The electronic health record as a patient engagement tool: mirroring clinicians’ screen to create a shared mental model

The electronic health record as a patient engagement tool: mirroring clinicians’ screen to... Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 1(1), 2018, 42–48 doi: 10.1093/jamiaopen/ooy006 Advance Access Publication Date: 20 April 2018 Research and Applications Research and Applications The electronic health record as a patient engagement tool: mirroring clinicians’ screen to create a shared mental model Onur Asan, Jeanne Tyszka, and Bradley Crotty Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Corresponding Author: Onur Asan, PhD, Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA (oasan@mcw.edu) Received 21 December 2017; Revised 13 February 2018; Accepted 14 March 2018 ABSTRACT Objective: Electronic health records (EHRs) in physician offices can both enhance and detract from the patient experience. Best practices have emerged focusing on screen sharing. We sought to determine if adding a sec- ond monitor, mirroring the EHR for patients, would be welcome and useful for patients and clinicians. Materials and Methods: This mixed-method study was conducted in a general medicine clinic from March to June 2016. Clinicians and patients met in a specially equipped exam room with a patient-facing monitor. Visits were video-recorded to assess time spent viewing the EHR and followed by interviews, which were transcribed and analyzed using established qualitative methods. Results: Eight clinicians and 24 patients participated. Main themes included the second screen serving as a cata- lyst for patient engagement, augmenting the clinic visit in a meaningful way, improving transparency of the care process and documentation, and providing a substantially different experience for patients than a shared single screen. Concerns and suggestions for improvement were also reported. Quantitative results showed high patient engagement times with the EHR (25% of the visit length) compared to reports in previous studies. The median satisfaction score was 5 out of 5 for patients and 3.3 out of 5 for clinicians. Discussion and Conclusion: Providing patient access to the EHRs with this design was linked with several bene- fits including improved patient engagement, education, transparency, comprehension, and trust. Future studies should explore how best to display information in such screens for patients and identify impact on care, safety, and quality. Key words: collaborative health IT, patient empowerment, human–computer interaction, doctor–patient communication 2,3 drivers for the adoption of EHRs. However, EHR systems can BACKGROUND AND SIGNIFICANCE harm patient–clinician interaction during ambulatory clinic visits by 4,5 adversely affecting communication and create less attentive clini- Fueled by a $32 billion federal investment through the Health Infor- 6,7 cians. These concerns have obscured the possibility that EHR use mation Technology For Economic and Clinical Health Act within visits could actually improve patient engagement and pro- (HITECH) of 2009 and the Center for Medicare and Medicaid’s mote effective communication. Electronic Health Record (EHR) Incentive Program known as Emerging evidence shows EHR use in the visit room is compli- “Meaningful Use,” 86.9% of physicians now use some version of an 1 8–10 cated, but under the right circumstances, can be quite patient- EHR in their offices. Improving the quality and safety of health centered. Best practices for using EHRs with patients have emerged care and making care more patient-centered have been strong V The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 42 Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 2018, Vol. 1, No. 1 43 and been promulgated, such as the Let the patient look on, Eye con- research team visited the clinic and used convenience sampling to in- tact with the patient, Value the computer as a tool, Explain what vite 57 eligible patients to participate. For patients who expressed you are doing, Log off and say you are doing so (LEVEL) mnemonic interest, we gave detailed information about what to expect during 11–14 that incorporates sharing of the clinician’s screen. Such strate- their visit, asked if they could remain for a 30-min interview after- gies mitigating the negative impact of EHRs and incorporating EHR ward, and proceeded with the informed consent process. We use into patient–clinician communication during the visit can en- stopped recruiting patients when we had interviewed 3 patients of 15,16 hance patient–centered care. Notably, active screen sharing has each clinician. 16,17 18 been linked to improved communication, patient engagement, trust, and a reduced sense of alienation when clinicians focus on Intervention and data collection 16,20,21 their screens. Patients may feel more involved in their visits We placed a second monitor in the exam room on an articulating 19 22 when they are able to see the screen or access the information. arm connected to the exam room’s computer (Figure 1). The display An important limitation of screen sharing is that clinicians have mirrored the clinician’s screen. Clinicians could disable the screen complete control over when the patient can view the screen, deter- by turning the display off, which was done when schedules with mining if and when it might be helpful to turn the screen and invite other patient names were accessed. Once the medical assistant com- patients to follow along. Even when invited, patients face an unfa- pleted rooming procedures, the research coordinator turned on the miliar user interface that can be cognitively challenging and filled cameras before the doctor entered the room. We placed 2 cameras 16,23 with jargon. Further, most exam rooms are not designed for at different angles to capture the interactions between the patients screen sharing, presenting ergonomic challenges to patients and and clinicians. To ensure privacy, we provided cloths to mask the clinicians alike. Empowered with data from OpenNotes and other cameras during physical exams. Clinicians were also free to stop the studies that have detailed several patient benefits to full access to recordings if they, or the patient, felt it necessary. 24,25 their health record, we sought to understand if providing After the visit, we captured the patient’s perceptions using a patients a full and unfiltered view of the EHR in the exam room semi-structured interview. Similarly, after each clinician had used would be accepted and perceived as useful. the second screen EHR with 3 patients, we interviewed her/him us- ing a semi-structured guide. We developed interview guides for both 19,21 patients and clinicians based on previous work and included OBJECTIVE questions on their perceptions, such as perceived usefulness, per- ceived ease of use, second screen’s contribution to communication The purpose of this paper is to assess patients’ and clinicians’ per- and understanding, negative perceptions and concerns, and sugges- ception of a second screen for the patient that mirrors the clinician’s tions for improving the design. A digital audio recorder captured screen. Aligning with the concept of “nothing about me without spoken data in all interviews. All participants provided a satisfaction me,” this design allows patients to see everything their doctor is rating of the experience and completed demographic surveys that doing on the main screen, including the creation of documentation, assessed age, sex, race, and comfort with computer use on a scale of review of data, and ordering of medications and tests. Our main out- 1 (very uncomfortable) to 5 (very comfortable). comes of interest were perceived usefulness of the second screen, and its perceived impact on patient education, patient engagement, and mutual trust. Data analysis All interviews were transcribed verbatim for the analysis. We then analyzed the transcripts using inductive content analysis. We de- MATERIALS AND METHODS