How can exam room computing foster – rather than hinder – patient-centered communication?

October 12, 2017

How can exam room computing foster – rather than hinder – patient-centered communication?

Institute for Healthcare Policy & Innovation

Building meaningful conversations out of Meaningful Use requirements

It’s something most of us experience several times throughout our day: the unsettling feeling that the smart phones and smart watches, tablets, and other technologies that have grown so pervasive in recent years are making unwelcome intrusions into our personal relationships, and stilting our human-to-human conversation.

We may experience this rather acutely in our healthcare providers’ offices too. Electronic health record (EHR) systems have revolutionized healthcare, mostly for good, and are here to stay. But the presence of yet another inescapable screen in the examination room can hinder communication between patients and clinicians.

What’s more, research has shown that ineffective use of EHR technology during patient encounters can interfere with treatment priorities and disease management goals, and has been associated with increased costs and unnecessary healthcare utilization.

How can IT devices in the exam room be used to improve, rather than detract from, patient engagement? Can providers be trained to conduct their computing in a way that guides and encourages conversations, rather than shutting them down? Can such training also simultaneously enhance therapeutic practice, which is the delivery of recommended treatment protocols, or guideline-based care?

Minal Patel, Ph.D., the John G. Searle Assistant Professor of Health Behavior and Health Education in the U-M School of Public Health, has been researching the answers to many of these questions, with the goal of promoting effective strategies to improve patient outcomes and patient and provider engagement and satisfaction within the context of health IT.

“The computer does not have to be this ‘third party’ in the patient visit,” Patel says. “It can be a way to triangulate communication in a way that continues to build the relationship with the patient.”

What can providers do to enhance communication in the presence of computerized systems? Seemingly simple things, like:

  • Maintaining eye contact or conversation while typing
  • Using the computer to facilitate conversation, by talking with patients about their understanding of the information in their electronic chart, and inviting them to share in decisions, such as pharmacy choice.
  • When feasible, adjusting room design or introducing laptops on wheeled stands so patients and providers can sit side-by-side to review data on screens.

Patel and her research team distilled these and other best practices strategies in a recent systematic literature review, and used the evidence to modify and expand an interactive communications training tool for primary care physicians about asthma (the evidence-based Physician Asthma Care Education (PACE) program) to include strategies on the effective use of EHRs at the point of care.

“How do you communicate with patients while you are trying to do all this computing that you have to do in the exam room?” -- Minal Patel

 

The researchers just concluded a pilot randomized controlled trial that looked at whether the adapted training improved physicians’ confidence in their ability to integrate these strategies into patient care. They found significant increases in providers’ ability to utilize these practices, as well as a significant decrease in their perceptions that the computer represents a barrier in the patient-physician relationship. Now, the team is preparing to launch a larger, longer-term study that could assess whether patient outcomes also improve as a result of the training.

Of course, the feasibility of the strategies Patel and team identified depend on the computing environment in which they are implemented. The most flexible exam rooms allow for the movement of furniture and computers to accommodate patients, while in others the computer is tied to a fixed spot in the room. In other scenarios, someone besides the provider (a transcriptionist, etc.) inputs the data into the EHR system following visits. Their adapted PACE training accommodates these differences and tailors to them.

“We’re thinking a lot about how these strategies actually translate into diverse practice settings,” Patel, who is also a member of the Institute for Healthcare Policy & Innovation, says, “and for each we’ve come up with suggestions for how providers can best integrate the patient into the visit while using the EHR.”

Are there implications here for more patient-centered design of EHR systems? Patel says we are seeing more and more of this, including more patient-friendly visualizations and other interactive data displays, and even discussion prompts to guide patient-provider conversation.

Throughout the implementation of federal “Meaningful Use” requirements across the U.S. healthcare system – in which providers must adopt certified EHR technology and use it to achieve specific objectives – much of the assistance offered to providers has focused on helping them with the technical elements of EHR systems. A sometimes overlooked component of meaningful use objectives is the use of EHR technology to engage patients and families; Patel’s research is unique in that it focuses on the human side of integration, and how people interact with health IT systems once implemented.

Her work has significance for physician well being as well. “If we can help physicians feel more confident in integrating these patient-centered communication strategies into their work, we hope that will help alleviate the burnout some may feel with all the extra computing now required in the exam room,” she says.

The review and pilot studies were funded in part by the Agency for Healthcare Research and Quality (AHRQ).

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