Ethnically diverse patients' perceptions of clinician computer use in a safety-net clinic

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.

Perspectives of English, Chinese, and Spanish-Speaking Safety-Net Patients on Clinician Computer Use: Qualitative Analysis

BACKGROUND

Safety-net systems serve patients with limited health literacy and limited English proficiency (LEP) who face communication barriers. However, little is known about how diverse safety-net patients feel about increasing clinician electronic health record (EHR) use.

OBJECTIVE

The aim of this study was to better understand how safety-net patients, including those with LEP, view clinician EHR use.

METHODS

We conducted focus groups in English, Spanish, and Cantonese (N=37) to elicit patient perspectives on how clinicians use EHRs during clinic visits. Using a grounded theory approach, we coded transcripts to identify key themes.

RESULTS

Across multiple language groups, participants accepted multitasking and silent clinician EHR use if focused on their care. However, participants desired more screen share and eye contact, especially when demonstrating physical concerns. All participants, including LEP participants, wanted clinicians to include them in EHR use.

CONCLUSIONS

Linguistically diverse patients accept the value of EHR use during outpatient visits but desire more eye contact, verbal warnings before EHR use, and screen-sharing. Safety-net health systems should support clinicians in completing EHR-related tasks during the visit using patient-centered strategies for all patients.

Clinically Excellent Use of the Electronic Health Record: Review

BACKGROUND

The transition to the electronic health record (EHR) has brought forth a rapid cultural shift in the world of medicine, presenting both new challenges as well as opportunities for improving health care. As clinicians work to adapt to the changes imposed by the EHR, identification of best practices around the clinically excellent use of the EHR is needed.

OBJECTIVE

Using the domains of clinical excellence previously defined by the Johns Hopkins Miller Coulson Academy of Clinical Excellence, this review aims to identify best practices around the clinically excellent use of the EHR.

METHODS

The authors searched the PubMed database, using keywords related to clinical excellence domains and the EHR, to capture the English-language, peer-reviewed literature published between January 1, 2000, and August 2, 2016. One author independently reviewed each article and extracted relevant data.

RESULTS

The search identified 606 titles, with the majority (393/606, 64.9%) in the domain of communication and interpersonal skills. Twenty-eight of the 606 (4.6%) titles were excluded from full-text review, primarily due to lack of availability of the full-text article. The remaining 578 full-text articles reviewed were related to clinical excellence generally (3/578, 0.5%) or the specific domains of communication and interpersonal skills (380/578, 65.7%), diagnostic acumen (31/578, 5.4%), skillful negotiation of the health care system (4/578, 0.7%), scholarly approach to clinical practice (41/578, 7.1%), professionalism and humanism (2/578, 0.4%), knowledge (97/578, 16.8%), and passion for clinical medicine (20/578, 3.5%).

CONCLUSIONS

Results suggest that as familiarity and expertise are developed, clinicians are leveraging the EHR to provide clinically excellent care. Best practices identified included deliberate physical configuration of the clinical space to involve sharing the screen with patients and limiting EHR use during difficult and emotional topics. Promising horizons for the EHR include the ability to augment participation in pragmatic trials, identify adverse drug effects, correlate genomic data to clinical outcomes, and follow data-driven guidelines. Clinician and patient satisfaction with the EHR has generally improved with time, and hopefully continued clinician, and patient input will lead to a system that satisfies all.

Finding Meaning in Medication Reconciliation Using Electronic Health Records: Qualitative Analysis in Safety Net Primary and Specialty Care

BACKGROUND

Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication.

OBJECTIVE

This mixed-methods observational study aimed to develop a conceptual framework of how clinicians balance the demands and risks of EHR and communication tasks during medication reconciliation discussions in a safety net system.