veloped a coding book to guide the coding process and uploaded transcripts to NVivo 10 (QSR International) to facilitate coding and Study setting analyzes. After thorough review of the data by 2 experienced quali- We used a mixed-method approach to gain a holistic understanding tative investigators (O.A. and J.T.), we created a preliminary code- of our research questions. We conducted our study in a hospital- book, with separate codes for patient and clinician transcripts. based general internal medicine clinic located within an urban Using inductive content analysis, the RA (J.T.) coded all transcripts; academic medical center from March to June, 2016. Participating a second coder (O.A.) analyzed 5 patients (20%) and 5 clinician clinicians and patients met in a specially equipped exam room in an transcripts (63%). A third experienced qualitative investigator outpatient clinic. We video-recorded entire patient encounters to (B.C.) reviewed each patient and clinician transcript to ensure valid- quantify EHR use and conducted post visit interviews with the ity. We addressed discrepancies and reached consensus in bi-weekly patients in a private setting. The Institutional Review Board at the meetings. Throughout the coding process, the team discussed and re- Medical College of Wisconsin approved this study. vised the codebook, and returned to previously analyzed transcripts to ensure consistency. We analyzed patient and clinician data Recruitment process and participants separately, though found that they had high degrees of conceptual We recruited clinicians using purposeful convenience sampling by overlap. sending email invitations and announcing details of the study at a To quantify behaviors in the visit, we used Noldus Observer XT clinic department meeting. Eight of 15 clinicians agreed to partici- 12 for video-based analysis. We coded the adjusted visit length, de- pate. After receiving clinicians’ consent, we worked with the staff to fined as total length of visit time excluding the physical exam period, identify times we could recruit 3 of the clinician’s patients without the duration of doctor’s gaze at the EHR (main screen), the duration disrupting the clinic workflow. Additionally, staff helped to identify of typing, and the duration of the patient’s gaze at the patient dis- ineligible patients, such as those with language or health barriers, or play (second screen). Start and stop times for each behavior were an- diminished mental capacity; we limited enrollment to visits of estab- notated using the software, which calculates total duration and lished patients scheduled for less than 30 min. On 27 half days, the frequency of behavior. Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 44 JAMIA Open, 2018, Vol. 1, No. 1 Table 1. Demographics’ of patients and clinicians Demographics Patients Clinicians Gender Patient Male 8 (23%) 4 (50%) Female 16 (67%) 4 (50%) Age (in years) 18–34 0 (0%) 1 (12.5%) Physician 35–44 4 (16.6%) 1 (12.5%) 45–64 8 (33.3%) 6 (75%) Above 65 12 (50%) 0 (0%) Race Camera 1 Camera 2 Non-Hispanic white 10 (41.6%) 6 (75%) Non-Hispanic black/African American 14 (58.3%) 1 (12.5%) Non-Hispanic Asian 0 (0%) 1 (12.5%) Computer use Comfortable 21 (87.5%) 7 (87.5%) Figure 1. The layout of the exam room with the cameras. Not comfortable 3 (12.5%) 1 (12.5%) We had 2 coders, each trained with 5 practice videos. When the coders achieved certain Kappa scores (0.60), they started to code study videos. Each coder reviewed and coded 2 videos per week, 1 being mutual for reliability check. Coders had 0.80 Kappa reliability score on average, considered very good for such work. RESULTS Twenty-four patients and 8 clinicians participated (Table 1). The content analysis yielded 4 themes from patients, and 2 from clini- cians, with high degrees of overlap, along with concerns and oppor- tunities for improvement from both groups. Themes are described in detail below. Characteristics’ of participants The average length of time patients had known their clinicians was 11 years (SD 10 years). Clinicians’ experience in using an EHR sys- tem ranged from 8 to 16 years, with a mean of 11 years. Figure 2. A representative snapshot of interaction with second screen EHR (interactions simulated by the research team, and the screens are blurred). Quantitative reports EHR: electronic health record. The video analysis also helped us to quantify the visit length and both clinicians’ and patients’ interactions with the EHR. The aver- screen. We also captured suggestions for improvement, and concerns age adjusted visit length, which excludes the physical exam period, about interest and health literacy as derived from patient interviews. was 23.6 (SD 11.2) min. Doctors looked at EHR (main screen) Figure 2 illustrates the room configuration. 39.1% (SD 14.4%) of adjusted visit length and typed/documented 8.2% (SD 6.3%) of the adjusted visit length on average. Clinicians typed for documentation purposes in 19 encounters. Patients also Catalyst for patient engagement through design looked at the “patient display” 25% (SD 16.7%) of the adjusted Patients noted that they felt more engaged in the discussions and visit length. process of care. The mere presence of the second screen invited We also assessed both patient and clinician satisfaction scores patients into the care process more so than a single screen. Patients with the intervention. The patient scale was from 1 (not at all satis- described the configuration as “more inclusive,” “more personal,” fied) to 5 (highly satisfied), with a median of 5 [interquartile range and some patients noted that it made them feel “more important.” (IQR) 4.5–5] out of 5. The clinician scale was 1–6 initially and One patient commented, “So I think it shows you that a person re- adjusted to 1–5, and adjusted satisfaction median was 3.3 (IQR ally do care. They took the time out to put that in there.” Patients 2.3–3.9). provided descriptions of the second screen prompting questions or comments, such as offering or amending family history, clarifying medications, and augmenting the conversation about data. Patients’ perceptions Four main themes emerged from our analysis of interviews with I think it generates a more inclusive feeling. When you’re there patients: the second screen (1) served as a catalyst for patient en- and not looking at it and just listening to the doctor explain to gagement through design; (2) augmented the clinical visit in a mean- you what’s happening, it – it’s a little bit more like you’re a by- ingful way; (3) improved the transparency of the care process; and stander. When you’re watching the – the secondary screen... it’s (4) was a substantially different experience than sharing a single more inclusive. And, I don’t know. I don’t—I don’t wanna Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 2018, Vol. 1, No. 1 45 oversell it, but I—to me, it feels like you’re taking more owner- thought that gave me confidence, even though I do have a lot of ship in your own process and health and what should be confidence in her. I just feel comfortable. happening next. Patients also reported being more engaged in the note-writing Substantially different from sharing a single screen process, for example being able to clarify a new diagnosis. One The second screen was substantially different from sharing a con- patient likened it to sports, “I’m on the field. I’m playing. I’m not on ventional single screen managed by clinicians. For reasons men- the sidelines.” tioned above, it was inherently more inviting and welcoming. The second screen was “available” and (with rare exception) always on, providing a more consistent viewing opportunity: Augmented clinical visit in a meaningful way We identified several areas where patients felt that the second screen Um, if there’s any question that’s laying in my mind or thoughts, it – it takes from interrupting the doctor where she’s doing what improved their experience of care, including better patient educa- she needs to do and I can