Modeling eye gaze patterns in clinician-patient interaction with lag sequential analysis

The relationship between caregivers' behaviors and resistant behaviors of persons living with dementia during personal care in long-term care facilities: A lag sequential analysis

Many older adults living with dementia exhibit resistant behaviors. Person-centered care is the gold standard of care; however, the sequential relationship between resistant and caregiving behaviors has not been identified. This study examined the sequential relationship between caregiving and care-resistant behaviors and analyzed 68 videos of personal care encounters of 21 residents living in four long-term care facilities. The videos were coded focusing on two sequences of behavior: residents' resistant behaviors and caregivers' behaviors. Lag sequential analysis was conducted using initial-response behavior pairs (resident-caregiver behavior or caregiver-resident behavior pairs). Person-centered care led to less resistant behavior (odds ratio 0.23; 95 % confidence interval 0.16, 0.33), whereas less person-centered care was followed by resistant behaviors (odds ratio 0.42; 95 % confidence interval 0.30, 0.59). A significant sequential association was found between task-centered behavior and resistant behavior. Hence, rigorous efforts are recommended to provide person-centered care through multilevel efforts.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quantitative CT imaging features for COVID-19 evaluation: The ability to differentiate COVID-19 from non- COVID-19 (highly suspected) pneumonia patients during the epidemic period

Objectives

COVID-19 and Non-Covid-19 (NC) Pneumonia encountered high CT imaging overlaps during pandemic. The study aims to evaluate the effectiveness of image-based quantitative CT features in discriminating COVID-19 from NC Pneumonia.

Materials and methods

145 patients with highly suspected COVID-19 were retrospectively enrolled from four centers in Sichuan Province during January 23 to March 23, 2020. 88 cases were confirmed as COVID-19, and 57 patients were NC. The dataset was randomly divided by 3:2 into training and testing sets. The quantitative CT radiomics features were extracted and screened sequentially by correlation analysis, Mann-Whitney U test, the least absolute shrinkage and selection operator (LASSO) logistic regression (LR) and backward stepwise LR with minimum AIC methods. The selected features were used to construct the LR model for differentiating COVID-19 from NC. Meanwhile, the differentiation performance of traditional quantitative CT features such as lesion volume ratio, ground glass opacity (GGO) or consolidation volume ratio were also considered and compared with Radiomics-based method. The receiver operating characteristic curve (ROC) analysis were conducted to evaluate the predicting performance.

Results

Compared with traditional CT quantitative features, radiomics features performed best with the highest Area Under Curve (AUC), sensitivity, specificity and accuracy in the training (0.994, 0.942, 1.0 and 0.965) and testing sets (0.977, 0.944, 0.870, 0.915) (Delong test, P < 0.001). Among CT volume-ratio based models using lesion or GGO component ratio, the model combining CT lesion score and component ratio performed better than others, with the AUC, sensitivity, specificity and accuracy of 0.84, 0.692, 0.853, 0.756 in the training set and 0.779, 0.667, 0.826, 0.729 in the testing set. The significant difference of the most selected wavelet transformed radiomics features between COVID-19 and NC might well reflect the CT signs.

Conclusions

The differentiation between COVID-19 and NC could be well improved by using radiomics features, compared with traditional CT quantitative values.

The doctor will see you now: eye gaze, conversation and patient engagement in the surgical outpatient clinic. An Australian observational cross-sectional study

BACKGROUND

Surgical outpatient consultations are demanding for the surgeon and patients without a definite formula for success. Various factors have been identified regarding factors that influence patient satisfaction and engagement. We aimed to examine the modern-day surgical outpatient consultation and report on these factors.

METHODS

An observational cross-sectional study was performed by reviewing video recordings of 182 surgical consultations by 12 surgeons at The Queen Elizabeth Hospital, South Australia, Australia.

RESULTS

The mean consultation time was 12.3 min, with pre-surgical consultations being the longest. There were 107 consultations for benign conditions (58%). Proportionally, the consultant spoke most (51.9% of total consultation time), followed by the patient (19.5%) and then companion (8.2%). Forty-eight (26.4%) patients brought a companion to the clinic but monopolisation of the consultation by the companion was rare. When a companion was present, there was more mutual eye gaze between the consultant and the patient. Interruptions were present in 23.6% of consultations and were associated with a significant increase of the length of the consultation. Table positioning did not seem to affect the dynamics of the outpatient consultation.

