Enhancing Patient-Centered Communication and Collaboration by Using the Electronic Health Record in the Examination Room

Abstract

As widespread adoption of the electronic health record (EHR) takes place in US medical practice, many health care experts have emphasized the promising capabilities of the EHR to foster patient activation, which is a characteristic of patients who view themselves as active collaborators in their own health care management.1 The use of EHRs has the potential to facilitate patient-physician communication via electronic messaging. It can also facilitate patient access to personal records, test results, health education tools, and tools for tracking and assessing the progress of chronic disease management. In addition to these features, new possibilities have arisen from innovative studies that enabled patients to read their physician notes online after the clinical encounter. After reviewing their visit notes, patients reported feeling more in control of their care.2 Yet the presence of a computer in the examination room and the pressure to document the visit in the EHR are often perceived as adversely affecting the patient-physician interaction.3,4 How can the EHR instead have a positive effect on this interaction and promote patient activation during the course of the outpatient visit? When clinicians invite patients to view the computer screen and parts of their electronic chart, it not only avoids uncomfortable periods of idle silence that sometimes accompany EHR-related tasks, but it may enhance the relational aspect of patient-physician communication in a way that fosters patient activation in real time. Although some emphasis has been placed on the role of the EHR and patient activation outside of the examination room, very few studies have examined the link between EHR-enhanced communication during the clinical encounter and the enhanced relational quality of the patient-physician relationship.3 When physicians miss the opportunity to take advantage of this untapped potential, the relational interaction is likely reduced. A video ethnographic study by Ventres and colleagues4 revealed that the majority of observed physicians settled into a workflow pattern of greeting a patient briefly and then walking directly to the computer, where they spent a few moments completing EHR-related tasks before reengaging the patient. Without directly intending to do so, a large number of clinicians in that study had developed patterns of EHR use that seemed to engender patient detachment rather than active involvement. One consistent theme that has emerged from early empirical studies on the styles of EHR use is that most physicians are comfortable with electronic charting as a means of organizing data and reviewing results.3,4 Recent behavioral studies have revealed a strong positive association between physicians gazing at the EHR screen and patients following the physician's gaze toward the screen. While this natural tendency could serve as an opportunity for collaborative information sharing, physicians generally reacted to patient screen-gazing by looking away from the screen more than 75% of the time.5 In place of nonverbal cues that tend to discourage patient screen-gazing, efforts to purposely facilitate patient EHR-gazing may enhance real-time communication as patients and physicians view the computer screen together. Introducing the EHR with a verbal explanation and patient-centered body language, by positioning the screen as a bridge rather than a divider, could enhance the relationship and jumpstart the process of activation. Dialogue is an important component of this process: “If you don't mind, I am going to be typing as you speak. I'm happy to show you what I'm writing”; “I'm going to look up your test results, would you like to look at them together?”; “Let's look at the trends in your blood pressure readings”; “Now that we've seen how you're doing, let's talk about how you can continue to improve ….” These verbal and nonverbal cues could potentiate collaboration by facilitating a joint assessment of the patient's current health status and highlighting opportunities for active patient involvement. Self-motivated and empowered patients are likely to regard the invitation to view their electronic chart as an act of transparency that enhances the collaborative nature of the patient-physician relationship. These patients may already be engaging in positive health behaviors, and their level of activation is likely to remain high. Clinicians can use the EHR as a tool to invite more passive patients into a participatory model of care by encouraging them to review their laboratory results, visualize their chronic disease trends, share in the decision-making process, and see what is documented in the plan of care. Even in the absence of chronic disease, strategies for activation can readily include accessing web-based information, comparing the prices of prescription or generic medications, printing self-help information about stress coping in the setting of new or continuing life stressors, or printing bilingual health information during the clinical encounter. This approach certainly has limitations, for clinicians may find it difficult to document sensitive patient issues candidly. Caution may be necessary when choosing how to document socially stigmatizing health conditions such as weight-related or mental health disorders in the written record. A recent study revealed that approximately 1 of 5 patients would avoid future appointments in response to a clinician using the term morbidly obese rather than more desirable terms such as unhealthy weight or overweight.6 Sharing the EHR screen has the potential to distress rather than motivate patients if they witness clinicians transcribing medical language that they perceive as judgmental. Yet this concern extends beyond interactions in the examination room because patients may request their medical records after the visit. It will become increasingly important for clinicians to develop the necessary writing skills and sensitivity to patient perceptions to document appearance, emotional state, symptoms, substance abuse, incomplete adherence to medical regimens, and other sensitive issues in a nonjudgmental way that patients may read at any time. On the other hand, some types of documentation such as psychotherapy notes may remain outside the scope of this approach to EHR collaboration.7 Furthermore, time pressures may limit patient participation in electronic chart review. In a busy office practice, clinicians lacking computer skills and familiarity with EHR software may struggle to display the medical record in light of other time-consuming tasks. Screen sharing with patients will therefore be most feasible for clinicians with strong computer navigation and typing skills. Even for those who have developed this technical skill set, apprehensions about the time required to answer patients' questions about their records may still concern many physicians. Indeed, 21% of the participating clinicians in a recent study allowing patients to access and ask questions about their electronic clinic notes reported spending more time writing notes.2 Presumably, this extra time may be the result of extensive efforts to avoid complex medical jargon that may be incomprehensible for patients. Although additional minutes may be necessary to replace shorthand abbreviations, spending the initial time writing within a patient's view may save time explaining the plan of care later. Ultimately, patient-physician communication lies at the heart of patient-centered care. Interventions that improve face-to-face communication during the clinical encounter are likely to have an effect on patient activation, with corresponding improvements in behaviors and health outcomes. Using the EHR as a relational tool is a strategy for improving individual and population-based health outcomes, for various studies have shown that interventions aimed at increasing patient activation have led to significant improvements in the management of chronic disease, mental illness, and other health-related behaviors or conditions.1,8 The health care community may find the EHR to be an untapped means of encouraging patient-physician collaboration and for enhancing patient activation during the clinic visit. Future empirical studies are needed to explore the potential benefits of this expanded use of the EHR on quantitative measures of patient activation.