just turn around and visualize it right tion, better discussions, and an ability to clarify concepts, instruc- on the computer. I mean, right on the screen. tions, and orders. Patients noted that being able to follow along on the screen improved their processing and internalization of trends, It was also ergonomically more appealing. activating both their auditory and visual pathways for learning. One patient noted, “you gettin’ it from both angles. You’re getting it the I would’ve craned my neck and I would’ve looked around, but because it was not facing me... um, I know there’s all these pri- verbal.. .and then you getting actually to see it. So that I – I think it vacies and – and I wonder – I would wonder because I’m a, um, I helps you to better understand instead of just somebody just telling follow the rules, whether I should be doing that. And here it was you something, versus you tellin’ and you seein’ it.” In particular, open to me, so I knew that this was comfortable. Just like the patients felt that seeing their clinician type notes served as a charts on the doors? Oh, secret, secret. “whiteboard,” enabling more of a shared mental model of the issues with their clinicians. The second screen helped patients “follow We heard that patients were concerned about privacy or appro- along” and maintain their attention to the discussions at hand. One priateness of looking at the conventional clinician’s monitor, even patient commented, “Because some doctors, when they speak, they when prompted to do so by the clinician. One patient noted that she don’t make it clear enough. If they have a screen in front of them, felt “like I was invading privacy of my doctor.” they can show them the direction, they can point it out just like in school.” Additionally, patients appreciated opportunities to ask Patients’ suggestions for improvement questions or offer corrections, such as removing old medications Patients provided concerns and suggestions regarding the mirrored from the list: “I – I had the chance to ask right away, you know.. . second screen as implemented in our study. Patients noted that the what, you know, what that meant.. .and this and that meant, so.. .it user interface of the EHR was very confusing to them, but assumed gave me better visibility.” that they, like clinicians, might become more familiar with “where to look” with more experience. Nearly all terms were medical jar- gon or technical terms; while some patients noted that this substan- Improved transparency of the care process tially impacted their ability to derive benefit from the screen, others The second screen demystified the care process, shedding light on were aware of this but nonetheless appreciated the opportunity to what clinicians were typing and how they ordered medications, con- follow along and learn. Patients were interested in a more simplified sultations, and tests. Our patient participants generally reported interface that could hide some of the clutter of the user interface and that they had high levels of trust in their clinicians, but that they ap- focus attention on important elements for patients. preciated the opportunity to observe, and this seemed to marginally Not all patients perceived benefits. Some found that the make them more confident in the process of care. Patients likened “flipping” through different screens in a fast manner made it diffi- this to a “trust but verify” approach, which they felt empowered to cult to follow along. Others voiced a lack of interest. Two patients do. They could see that the doctor “wasn’t hiding something” by thought that the computer was distracting and taking away from the seeing the screen. ability to converse with the clinician: “I didn’t know what to do, When the doctor has the screen by himself, you almost get the should I look at the doctor, should I look at the screen. Um, she was sensation like something’s being kept from you. Like there’s not typing and stuff that she always puts on this sheet anyway.” Interest- full disclosure, like they have some kind of secret information. ingly, even the patients who voiced at the beginning of the interview Whereas when you have the second screen.. . you – you know that they did not find interest in the second screen identified poten- that’s not the case tial benefits of the screen. The transparency also provided for patients to see exactly how the clinician was documenting the visit, and that seeing diagnoses, Clinicians’ perceptions goals, and instructions in “black and white” helped solidify their un- Two primary themes emerged from clinician data: (1) the second derstanding of what they needed to do for next steps. Lastly, screen provided an opportunity to promote engagement and (2) doc- patients noted that seeing data and medications in real time, as op- umentation was transparent, with related benefits and concerns. posed to after the fact on after visit summaries, improved their con- Clinicians identified areas of improvement, centering on ergonom- fidence in the care process. ics, and information display. I like seeing that the medications that were correct, even though Opportunities to promote patient engagement we get a – a, um... a paper at the end -right in the real time I like Similar to patients, clinicians also identified ways that the second to see that and...I like to see what she was typing when I had questions and she was going to do follow-up work. Um, I screen could enable better patient engagement and improve patient Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 46 JAMIA Open, 2018, Vol. 1, No. 1 education. Most clinicians thought that the second screen made bonus of them seeing while I’m typing, so they can correct me if they screen sharing substantially easier. One clinician reported that the see any mistakes that I make based on what they are saying to me.” presence of the second screen seemed to give patients the unspoken A clinician also reported turning off the second screen from time message that they were allowed, and even encouraged, to look at the to time due to sensitive material, but then felt it created a feeling of EHR screen: “my experience with two of the three patients was that less transparency or might impact trust negatively. Another clinician they were – they felt allowed, entitled to look at the other screen.. . I expressed a desire to control when the screen would be shared. On think probably gives the patients an extra layer of ‘oh this is okay to the other hand, several clinicians also acknowledged the information do.’” This continuous access might improve communication accord- belongs to patients and should not be hidden from them. In addi- ing to some clinicians, especially if patients see clinicians’ entries in tion, 2 clinicians thought the second screen would distract some notes, and confirm or offer edits to the notes. patients, and they reported not being sure if patients were listening to them while they looked at the second screen. I’ve already had it happen. Patients look at their after-visit sum- mary, they come back the next time and they say this is listed as a Clinicians’ suggestions for improvement diagnosis, this is incorrect... [the second screen] is huge for pa- tient empowerment. Especially the patients that want the infor- One of the major concepts reported was about the current physical mation, the more access they have to their own health informa- design of the monitors and physical layout of the room in which we tion really oughta help. tested the intervention. Although the potential of the second screen was recognized, a few clinicians reported the current design of the Clinicians had diverging opinions on the potential of the second room limited the benefits due to small desk space and large screens, screen to lead to more productive patient questions than would a sometimes blocking the eye gaze or impeding nonverbal communi- single shared screen. In order to lead to more productive questions, cation. Clinicians also acknowledged that this is something