Informatics tools and medical communication: patient perspectives of "knowledge coupling" in primary care

Use of the Electronic Health Record During Clinical Encounters: An Experience Survey

PURPOSE

Use of the electronic health record (EHR) during face-to-face clinical encounters affects communication, and prior research has been inconclusive regarding its effect. This survey study assessed health care practitioner use of EHR-specific communication skills and patient and practitioner experiences and attitudes regarding EHR use during clinical encounters.

METHODS

For this US-based study, we distributed previously validated surveys to practitioners and adult patients (aged >18 years) at academic primary care practices from July 1, 2018 through August 31, 2018. The electronic practitioner survey was completed first; a paper survey was administered to patients after appointments. Descriptive statistics were calculated, and the Cochran-Armitage test was used to assess for associations between key variables.

RESULTS

The practitioner response was 72.9% (43/59); patient response, 45.2% (452/1,000). Practitioners reported maintaining less eye contact (79.1%), listening less carefully (53.5%), focusing less on patients (65.1%), and visits feeling less personal (62.8%). However, patients reported that practitioners provided sufficient eye contact (96.8%) and listened carefully (97.0%); they disagreed that practitioners focused less on them (86.7%) or that visits felt less personal (87.2%). Patients thought EHR use was positive (91.7%); only one-third of practitioners (37.2%) thought that patients would agree with that statement. Practitioners reported stress, burnout, and a lack of sufficient time for EHR documentation.

CONCLUSIONS

A discrepancy existed in this study between patient and practitioner experiences and attitudes about EHR use, which appeared to negatively affect the experience of health care practitioners but not patients. Organizations should adopt formal strategies to improve practitioner experiences with EHR use.

Electronic-clinical evaluation exercise (e-CEX): A new patient-centered EHR use tool

INTRODUCTION

Electronic Health Record (EHR) use can enhance or weaken patient-provider communication. Despite EHR adoption, no validated tool exists to assess EHR communication skills. We aimed to develop and validate such a tool.

METHODS

Electronic-Clinical Evaluation Exercise (e-CEX) is a 10-item-tool based on systematic literature review and pilot-testing. Second-year (MS2s) students participated in an EHR-use lecture and structured Clinical Examination (OSCE). Untrained third-year students (MS3s) participated in the same OSCE. OSCEs were scored with e-CEX compared to a standardized patient (SP) tool. Internal consistency, discriminant validity, and concurrent validity were analyzed.

RESULTS

Three investigators used e-CEX to rate 70 videos (20 MS2, 50 MS3). Reliability testing indicated high internal consistency (Cronbach's alpha=0.89). MS2s scored significantly higher than untrained MS3s on e-CEX [e-CEX 55(10.7) vs. 44.9 (12.7), P=0.003], providing evidence of discriminant validity. e-CEX and SP score correlation was high (Pearson correlation=0.74, P<0.001), providing concurrent validity evidence. Item reduction suggested a three-item tool had similar explanatory power (R-squared=0.85 vs 0.86).

CONCLUSION

e-CEX is a reliable, valid tool to assess medical student patient-centered EHR communication skills.

PRACTICE IMPLICATIONS

While validation is needed with other healthcare providers, e-CEX may help improve provider behaviors and enhance patients' overall experience of EHR use in their care.

Impact of Electronic Medical Record Use on the Patient-Doctor Relationship and Communication: A Systematic Review

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.

Seeking high reliability in primary care: Leadership, tools, and organization

BACKGROUND

Leaders in health care increasingly recognize that improving health care quality and safety requires developing an organizational culture that fosters high reliability and continuous process improvement. For various reasons, a reliability-seeking culture is lacking in most health care settings. Developing a reliability-seeking culture requires leaders' sustained commitment to reliability principles using key mechanisms to embed those principles widely in the organization.

PURPOSE

The aim of this study was to examine how key mechanisms used by a primary care practice (PCP) might foster a reliability-seeking, system-oriented organizational culture.

METHODOLOGY

A case study approach was used to investigate the PCP's reliability culture. The study examined four cultural artifacts used to embed reliability-seeking principles across the organization: leadership statements, decision support tools, and two organizational processes. To decipher their effects on reliability, the study relied on observations of work patterns and the tools' use, interactions during morning huddles and process improvement meetings, interviews with clinical and office staff, and a "collective mindfulness" questionnaire. The five reliability principles framed the data analysis.