CONCLUSION

Companions are highly valuable for promoting patient engagement and their presence should be encouraged in surgical outpatients. Interruptions should be kept to a minimum to avoid unnecessary delays. Further studies should be conducted to investigate the effect of companions, interruptions and table positioning during a consultation on patient outcomes.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Student pharmacist opioid consultations with standardized limited English proficiency patients: A pre-post educational intervention study

BACKGROUND AND PURPOSE

This study explored the effect of a structured educational intervention for student pharmacists to counsel limited English proficiency (LEP) patients on risks and safety of opioid medications for chronic pain. Specific aims were to compare 2018 pre-intervention versus 2019 post-intervention groups regarding: (1) dose and side effects discussed, (2) opioid risks and safety measures covered, and (3) LEP specific communication practices.

EDUCATIONAL ACTIVITY AND SETTING

Third-year student pharmacists (P3s) in a required communications course consulted LEP standardized patients (SPs) on opioid medications in 2018 and 2019. An educational intervention for the 2019 P3s consisted of a 50-min lecture, pre-lab instructions about techniques for communication about opioid risks and safety, and for LEP specific communication stressing teach-back. All consultations in the pre- and post-intervention phases were video recorded and quantitatively coded for verbal and non-verbal communication skills. Descriptive statistics and Fisher's exact tests were conducted on data.

FINDINGS

Twenty-three consultations were recorded in 2018 for the pre-intervention phase and 49 consultations were recorded in 2019 for the post-intervention phase. Only 17% of students in the pre- intervention phase called the medication an "opioid" or "narcotic" in the consultation as compared to 84% in the post-intervention phase. While 100% of students in the post-intervention phase used teach-back, only 61% did so in the pre-intervention group. Significant differences between the two groups were observed for minimizing dependency and overdose, offering naloxone, teach-back, integrating a patient handout into the consultation, and discussing use of alternate pain medications.

Improving Patient Experience by Teaching Empathic Touch and Eye Gaze: A Randomized Controlled Trial of Medical Students

Background

Empathy is critical for optimal patient experience with health-care providers. Verbal empathy is routinely taught to medical students, but nonverbal empathy, including touch, less so. Our objective was to determine whether instruction encouraging empathic touch and eye gaze at exit can impact behaviors and change patient-perceived empathy.

Materials

A randomized, controlled, double-blinded trial of 34 first-year medical students was conducted during standardized patient (SP) interviews. A video either encouraging empathic touch and eye gaze at exit or demonstrating proper hand hygiene (control) was shown. Encounter videos were analyzed for touch and eye gaze at exit. The Jefferson Scale of Patient Perceptions of Physician Empathy was used to measure correlations. Intervention students were surveyed regarding patient touch.

Results

Of this, 23.5% of intervention students touched the SP versus zero controls; 88.2% of intervention students demonstrated eye gaze at exit. Eye gaze at exit positively impacted patient-perceived empathy (correlation = 0.48, P > .001). Survey responses revealed specific barriers to touch.

Conclusion

Medical students may increase perceived empathy using eye gaze at exit. Instruction on empathic touch and sustained eye gaze at exit at the medical school level may be useful in promoting empathic nonverbal communication. Medical educators should consider providing specific instructions on how to appropriately touch patients during history-taking. This is one of the few studies to explore touch with patients and the first ever to report the positive correlation of a health provider's sustained eye gaze at exit with the patient's perceived empathy. Further studies are needed to explore barriers to empathic touch.

Pharmacy Student Opioid Consultations with Standardized Limited English Proficiency Patients

INTRODUCTION

Limited healthcare studies have analyzed communication practices with limited English proficiency (LEP) patients. Empirical literature lacks evidence about LEP patient-pharmacist communication about opioid risks. This study aimed to (1) explore topics discussed in opioid medication consults, (2) assess if students inform patients about dependency and overdose risks associated with opioid use and the manner in which those risks were introduced and discussed, and (3) assess LEP specific communication practices.