that one clinician stated there is a need for guidance on where to focus could easily be fixed with a better ergonomic design of the seating on the screen for patients. Finally, several clinicians thought that and the room. having a second screen would prolong the visit, as patients might un- Finally, themes also emerged regarding the design and informa- necessarily question more. tion presentation in the current EHR, regardless of the number of Clinicians had mixed reports regarding the impact of the second screens. One argument was that most information in the EHR is not screen on patient education, engagement, and empowerment. Clini- presented in a patient-centered way and might overwhelm patients. cians reported that this setting has potential to improve patient en- Another clinician thought that the second screen will create sympa- gagement, but also noted that it depends on patient interest. Some thy for clinicians, since patients will be able to see how cumbersome other clinicians supported this with saying it might give more em- the EHR is to navigate, so they might blame the technology (rather powerment to those patients who are more engaged and want more than clinician) for some of the technical difficulties or delays in find- information. Many clinicians noted that they tried to be engaging ing certain information. and to share the screen when they considered it helpful, as to make a Clinicians voiced privacy concerns when using mirrored screens, point with an X-ray, weight trend, or lab value. Some clinicians such as when needing to look for a piece of information in their compared this setting to the OpenNotes concept and highlighted the email that was germane to the visit, when desiring to make a private potential to facilitate overall patient empowerment and engage- 29,30 note to self, or when needing to flip to a schedule screen that may ment. Furthermore, a few clinicians thought the mirrored EHR contain other patient names. experience on the second screen did not necessarily augment patient education by itself; if they had specific content for patients; how- ever, the second screen would have the potential to improve patient DISCUSSION education. Some clinicians also reported that the second screen was really helpful to use for risk calculators, decision aids tools and shar- In this study of clinicians and their patients using a second screen ing web pages. In contrast, a few clinicians argued that the second dedicated to mirroring the clinician’s EHR view for the patient, par- screen made them lose the feeling of a shared experience with the ticipants identified several benefits for patient engagement, educa- same screen. tion, and transparency, as well as opportunities for improvement. Overall, patients perceived more benefits than clinicians and were Transparency of documentation more satisfied with the additional screen than clinicians. Patients in Clinicians’ level of comfort in sharing documentation with their particular identified that the second screen was more inviting of patients emerged as another theme; some were completely at ease their participation in the care process, complemented conversation with sharing, while others reported less comfort for 2 reasons: (1) to enhance comprehension, and fostered additional trust in their the notes might contain sensitive information, and (2) during the doctors. visit, the note is a draft rather than a finished product—as such it Despite the majority of patients voicing that their clinicians often might lead to misunderstanding. A few clinicians reported this af- share screens, our data show that patients experience their dedicated fecting their workflow, their documentation style (typing less than screen in a fundamentally different way than when looking onto the usual), and their awareness of the patient’s loss of focus: “I defi- clinician’s screen. Compared with our prior studies of screen shar- nitely was not writing my note, because I was very conscious that he ing, patients’ viewing of the EHR was increased when using the sec- was, uh, was there and regularly looking at it.” Another doctor ond screen. Patients looked at the “second screen” 25% of the noted, “I actually think because I was worried about distraction.. . adjusted visit length on average which is longer than reported values that I did a little less computer order entry and typing than I might in our previous studies where the most active clinician sharing led to 18,31 normally have, because they could see me doing it.” Other clinicians patients viewing the screen 18% of the time. The typical exam thought it was helpful to share the writing process, “I actually think room configuration, with a monitor and keyboard aligned for the that patients should have access to their notes. I see on one hand a clinician, project a sense of the computer belonging to the domain of Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 2018, Vol. 1, No. 1 47 21,34 the clinician. While some patients voiced that they were curious and the potential to make use of the screen for patient interactions. would peek, others felt uncertain about the ethics and rules around The usability of EHRs presents well known challenges to clinicians, looking at the screen. Self-motivated and empowered patients are but also makes it challenging to clearly present data to the patient. more likely to regard the invitation to view their information on the Screens that focus on single tasks or enable a “focus” view may help screen as an act of transparency that might enhance the collabora- facilitate discussions. Despite these challenges, however, patients tive nature of the patient–clinician relationship as well as patient were able to identify benefits to viewing the record. Future iterations trust in clinicians. The simple presence of the second screen invited may also include dedicated “patient views” that simplify the tasks at all patients to participate. hand while enabling clinicians to access advanced options when A principal inference from our study is that patients gained con- needed. trol in the visit and in their relationship with their clinician, despite Our results must be interpreted within the confines of the study only being able to view what the clinician was doing or viewing. design and limitations. The study was done at a single site at an aca- Control over the data and narrative recorded in these EHRs still demic medical center. However, our participants were very diverse rests primarily with the clinician. In our study, patients voiced that in terms of age, race, and education. The sample size was modest, they felt more in control of visits, and the clinicians noted areas but within generally accepted ranges for qualitative studies focused where their control was ceded, such as enabling patients to pause on usability. As patients opted into the study, a selection bias favor- and reflect on what they see within the chart, and to see notes being ing the technology might have been present; we found, however, composed. We heard recurrently that patients had high trust in their while patient ratings were fairly high, not all patients found it imme- clinicians before the second screen, which was augmented further diately useful. through this access. Clinicians may also need to trust their patients, such that the distributed control will not interfere or distract with tasks but rather make the visits even more useful for patients. CONCLUSION As clinicians, practices, and hospitals seek to improve patient en- In conclusion, this study shows that designs providing patient access gagement, looking at the physical design of space and resources may to the EHRs during the visit may improve patient engagement. be very helpful. Our experience strongly suggests that patient en- According to respondents in our study, this type of design also might gagement can be positively facilitated by design that is unambigu- contribute to education, transparency, enhancing comprehension, ously inviting of their