Joubert G. Patient preferences regarding the dress code, conduct and resources used by doctors during consultations in the public healthcare sector in Bloemfontein, Free State. S Afr Fam Pract (2004) 2016. [DOI: 10.1080/20786190.2016.1187865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
|
18
|
Impact of Electronic Medical Record Use on the Patient-Doctor Relationship and Communication: A Systematic Review. J Gen Intern Med 2016; 31:548-60. [PMID: 26786877 PMCID: PMC4835363 DOI: 10.1007/s11606-015-3582-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 12/07/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND While Electronic Medical Record (EMR) use has increased dramatically, the EMR's impact on the patient-doctor relationship remains unclear. This systematic literature review sought to understand the impact of EMR use on patient-doctor relationships and communication. METHODS Parallel searches in Ovid MEDLINE, PubMed, Scopus, PsycINFO, Cochrane Library, reference review of prior systematic reviews, meeting abstract reviews, and expert reviews from August 2013 to March 2015 were conducted. Medical Subject Heading terms related to EMR use were combined with keyword terms identifying face-to-face patient-doctor communication. English language observational or interventional studies (1995-2015) were included. Studies examining physician attitudes only were excluded. Structured data extraction compared study population, design, data collection method, and outcomes. RESULTS Fifty-three of 7445 studies reviewed met inclusion criteria. Included studies used behavioral analysis (28) to objectively measure communication behaviors using video or direct observation and pre-post or cross-sectional surveys to examine patient perceptions (25). Objective studies reported EMR communication behaviors that were both potentially negative (i.e., interrupted speech, low rates of screen sharing) and positive (i.e., facilitating questions). Studies examining overall patient perceptions of satisfaction, communication or the patient-doctor relationship (n = 22) reported no change with EMR use (16); a positive impact (5) or showed mixed results (1). Study quality was not assessable. Small sample sizes limited generalizability. Publication bias may limit findings. DISCUSSION Despite objective evidence that EMR use may negatively impact patient-doctor communication, studies examining patient perceptions found no change in patient satisfaction or patient-doctor communication. Therefore, our findings should encourage providers to adopt the EMR as a communication tool. Future research is needed to better understand how to enhance patient-doctor- EMR communication. This research should correlate observed physician behavior to patient satisfaction, focus on physician communication skills training, and explore inpatient experiences.
Collapse
|
19
|
Crampton NH, Reis S, Shachak A. Computers in the clinical encounter: a scoping review and thematic analysis. J Am Med Inform Assoc 2016; 23:654-65. [PMID: 26769911 PMCID: PMC7839926 DOI: 10.1093/jamia/ocv178] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/23/2015] [Accepted: 10/26/2015] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Patient-clinician communication has been associated with increased patient satisfaction, trust in the clinician, adherence to prescribed therapy, and various health outcomes. The impact of health information technology (HIT) on the clinical encounter in general and patient-clinician communication in particular is a growing concern. The purpose of this study was to review the current literature on HIT use during the clinical encounter to update best practices and inform the continuous development of HIT policies and educational interventions. METHODS We conducted a literature search of four databases. After removing duplicates, reviewing titles and abstracts, performing a full-text review, and snowballing from references and citations, 51 articles were included in the analysis. We employed a qualitative thematic analysis to compare and contrast the findings across studies. RESULTS Our analysis revealed that the use of HIT affects consultations in complex ways, impacting eye contact and gaze, information sharing, building relationships, and pauses in the conversation. Whether these impacts are positive or negative largely depends on the combination of consultation room layout, patient and clinician styles of interaction with HIT as well as each other, and the strategies and techniques employed by clinicians to integrate HIT into consultations. DISCUSSION The in-depth insights into the impact of HIT on the clinical encounter, especially the strategies and techniques employed by clinicians to adapt to using HIT in consultations, can inform policies, educational interventions, and research. CONCLUSION In contrast to the common negative views of HIT, it affects the clinical encounter in multiple ways. By applying identified strategies and best practices, HIT can support patient-clinician interactions rather than interfering with them.
Collapse
Affiliation(s)
- Noah H Crampton
- Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Shmuel Reis
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Aviv Shachak
- Institute of Health Policy, Management & Evaluation (Dalla Lana School of Public Health) and Faculty of Information, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
20
|
Carter SR, Moles R, White L, Chen TF. The impact of patients' perceptions of the listening skills of the pharmacist on their willingness to re-use Home Medicines Reviews: A structural equation model. Res Social Adm Pharm 2015; 11:163-75. [DOI: 10.1016/j.sapharm.2014.07.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 07/11/2014] [Accepted: 07/11/2014] [Indexed: 11/26/2022]
|
21
|
Bacon L, Coley D, Draeger E, Evans J. Five years' experience with a primary care electronic patient record in a community sexual and reproductive health service. ACTA ACUST UNITED AC 2014; 41:68-71. [PMID: 25406454 DOI: 10.1136/jfprhc-2014-100969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Lesley Bacon
- Consultant in Sexual and Reproductive Health, Lewisham and Greenwich NHS Trust, London, UK
| | - Dale Coley
- IT Analyst, Sexual and Reproductive Health, Lewisham and Greenwich NHS Trust, London, UK
| | - Eleanor Draeger
- Genitourinary Medicine Consultant, Lewisham and Greenwich NHS Trust, London, UK
| | - Jacqueline Evans
- Associate Specialist in Sexual and Reproductive Health, Lewisham and Greenwich NHS Trust, London, UK
| |
Collapse
|