METHODS

Third-year pharmacy students in a required communications course consulted LEP standardized patients (SPs) who spoke 30% English and 70% non-English language. The SP followed a script simulating an encounter between a pharmacist and patient picking up a new, month long prescription of oxycodone. All consultations were video recorded and quantitatively coded for verbal and non-verbal communication skills.

RESULTS

Twenty-three pharmacy students conducted consultations with LEP SPs. The majority of students discussed common side effects, but only a few discussed severe side effects. Four of 23 students named the medication as an "opioid" or "narcotic" and described dependency, overdose, or other opioid specific risks. Students used several filler words, long sentences, and a fast pace. A majority of students used teach back methods to identify patient understanding. Students expressed the need for more structured education and training in providing patient counseling for opioids and communicating with LEP patients.

CONCLUSIONS

Pharmacy students lack confidence and skills in communicating with LEP patients regarding opioid-specific risks, suggesting structured training is needed.

Sequential Analysis of Livestock Herding Dog and Sheep Interactions

Simple Summary

Although livestock herding dogs have contributed significantly to Australian agriculture, there are virtually no studies examining the interactions between dog and livestock during herding. One statistical approach that may assist our understanding of such interactions during herding is lag sequential analysis that reveals links between one event and the next. Using high-definition video recordings of herding in a yard-based competition trial and software to code the main dog and sheep behaviours, we identified several significant behavioural interactions. These included the dog ceasing all movement followed by the sheep also ceasing movement; the dog chasing the sheep and a group of sheep escaping the main flock; a single sheep escaping the flock and the dog chasing; sheep initiating movement followed by the dog following; foot-stamping followed by the dog ceasing all movement; and, foot-stamping by the sheep and the dog lip-licking in response. Further statistical analysis found no significant sex differences in the herding styles of the dogs included in the study. Of benefit to livestock herding dog handlers and breeders was the identification of trial score as a predictor of efficient performance.

Abstract

Livestock herding dogs are crucial contributors to Australian agriculture. However, there is a dearth of empirical studies of the behavioural interactions between dog and livestock during herding. A statistical approach that may reveal cause and effect in such interactions is lag sequential analysis. Using 48 video recordings of livestock herding dogs and sheep in a yard trial competition, event-based (time between behaviours is irrelevant) and time-based (time between behaviours is defined) lag sequential analyses identified several significant behavioural interactions (adjusted residuals greater than 2.58; the maximum likelihood-ratio chi-squared statistic for all eight contingency tables identified all sequences as highly significant (p < 0.001)). These sequences were: The dog ceasing all movement followed by the sheep also ceasing movement; the dog chasing the sheep and a group of sheep escaping the main flock; a single sheep escaping the flock and the dog chasing; sheep initiating movement followed by the dog following; foot-stamping followed by the dog ceasing all movement; and, foot-stamping by the sheep and the dog lip-licking in response. Log linear regression identified significant relationships among undesirable behaviours in sheep and both observed trial duration (p = 0.001) and trial score (p = 0.009). No differences in the herding styles of dogs were identified between sex of dog and frequency of sheep escape behaviours (p = 0.355) nor the sex of dog and competition level (p = 0.116). The identification of trial score as a predictor of efficient performance confirms the benefits of incorporating extant objective measures to assess livestock herding dogs.

Evaluating Pharmacy Student Consultations with Standardized Patients on Opioid Medication Use and Opioid-Specific Risks

Objective. To assess third-year pharmacy students' entry-level verbal and nonverbal communication skills when addressing sensitive topics during opioid consultations with standardized patients. Methods. Seventy-one students were video-taped while consulting with standardized patients who were receiving a one-month supply of oxycodone for lower back pain. Consults were coded quantitatively for the topics students discussed with the patient, terms used, eye contact, and filler words. Results. The majority of pharmacy students discussed common and severe opioid side effects, such as respiratory depression. However, only 30% explained that the medication being dispensed was an opioid or narcotic, and only 23% of students initiated a conversation regarding dependence, addiction, or overdose risk. Students used more filler words when discussing dependence, addiction, or overdose risk as compared to the rest of the consult. Afterwards, students expressed discomfort and the need for additional training and resources for communicating with patients about opioids. Conclusion. Many students lacked confidence with regards to educating patients about opioid-specific risks. This necessitates expanding education regarding discussing sensitive information about opioids at this school of pharmacy. Other schools of pharmacy would benefit from an evaluation of their curriculum to assess the necessity for additional education and training.