METHODS

This study occurred 3 to 16 (median 9) months after new EHR implementation in five academic public hospital clinics. We video recorded visits between English-/Spanish-speaking patients and their primary/specialty care clinicians. We analyzed the proportion of medications addressed and coded time spent on nonverbal tasks during medication reconciliation as "multitasking EHR use," "silent EHR use," "non-EHR multitasking," and "focused patient-clinician talk." Finally, we analyzed communication patterns to develop a conceptual framework.

RESULTS

We examined 35 visits (17%, 6/35 Spanish) between 25 patients (mean age 57, SD 11 years; 44%, 11/25 women; 48%, 12/25 Hispanic; and 20%, 5/25 with limited health literacy) and 25 clinicians (48%, 12/25 primary care). Patients had listed a median of 7 (IQR 5-12) relevant medications, and clinicians addressed a median of 3 (interquartile range [IQR] 1-5) medications. The median duration of medication reconciliation was 2.1 (IQR 1.0-4.2) minutes, comprising a median of 10% (IQR 3%-17%) of visit time. Multitasking EHR use occurred in 47% (IQR 26%-70%) of the medication reconciliation time. Silent EHR use and non-EHR multitasking occurred a smaller proportion of medication reconciliation time, with a median of 0% for both. Focused clinician-patient talk occurred a median of 24% (IQR 0-39%) of medication reconciliation time. Five communication patterns with EHR medication reconciliation were observed: (1) typical EHR multitasking for medication reconciliation, (2) dynamic EHR use to negotiate medication discrepancies, (3) focused patient-clinician talk for medication counseling and addressing patient concerns, (4) responding to patient concerns while maintaining EHR use, and (5) using EHRs to engage patients during medication reconciliation. We developed a conceptual diagram representing the dilemma of the multitasking clinician during medication reconciliation.

CONCLUSIONS

Safety net visits involve multitasking EHR use during almost half of medication reconciliation time. The multitasking clinician balances the cognitive and emotional demands posed by incoming information from multiple sources, attempts to synthesize and act on this information through EHR and communication tasks, and adopts strategies of silent EHR use and focused patient-clinician talk that may help mitigate the risks of multitasking. Future studies should explore diverse patient perspectives about clinician EHR multitasking, clinical outcomes related to EHR multitasking, and human factors and systems engineering interventions to improve the safety of EHR use during the complex process of medication reconciliation.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

PRACTICE IMPLICATIONS

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

Patient Perceptions of Electronic Medical Record Use by Faculty and Resident Physicians: A Mixed Methods Study

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.

Computer use, language, and literacy in safety net clinic communication

OBJECTIVE

Patients with limited health literacy (LHL) and limited English proficiency (LEP) experience suboptimal communication and health outcomes. Electronic health record implementation in safety net clinics may affect communication with LHL and LEP patients.We investigated the associations between safety net clinician computer use and patient-provider communication for patients with LEP and LHL.

MATERIALS AND METHODS

We video-recorded encounters at 5 academically affiliated US public hospital clinics between English- and Spanish-speaking patients with chronic conditions and their primary and specialty care clinicians. We analyzed changes in communication behaviors (coded with the Roter Interaction Analysis System) with each additional point on a clinician computer use score, controlling for clinician type and visit length and stratified by English proficiency and health literacy status.

RESULTS

Greater clinician computer use was associated with more biomedical statements (+12.4, P = .03) and less positive affect (-0.6, P < .01) from LEP/LHL patients. In visits with patients with adequate English proficiency/health literacy, greater clinician computer use was associated with less positive patient affect (-0.9, P < .01), fewer clinician psychosocial statements (-3.5, P < .05), greater clinician verbal dominance (+0.09, P < .01), and lower ratings on quality of care and communication.

CONCLUSION

Higher clinician computer use was associated with more biomedical focus with LEP/LHL patients, and clinician verbal dominance and lower ratings with patients with adequate English proficiency and health literacy.

DISCUSSION

Implementation research should explore interventions to enhance relationship-centered communication for diverse patient populations in the computer era.

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.

Computers in the clinical encounter: a scoping review and thematic analysis

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.