participation. Despite the majority of patients and improving trust. Finally, future studies should explore the best noting that their clinicians often share screens, our data show that ergonomic approach for various exam rooms layout as well as elimi- patients experience their dedicated screen in a fundamentally differ- nating clutter and making the information display in the second ent way. The second screen dispelled concerns about propriety of screen more patient-friendly. looking at the screen and also projected a sense that the patient was important and respected. It is difficult to not compare the experience to that of Open- Notes. In the OpenNotes study, patients valued access to their notes FUNDING far above the expectations of their clinicians, suggesting that clini- This study was funded by the Presidential Faculty Scholar Award and Re- cians may take data for granted but patients increasingly are seeing search and Education Program Fund, a component of the Advancing a direct access as valuable. It is therefore unsurprising that patients Healthier Wisconsin endowment at the Medical College of Wisconsin. also valued the ability to see the clinician create the note in real time. Also similar to OpenNotes is the concept that clinicians are de- Conflict of interest statement. None declared. veloping trust in their patients to engage without unduly or unneces- sarily hindering flow. Clinicians voiced some concerns about notes not being finished products, or typing in sensitive information. The CONTRIBUTORS future of OpenNotes is of shared note creation among patients and their clinicians. The second screen may facilitate such future O.A. conceived and designed the study, obtained funding, partici- endeavors. pated in data collection, analysis, and interpretation, drafted and re- vised the manuscript, and approved the final version for submission. B.C. assisted with study conception and design and data interpreta- tion, made critical manuscript revisions and approved the final ver- Concerns related to mirrored EHR displays sion for submission. J.T. assisted with data collection, and data Several caveats exist to mirrored screens that are important to men- analysis, and made critical manuscript revisions and approved the fi- tion. Clinicians commonly need to access other areas of the EHR or nal version for submission. other secured systems that could expose sensitive information, such as other patient names when accessing schedules. Being able to sup- press displays as necessary and outline workflows for rooming that address these important areas are needed. The literacy levels of ACKNOWLEDGMENTS patients, including health literacy and computer literacy specifically, We would like to thank all participating clinicians and patients for their valu- likely will impact benefits experienced by patients. We found evi- able insight. We also thank to Paul Iglar and Rabia Copuroglu for helping in dence, however, that patients perceived benefits despite the challeng- video coding. ing interface and jargon. Lastly, the second screen may indeed take away from a shared experience, such as with a large wall-mounted REFERENCES monitor for both clinicians and patients to use. 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The electronic health record as a patient engagement tool: mirroring clinicians’ screen to create a shared mental model

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Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 1(1), 2018, 42–48 doi: 10.1093/jamiaopen/ooy006 Advance Access Publication Date: 20 April 2018 Research and Applications Research and Applications The electronic health record as a patient engagement tool: mirroring clinicians’ screen to create a shared mental model Onur Asan, Jeanne Tyszka, and Bradley Crotty Division of General Internal Medicine, Department of Medicine, Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin, USA Corresponding Author: Onur Asan, PhD, Center for Patient Care and Outcomes Research, Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA (oasan@mcw.edu) Received 21 December 2017; Revised 13 February 2018; Accepted 14 March 2018 ABSTRACT Objective: Electronic health records (EHRs) in physician offices can both enhance and detract from the patient experience. Best practices have emerged focusing on screen sharing. We sought to determine if adding a sec- ond monitor, mirroring the EHR for patients, would be welcome and useful for patients and clinicians. Materials and Methods: This mixed-method study was conducted in a general medicine clinic from March to June 2016. Clinicians and patients met in a specially equipped exam room with a patient-facing monitor. Visits were video-recorded to assess time spent viewing the EHR and followed by interviews, which were transcribed and analyzed using established qualitative methods. Results: Eight clinicians and 24 patients participated. Main themes included the second screen serving as a cata- lyst for patient engagement, augmenting the clinic visit in a meaningful way, improving transparency of the care process and documentation, and providing a substantially different experience for patients than a shared single screen. Concerns and suggestions for improvement were also reported. Quantitative results showed high patient engagement times with the EHR (25% of the visit length) compared to reports in previous studies. The median satisfaction score was 5 out of 5 for patients and 3.3 out of 5 for clinicians. Discussion and Conclusion: Providing patient access to the EHRs with this design was linked with several bene- fits including improved patient engagement, education, transparency, comprehension, and trust. Future studies should explore how best to display information in such screens for patients and identify impact on care, safety, and quality. Key words: collaborative health IT, patient empowerment, human–computer interaction, doctor–patient communication 2,3 drivers for the adoption of EHRs. However, EHR systems can BACKGROUND AND SIGNIFICANCE harm patient–clinician interaction during ambulatory clinic visits by 4,5 adversely affecting communication and create less attentive clini- Fueled by a $32 billion federal investment through the Health Infor- 6,7 cians. These concerns have obscured the possibility that EHR use mation Technology For Economic and Clinical Health Act within visits could actually improve patient engagement and pro- (HITECH) of 2009 and the Center for Medicare and Medicaid’s mote effective communication. Electronic Health Record (EHR) Incentive Program known as Emerging evidence shows EHR use in the visit room is compli- “Meaningful Use,” 86.9% of physicians now use some version of an 1 8–10 cated, but under the right circumstances, can be quite patient- EHR in their offices. Improving the quality and safety of health centered. Best practices for using EHRs with patients have emerged care and making care more patient-centered have been strong V The Author(s) 2018. Published by Oxford University Press on behalf of the American Medical Informatics Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 42 Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 2018, Vol. 1, No. 1 43 and been promulgated, such as the Let the patient look on, Eye con- research team visited the clinic and used convenience sampling to in- tact with the patient, Value the computer as a tool, Explain what vite 57 eligible patients to participate. For patients who expressed you are doing, Log off and say you are doing so (LEVEL) mnemonic interest, we gave detailed information about what to expect during 11–14 that incorporates sharing of the clinician’s screen. Such strate- their visit, asked if they could remain for a 30-min interview after- gies mitigating the negative impact of EHRs and incorporating EHR ward, and proceeded with the informed consent process. We use into patient–clinician communication during the visit can en- stopped recruiting patients when we had interviewed 3 patients of 15,16 hance patient–centered care. Notably, active screen sharing has each clinician. 