Ambulatory Clinic Exam Room Design with respect to Computing Devices: A Laboratory Simulation Study

Background

Challenges persist regarding how to integrate computing effectively into the exam room, while maintaining patient-centered care.

Purpose

Our objective was to evaluate a new exam room design with respect to the computing layout, which included a wall-mounted monitor for ease of (re)-positioning.

Methods

In a lab-based experiment, 28 providers used prototypes of the new and older "legacy" outpatient exam room layouts in a within-subject comparison using simulated patient encounters. We measured efficiency, errors, workload, patient-centeredness (proportion of time the provider was focused on the patient), amount of screen sharing with the patient, workflow integration, and provider situation awareness.

Results

There were no statistically significant differences between the exam room layouts for efficiency, errors, or time spent focused on the patient. However, when using the new layout providers spent 75% more time in screen sharing activities with the patient, had 31% lower workload, and gave higher ratings for situation awareness (14%) and workflow integration (17%).

Conclusions

Providers seemed to be unwilling to compromise their focus on the patient when the computer was in a fixed position in the corner of the room and, as a result, experienced greater workload, lower situation awareness, and poorer workflow integration when using the old "legacy" layout. A thoughtful design of the exam room with respect to the computing may positively impact providers' workload, situation awareness, time spent in screen sharing activities, and workflow integration.

Designing Patient-facing Health Information Technologies for the Outpatient Settings: A Literature Review

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.

The myth of standardized workflow in primary care

OBJECTIVE

Primary care efficiency and quality are essential for the nation's health. The demands on primary care physicians (PCPs) are increasing as healthcare becomes more complex. A more complete understanding of PCP workflow variation is needed to guide future healthcare redesigns.

METHODS

This analysis evaluates workflow variation in terms of the sequence of tasks performed during patient visits. Two patient visits from 10 PCPs from 10 different United States Midwestern primary care clinics were analyzed to determine physician workflow. Tasks and the progressive sequence of those tasks were observed, documented, and coded by task category using a PCP task list. Variations in the sequence and prevalence of tasks at each stage of the primary care visit were assessed considering the physician, the patient, the visit's progression, and the presence of an electronic health record (EHR) at the clinic.

RESULTS

PCP workflow during patient visits varies significantly, even for an individual physician, with no single or even common workflow pattern being present. The prevalence of specific tasks shifts significantly as primary care visits progress to their conclusion but, notably, PCPs collect patient information throughout the visit.

DISCUSSION

PCP workflows were unpredictable during face-to-face patient visits. Workflow emerges as the result of a "dance" between physician and patient as their separate agendas are addressed, a side effect of patient-centered practice.

CONCLUSIONS

Future healthcare redesigns should support a wide variety of task sequences to deliver high-quality primary care. The development of tools such as electronic health records must be based on the realities of primary care visits if they are to successfully support a PCP's mental and physical work, resulting in effective, safe, and efficient primary care.

Quantitative ethnographic study of physician workflow and interactions with electronic health record systems

This study explores the relationship between primary care physicians' interactions with health information technology and primary care workflow. Clinical encounters were recorded with high-resolution video cameras to capture physicians' workflow and interaction with two objects of interest, the electronic health record (EHR) system, and their patient. To analyze the data, a coding scheme was developed based on a validated list of primary care tasks to define the presence or absence of a task, the time spent on each task, and the sequence of tasks. Results revealed divergent workflows and significant differences between physicians' EHR use surrounding common workflow tasks: gathering information, documenting information, and recommend/discuss treatment options. These differences suggest impacts of EHR use on primary care workflow, and capture types of workflows that can be used to inform future studies with larger sample sizes for more effective designs of EHR systems in primary care clinics. Future research on this topic and design strategies for effective health information technology in primary care are discussed.

Using video-based observation research methods in primary care health encounters to evaluate complex interactions

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.