FINDINGS

Leadership statements articulated principles that oriented the PCP toward a reliability-seeking culture of care. Reliability principles became embedded in the everyday discourse and actions through the use of "problem knowledge coupler" decision support tools and daily "huddles." Practitioners and staff were encouraged to report unexpected events or close calls that arose and which often initiated a formal "process change" used to adjust routines and prevent adverse events from recurring. Activities that foster reliable patient care became part of the taken-for-granted routine at the PCP.

PRACTICE IMPLICATIONS

The analysis illustrates the role leadership, tools, and organizational processes play in developing and embedding a reliable-seeking culture across an organization. Progress toward a reliability-seeking, system-oriented approach to care remains ongoing, and movement in that direction requires deliberate and sustained effort by committed leaders in health care.

Reconciling evidence-based medicine and patient-centred care: defining evidence-based inputs to patient-centred decisions

Evidence-based and patient-centred health care movements have each enhanced the discussion of how health care might best be delivered, yet the two have evolved separately and, in some views, remain at odds with each other. No clear model has emerged to enable practitioners to capitalize on the advantages of each so actual practice often becomes, to varying degrees, an undefined mishmash of each. When faced with clinical uncertainty, it becomes easy for practitioners to rely on formulas for care developed explicitly by expert panels, or on the tacit ones developed from experience or habit. Either way, these tendencies towards 'cookbook' medicine undermine the view of patients as unique particulars, and diminish what might be considered patient-centred care. The sequence in which evidence is applied in the care process, however, is critical for developing a model of care that is both evidence based and patient centred. This notion derives from a paradigm for knowledge delivery and patient care developed over decades by Dr. Lawrence Weed. Weed's vision enables us to view evidence-based and person-centred medicine as wholly complementary, using computer tools to more fully and reliably exploit the vast body of collective knowledge available to define patients' uniqueness and identify the options to guide patients. The transparency of the approach to knowledge delivery facilitates meaningful practitioner-patient dialogue in determining the appropriate course of action. Such a model for knowledge delivery and care is essential for integrating evidence-based and patient-centred approaches.

Qualified doctor and medical students' use of resources for accessing information: what is used and why?

BACKGROUND

Learning to access information using resources such as books and search engines is an important and fast changing challenge for doctors and medical students. Many resources exist to support evidence-based clinical decision-making, but a wide range of factors influences their use.

OBJECTIVE

To explore qualified doctor and medical students' use of resources for accessing information and to determine what is used and why.

METHODS

A stratified sample of 46 participants was recruited in Devon, UK. Participants kept a self-report diary of resources used over a week. The diaries were then used to stimulate recall within a semi-structured interview. Diary data were collated into tables of resource use. Qualitative data from the interviews were transcribed verbatim and thematically analysed.

RESULTS

Many resources were used by participants but typically for a short duration of time. Categories of reasons for accessing resources were 'to check', 'to learn' and 'to demonstrate'. The two main factors influencing choice of information resource were 'ease of access' and 'quality of information'. Students accessed more information, for a longer duration.

DISCUSSION & CONCLUSION

Resources must be quick to use, easy to access and tailored to the different purposes that they serve for qualified doctors and medical students.

Patients' perceptions of general practitioners using computers during the patient-doctor consultation

In this study 85 adult patients attending a Sydney general practice were asked for their views on computer-assisted consultations; 77 (91%) agreed to participate. In general, patients agreed they could still talk easily with their doctor, and felt listened to, while the doctor used the computer (87% & 75% respectively). More than half the patients felt the computer contributed to better treatment, although a quarter believed consultations were prolonged. About half the patients agreed that the doctor did not often explain the role of the computer. Given the national plans for increasing computerisation of health records (HealthConnect), this research suggests that more attention should be given to involving patients in e-health developments.

Promoting health literacy

This report reviews some of the extensive literature in health literacy, much of it focused on the intersection of low literacy and the understanding of basic health care information. Several articles describe methods for assessing health literacy as well as methods for assessing the readability of texts, although generally these latter have not been developed with health materials in mind. Other studies have looked more closely at the mismatch between patients' literacy levels and the readability of materials intended for use by those patients. A number of studies have investigated the phenomenon of literacy from the perspective of patients' interactions in the health care setting, the disenfranchisement of some patients because of their low literacy skills, the difficulty some patients have in navigating the health care system, the quality of the communication between doctors and their patients including the cultural overlay of such exchanges, and ultimately the effect of low literacy on health outcomes. Finally, the impact of new information technologies has been studied by a number of investigators. There remain many opportunities for conducting further research to gain a better understanding of the complex interactions between general literacy, health literacy, information technologies, and the existing health care infrastructure.