16,17 18 been linked to improved communication, patient engagement, trust, and a reduced sense of alienation when clinicians focus on Intervention and data collection 16,20,21 their screens. Patients may feel more involved in their visits We placed a second monitor in the exam room on an articulating 19 22 when they are able to see the screen or access the information. arm connected to the exam room’s computer (Figure 1). The display An important limitation of screen sharing is that clinicians have mirrored the clinician’s screen. Clinicians could disable the screen complete control over when the patient can view the screen, deter- by turning the display off, which was done when schedules with mining if and when it might be helpful to turn the screen and invite other patient names were accessed. Once the medical assistant com- patients to follow along. Even when invited, patients face an unfa- pleted rooming procedures, the research coordinator turned on the miliar user interface that can be cognitively challenging and filled cameras before the doctor entered the room. We placed 2 cameras 16,23 with jargon. Further, most exam rooms are not designed for at different angles to capture the interactions between the patients screen sharing, presenting ergonomic challenges to patients and and clinicians. To ensure privacy, we provided cloths to mask the clinicians alike. Empowered with data from OpenNotes and other cameras during physical exams. Clinicians were also free to stop the studies that have detailed several patient benefits to full access to recordings if they, or the patient, felt it necessary. 24,25 their health record, we sought to understand if providing After the visit, we captured the patient’s perceptions using a patients a full and unfiltered view of the EHR in the exam room semi-structured interview. Similarly, after each clinician had used would be accepted and perceived as useful. the second screen EHR with 3 patients, we interviewed her/him us- ing a semi-structured guide. We developed interview guides for both 19,21 patients and clinicians based on previous work and included OBJECTIVE questions on their perceptions, such as perceived usefulness, per- ceived ease of use, second screen’s contribution to communication The purpose of this paper is to assess patients’ and clinicians’ per- and understanding, negative perceptions and concerns, and sugges- ception of a second screen for the patient that mirrors the clinician’s tions for improving the design. A digital audio recorder captured screen. Aligning with the concept of “nothing about me without spoken data in all interviews. All participants provided a satisfaction me,” this design allows patients to see everything their doctor is rating of the experience and completed demographic surveys that doing on the main screen, including the creation of documentation, assessed age, sex, race, and comfort with computer use on a scale of review of data, and ordering of medications and tests. Our main out- 1 (very uncomfortable) to 5 (very comfortable). comes of interest were perceived usefulness of the second screen, and its perceived impact on patient education, patient engagement, and mutual trust. Data analysis All interviews were transcribed verbatim for the analysis. We then analyzed the transcripts using inductive content analysis. We de- MATERIALS AND METHODS veloped a coding book to guide the coding process and uploaded transcripts to NVivo 10 (QSR International) to facilitate coding and Study setting analyzes. After thorough review of the data by 2 experienced quali- We used a mixed-method approach to gain a holistic understanding tative investigators (O.A. and J.T.), we created a preliminary code- of our research questions. We conducted our study in a hospital- book, with separate codes for patient and clinician transcripts. based general internal medicine clinic located within an urban Using inductive content analysis, the RA (J.T.) coded all transcripts; academic medical center from March to June, 2016. Participating a second coder (O.A.) analyzed 5 patients (20%) and 5 clinician clinicians and patients met in a specially equipped exam room in an transcripts (63%). A third experienced qualitative investigator outpatient clinic. We video-recorded entire patient encounters to (B.C.) reviewed each patient and clinician transcript to ensure valid- quantify EHR use and conducted post visit interviews with the ity. We addressed discrepancies and reached consensus in bi-weekly patients in a private setting. The Institutional Review Board at the meetings. Throughout the coding process, the team discussed and re- Medical College of Wisconsin approved this study. vised the codebook, and returned to previously analyzed transcripts to ensure consistency. We analyzed patient and clinician data Recruitment process and participants separately, though found that they had high degrees of conceptual We recruited clinicians using purposeful convenience sampling by overlap. sending email invitations and announcing details of the study at a To quantify behaviors in the visit, we used Noldus Observer XT clinic department meeting. Eight of 15 clinicians agreed to partici- 12 for video-based analysis. We coded the adjusted visit length, de- pate. After receiving clinicians’ consent, we worked with the staff to fined as total length of visit time excluding the physical exam period, identify times we could recruit 3 of the clinician’s patients without the duration of doctor’s gaze at the EHR (main screen), the duration disrupting the clinic workflow. Additionally, staff helped to identify of typing, and the duration of the patient’s gaze at the patient dis- ineligible patients, such as those with language or health barriers, or play (second screen). Start and stop times for each behavior were an- diminished mental capacity; we limited enrollment to visits of estab- notated using the software, which calculates total duration and lished patients scheduled for less than 30 min. On 27 half days, the frequency of behavior. Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 44 JAMIA Open, 2018, Vol. 1, No. 1 Table 1. Demographics’ of patients and clinicians Demographics Patients Clinicians Gender Patient Male 8 (23%) 4 (50%) Female 16 (67%) 4 (50%) Age (in years) 18–34 0 (0%) 1 (12.5%) Physician 35–44 4 (16.6%) 1 (12.5%) 45–64 8 (33.3%) 6 (75%) Above 65 12 (50%) 0 (0%) Race Camera 1 Camera 2 Non-Hispanic white 10 (41.6%) 6 (75%) Non-Hispanic black/African American 14 (58.3%) 1 (12.5%) Non-Hispanic Asian 0 (0%) 1 (12.5%) Computer use Comfortable 21 (87.5%) 7 (87.5%) Figure 1. The layout of the exam room with the cameras. Not comfortable 3 (12.5%) 1 (12.5%) We had 2 coders, each trained with 5 practice videos. When the coders achieved certain Kappa scores (0.60), they started to code study videos. Each coder reviewed and coded 2 videos per week, 1 being mutual for reliability check. Coders had 0.80 Kappa reliability score on average, considered very good for such work. RESULTS Twenty-four patients and 8 clinicians participated (Table 1). The content analysis yielded 4 themes from patients, and 2 from clini- cians, with high degrees of overlap, along with concerns and oppor- tunities for improvement from both groups. Themes are described in detail below. Characteristics’ of participants The average length of time patients had known their clinicians was 11 years (SD 10 years). Clinicians’ experience in using an EHR sys- tem ranged from 8 to 16 years, with a mean of 11 years. Figure 2. A representative snapshot of interaction with second screen EHR (interactions simulated by the research team, and the screens are blurred). Quantitative reports EHR: electronic health record. The video analysis also helped us to quantify the visit length and both clinicians’ and patients’ interactions with the EHR. The aver- screen. We also captured suggestions for improvement, and concerns age adjusted visit length, which excludes the physical exam period, about interest and health literacy as derived from patient interviews. was 23.6 (SD 11.2) min. Doctors looked at EHR (main screen) Figure 2 illustrates the room configuration. 