Parents Produce Explicit Cues That Help Toddlers Distinguish Joking and Pretending

While separate pieces of research found parents offer toddlers cues to express that they are (1) joking and (2) pretending, and that toddlers and preschoolers understand intentions to (1) joke and (2) pretend, it is not yet clear whether parents and toddlers consider joking and pretending to be distinct concepts. This is important as distinguishing these two forms of non-literal acts could open a gateway to understanding the complexities of the non-literal world, as well as the complexities of intentions in general. Two studies found parents offer explicit cues to help 16- to 24-month-olds distinguish pretending and joking. Across an action play study (n = 25) and a verbal play study (n = 40) parents showed more disbelief and less belief through their actions and language when joking versus pretending. Similarly, toddlers showed less belief through their actions, and older toddlers showed less belief through their language. Toddlers' disbelief could be accounted for by their response to parents' language and actions. Thus, these studies reveal a mechanism by which toddlers learn to distinguish joking and pretending. Parents offer explicit cues to distinguish these intentions, and toddlers use these cues to guide their own behaviors, which in turn allows toddlers to distinguish these intentional contexts.

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

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.

More screen time, less face time - implications for EHR design

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.

Electronic Health Records (EHRs) in the oncology clinic: how clinician interaction with EHRs can improve communication with the patient

Electronic health records pose a particularly difficult problem in the oncology clinic, where difficult topics require much time and attention to address. But with careful attention, they might actually enhance communication in the clinic.

Real-time feedback on nonverbal clinical communication. Theoretical framework and clinician acceptance of ambient visual design

INTRODUCTION

This article is part of the focus theme of Methods of Information in Medicine on "Pervasive Intelligent Technologies for Health".

BACKGROUND

Effective nonverbal communication between patients and clinicians fosters both the delivery of empathic patient-centered care and positive patient outcomes. Although nonverbal skill training is a recognized need, few efforts to enhance patient-clinician communication provide visual feedback on nonverbal aspects of the clinical encounter.

OBJECTIVES

We describe a novel approach that uses social signal processing technology (SSP) to capture nonverbal cues in real time and to display ambient visual feedback on control and affiliation--two primary, yet distinct dimensions of interpersonal nonverbal communication. To examine the design and clinician acceptance of ambient visual feedback on nonverbal communication, we 1) formulated a model of relational communication to ground SSP and 2) conducted a formative user study using mixed methods to explore the design of visual feedback.

METHODS

Based on a model of relational communication, we reviewed interpersonal communication research to map nonverbal cues to signals of affiliation and control evidenced in patient-clinician interaction. Corresponding with our formulation of this theoretical framework, we designed ambient real-time visualizations that reflect variations of affiliation and control. To explore clinicians' acceptance of this visual feedback, we conducted a lab study using the Wizard-of-Oz technique to simulate system use with 16 healthcare professionals. We followed up with seven of those participants through interviews to iterate on the design with a revised visualization that addressed emergent design considerations.

RESULTS

Ambient visual feedback on non- verbal communication provides a theoretically grounded and acceptable way to provide clinicians with awareness of their nonverbal communication style. We provide implications for the design of such visual feedback that encourages empathic patient-centered communication and include considerations of metaphor, color, size, position, and timing of feedback.

CONCLUSIONS

Ambient visual feedback from SSP holds promise as an acceptable means for facilitating empathic patient-centered nonverbal communication.

Considering social ergonomics: the effects of HIT on interpersonal relationships between patients and clinicians

This study explored physicians' interactions with EHRs to understand the qualities that contribute to patient satisfaction with their use of the technologies and patient satisfaction with physician. Video-taped observations of 100 medical consultations were used to distinguish interaction patterns between physicians and EHRs. Quantified observational methods were used to contribute to ecological validity. Ten primary care physicians and 100 patients from five clinics participated in the study. Visits were videotaped and coded using an objective coding methodology to understand how physicians interacted with electronic health records. Results indicate, a variety of EHR interaction styles may be effective in providing patient-centered care.

Dynamic Comparison of Physicians' Interaction Style with Electronic Health Records in Primary Care Settings

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.

Dynamic modeling of patient and physician eye gaze to understand the effects of electronic health records on doctor-patient communication and attention

OBJECTIVE

The aim of this study was to examine eye gaze patterns between patients and physicians while electronic health records were used to support patient care.

BACKGROUND

Eye gaze provides an indication of physician attention to patient, patient/physician interaction, and physician behaviors such as searching for information and documenting information.

METHODS

A field study was conducted where 100 patient visits were observed and video recorded in a primary care clinic. Videos were then coded for gaze behaviors where patients' and physicians' gaze at each other and artifacts such as electronic health records were coded using a pre-established objective coding scheme. Gaze data were then analyzed using lag sequential methods.

RESULTS

Results showed that there are several eye gaze patterns significantly dependent to each other. All doctor-initiated gaze patterns were followed by patient gaze patterns. Some patient-initiated gaze patterns were also followed by doctor gaze patterns significantly unlike the findings in previous studies. Health information technology appears to contribute to some of the new significant patterns that have emerged. Differences were also found in gaze patterns related to technology that differ from patterns identified in studies with paper charts. Several sequences related to patient-doctor-technology were also significant. Electronic health records affect the patient-physician eye contact dynamic differently than paper charts.

CONCLUSION

This study identified several patterns of patient-physician interaction with electronic health record systems. Consistent with previous studies, physician initiated gaze is an important driver of the interactions between patient and physician and patient and technology.

Technology-mediated information sharing between patients and clinicians in primary care encounters

OBJECTIVE

The aim of this study was to identify and describe the use of electronic health records for information sharing between patients and clinicians in primary care encounters. This topic is particularly important as computers and other technologies are increasingly implemented in multi-user health care settings where interactions and communication between patients and clinicians are integral to interpersonal and organizational outcomes.

METHOD

An ethnographic approach was used to classify the encounters into distinct technology-use patterns based on clinicians` interactions with the technology and patients. Each technology-use pattern was quantitatively analysed to assist with comparison. Quantitative analysis was based on duration of patient and clinician gaze at EHR.

FINDINGS

Physicians employed three different styles to share information using EHRs: Active information-sharing, in which a clinician turns the monitor towards the patient and uses the computer to actively share information with the patient;Passive information-sharing, when a clinician does not move the monitor, but the patient might see the monitor by leaning in if they choose; andTechnology withdrawal, when a clinician does not share the monitor with the patient.

CONCLUSION

A variety of technology-mediated information-sharing styles may be effective in providing patient-centred care. New EHR designs may be needed to facilitate information sharing between patients and clinicians.

Physician Interactions with Electronic Health Records in Primary Care

OBJECTIVE

It is essential to design technologies and systems that promote appropriate interactions between physicians and patients. This study explored how physicians interact with Electronic Health Records (EHRs) to understand the qualities of the interaction between the physician and the EHR that may contribute to positive physician-patient interactions.

STUDY DESIGN

Video-taped observations of 100 medical consultations were used to evaluate interaction patterns between physicians and EHRs. Quantified observational methods were used to contribute to ecological validity.

METHODS

Ten primary care physicians and 100 patients from five clinics participated in the study. Clinical encounters were recorded with video cameras and coded using a validated objective coding methodology in order to examine how physicians interact with electronic health records.

RESULTS

Three distinct styles were identified that characterize physician interactions with the EHR: technology-centered, human-centered, and mixed. Physicians who used a technology-centered style spent more time typing and gazing at the computer during the visit. Physicians who used a mixed style shifted their attention and body language between their patients and the technology throughout the visit. Physicians who used the human-centered style spent the least amount of time typing and focused more on the patient.

CONCLUSION

A variety of EHR interaction styles may be effective in facilitating patient-centered care. However, potential drawbacks of each style exist and are discussed. Future research on this topic and design strategies for effective health information technology in primary care are also discussed.

Assessing Patient and Doctor Eye Gaze Patterns Between Two Styles of Doctor Ehr Use in Primary Care Encounters

The purpose of this study is to understand the potential relationship between the ways primary care doctors interact with electronic health records (EHRs) and the eye gaze patterns of doctors and patients during primary care visits. Forty primary care encounters where doctors used two different EHR interaction styles were analyzed. This study used a lag analysis method to analyze the eye-gaze patterns between doctor and patient for each style. Differences and similarities in eye gaze behavior patterns were found between the two styles. The results of this study may inform guidelines for EHR design and implementation and inform EHR interaction training.