39.1% (SD 14.4%) of adjusted visit length and typed/documented 8.2% (SD 6.3%) of the adjusted visit length on average. Clinicians typed for documentation purposes in 19 encounters. Patients also Catalyst for patient engagement through design looked at the “patient display” 25% (SD 16.7%) of the adjusted Patients noted that they felt more engaged in the discussions and visit length. process of care. The mere presence of the second screen invited We also assessed both patient and clinician satisfaction scores patients into the care process more so than a single screen. Patients with the intervention. The patient scale was from 1 (not at all satis- described the configuration as “more inclusive,” “more personal,” fied) to 5 (highly satisfied), with a median of 5 [interquartile range and some patients noted that it made them feel “more important.” (IQR) 4.5–5] out of 5. The clinician scale was 1–6 initially and One patient commented, “So I think it shows you that a person re- adjusted to 1–5, and adjusted satisfaction median was 3.3 (IQR ally do care. They took the time out to put that in there.” Patients 2.3–3.9). provided descriptions of the second screen prompting questions or comments, such as offering or amending family history, clarifying medications, and augmenting the conversation about data. Patients’ perceptions Four main themes emerged from our analysis of interviews with I think it generates a more inclusive feeling. When you’re there patients: the second screen (1) served as a catalyst for patient en- and not looking at it and just listening to the doctor explain to gagement through design; (2) augmented the clinical visit in a mean- you what’s happening, it – it’s a little bit more like you’re a by- ingful way; (3) improved the transparency of the care process; and stander. When you’re watching the – the secondary screen... it’s (4) was a substantially different experience than sharing a single more inclusive. And, I don’t know. I don’t—I don’t wanna Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 2018, Vol. 1, No. 1 45 oversell it, but I—to me, it feels like you’re taking more owner- thought that gave me confidence, even though I do have a lot of ship in your own process and health and what should be confidence in her. I just feel comfortable. happening next. Patients also reported being more engaged in the note-writing Substantially different from sharing a single screen process, for example being able to clarify a new diagnosis. One The second screen was substantially different from sharing a con- patient likened it to sports, “I’m on the field. I’m playing. I’m not on ventional single screen managed by clinicians. For reasons men- the sidelines.” tioned above, it was inherently more inviting and welcoming. The second screen was “available” and (with rare exception) always on, providing a more consistent viewing opportunity: Augmented clinical visit in a meaningful way We identified several areas where patients felt that the second screen Um, if there’s any question that’s laying in my mind or thoughts, it – it takes from interrupting the doctor where she’s doing what improved their experience of care, including better patient educa- she needs to do and I can just turn around and visualize it right tion, better discussions, and an ability to clarify concepts, instruc- on the computer. I mean, right on the screen. tions, and orders. Patients noted that being able to follow along on the screen improved their processing and internalization of trends, It was also ergonomically more appealing. activating both their auditory and visual pathways for learning. One patient noted, “you gettin’ it from both angles. You’re getting it the I would’ve craned my neck and I would’ve looked around, but because it was not facing me... um, I know there’s all these pri- verbal.. .and then you getting actually to see it. So that I – I think it vacies and – and I wonder – I would wonder because I’m a, um, I helps you to better understand instead of just somebody just telling follow the rules, whether I should be doing that. And here it was you something, versus you tellin’ and you seein’ it.” In particular, open to me, so I knew that this was comfortable. Just like the patients felt that seeing their clinician type notes served as a charts on the doors? Oh, secret, secret. “whiteboard,” enabling more of a shared mental model of the issues with their clinicians. The second screen helped patients “follow We heard that patients were concerned about privacy or appro- along” and maintain their attention to the discussions at hand. One priateness of looking at the conventional clinician’s monitor, even patient commented, “Because some doctors, when they speak, they when prompted to do so by the clinician. One patient noted that she don’t make it clear enough. If they have a screen in front of them, felt “like I was invading privacy of my doctor.” they can show them the direction, they can point it out just like in school.” Additionally, patients appreciated opportunities to ask Patients’ suggestions for improvement questions or offer corrections, such as removing old medications Patients provided concerns and suggestions regarding the mirrored from the list: “I – I had the chance to ask right away, you know.. . second screen as implemented in our study. Patients noted that the what, you know, what that meant.. .and this and that meant, so.. .it user interface of the EHR was very confusing to them, but assumed gave me better visibility.” that they, like clinicians, might become more familiar with “where to look” with more experience. Nearly all terms were medical jar- gon or technical terms; while some patients noted that this substan- Improved transparency of the care process tially impacted their ability to derive benefit from the screen, others The second screen demystified the care process, shedding light on were aware of this but nonetheless appreciated the opportunity to what clinicians were typing and how they ordered medications, con- follow along and learn. Patients were interested in a more simplified sultations, and tests. Our patient participants generally reported interface that could hide some of the clutter of the user interface and that they had high levels of trust in their clinicians, but that they ap- focus attention on important elements for patients. preciated the opportunity to observe, and this seemed to marginally Not all patients perceived benefits. Some found that the make them more confident in the process of care. Patients likened “flipping” through different screens in a fast manner made it diffi- this to a “trust but verify” approach, which they felt empowered to cult to follow along. Others voiced a lack of interest. Two patients do. They could see that the doctor “wasn’t hiding something” by thought that the computer was distracting and taking away from the seeing the screen. ability to converse with the clinician: “I didn’t know what to do, When the doctor has the screen by himself, you almost get the should I look at the doctor, should I look at the screen. Um, she was sensation like something’s being kept from you. Like there’s not typing and stuff that she always puts on this sheet anyway.” Interest- full disclosure, like they have some kind of secret information. ingly, even the patients who voiced at the beginning of the interview Whereas when you have the second screen.. . you – you know that they did not find interest in the second screen identified poten- that’s not the case tial benefits of the screen. The transparency also provided for patients to see exactly how the clinician was documenting the visit, and that seeing diagnoses, Clinicians’ perceptions goals, and instructions in “black and white” helped solidify their un- Two primary themes emerged from clinician data: (1) the second derstanding of what they needed to do for next steps. Lastly, screen provided an opportunity to promote engagement and (2) doc- patients noted that seeing data and medications in real time, as op- umentation was transparent, with related benefits and concerns. posed to after the fact on after visit summaries, improved their con- Clinicians identified areas of improvement, centering on ergonom- fidence in the care process. ics, and information display. I like seeing that the medications that were correct, even though Opportunities to promote patient engagement we get a – a, um... a paper at the end -right in the real time I like Similar to patients, clinicians also identified ways that the second to see that and...I like to see what she was typing when I had questions and she was going to do follow-up work. Um, I screen could enable better patient engagement and improve patient Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 46 JAMIA Open, 2018, Vol. 1, No. 1 education. Most clinicians thought that the second screen made bonus of them seeing while I’m typing, so they can correct me if they screen sharing substantially easier. One clinician reported that the see any mistakes that I make based on what they are saying to me.” presence of the second screen seemed to give patients the unspoken A clinician also reported turning off the second screen from time message that they were allowed, and even encouraged, to look at the to time due to sensitive material, but then felt it created a feeling of EHR screen: “my experience with two of the three patients was that less transparency or might impact trust negatively. Another clinician they were – they felt allowed, entitled to look at the other screen.. . I expressed a desire to control when the screen would be shared. On think probably gives the patients an extra layer of ‘oh this is okay to the other hand, several clinicians also acknowledged the information do.’” This continuous access might improve communication accord- belongs to patients and should not be hidden from them. In addi- ing to some clinicians, especially if patients see clinicians’ entries in tion, 2 clinicians thought the second screen would distract some notes, and confirm or offer edits to the notes. patients, and they reported not being sure if patients were listening to them while they looked at the second screen. I’ve already had it happen. Patients look at their after-visit sum- mary, they come back the next time and they say this is listed as a Clinicians’ suggestions for improvement diagnosis, this is incorrect... [the second screen] is huge for pa- tient empowerment. Especially the patients that want the infor- One of the major concepts reported was about the current physical mation, the more access they have to their own health informa- design of the monitors and physical layout of the room in which we tion really oughta help. tested the intervention. Although the potential of the second screen was recognized, a few clinicians reported the current design of the Clinicians had diverging opinions on the potential of the second room limited the benefits due to small desk space and large screens, screen to lead to more productive patient questions than would a sometimes blocking the eye gaze or impeding nonverbal communi- single shared screen. In order to lead to more productive questions, cation. Clinicians also acknowledged that this is something that one clinician stated there is a need for guidance on where to focus could easily be fixed with a better ergonomic design of the seating on the screen for patients. Finally, several clinicians thought that and the room. having a second screen would prolong the visit, as patients might un- Finally, themes also emerged regarding the design and informa- necessarily question more. tion presentation in the current EHR, regardless of the number of Clinicians had mixed reports regarding the impact of the second screens. One argument was that most information in the EHR is not screen on patient education, engagement, and empowerment. Clini- presented in a patient-centered way and might overwhelm patients. cians reported that this setting has potential to improve patient en- Another clinician thought that the second screen will create sympa- gagement, but also noted that it depends on patient interest. Some thy for clinicians, since patients will be able to see how cumbersome other clinicians supported this with saying it might give more em- the EHR is to navigate, so they might blame the technology (rather powerment to those patients who are more engaged and want more than clinician) for some of the technical difficulties or delays in find- information. Many clinicians noted that they tried to be engaging ing certain information. and to share the screen when they considered it helpful, as to make a Clinicians voiced privacy concerns when using mirrored screens, point with an X-ray, weight trend, or lab value. Some clinicians such as when needing to look for a piece of information in their compared this setting to the OpenNotes concept and highlighted the email that was germane to the visit, when desiring to make a private potential to facilitate overall patient empowerment and engage- 29,30 note to self, or when needing to flip to a schedule screen that may ment. Furthermore, a few clinicians thought the mirrored EHR contain other patient names. experience on the second screen did not necessarily augment patient education by itself; if they had specific content for patients; how- ever, the second screen would have the potential to improve patient DISCUSSION education. Some clinicians also reported that the second screen was really helpful to use for risk calculators, decision aids tools and shar- In this study of clinicians and their patients using a second screen ing web pages. In contrast, a few clinicians argued that the second dedicated to mirroring the clinician’s EHR view for the patient, par- screen made them lose the feeling of a shared experience with the ticipants identified several benefits for patient engagement, educa- same screen. tion, and transparency, as well as opportunities for improvement. Overall, patients perceived more benefits than clinicians and were Transparency of documentation more satisfied with the additional screen than clinicians. Patients in Clinicians’ level of comfort in sharing documentation with their particular identified that the second screen was more inviting of patients emerged as another theme; some were completely at ease their participation in the care process, complemented conversation with sharing, while others reported less comfort for 2 reasons: (1) to enhance comprehension, and fostered additional trust in their the notes might contain sensitive information, and (2) during the doctors. visit, the note is a draft rather than a finished product—as such it Despite the majority of patients voicing that their clinicians often might lead to misunderstanding. A few clinicians reported this af- share screens, our data show that patients experience their dedicated fecting their workflow, their documentation style (typing less than screen in a fundamentally different way than when looking onto the usual), and their awareness of the patient’s loss of focus: “I defi- clinician’s screen. Compared with our prior studies of screen shar- nitely was not writing my note, because I was very conscious that he ing, patients’ viewing of the EHR was increased when using the sec- was, uh, was there and regularly looking at it.” Another doctor ond screen. Patients looked at the “second screen” 25% of the noted, “I actually think because I was worried about distraction.. . adjusted visit length on average which is longer than reported values that I did a little less computer order entry and typing than I might in our previous studies where the most active clinician sharing led to 18,31 normally have, because they could see me doing it.” Other clinicians patients viewing the screen 18% of the time. The typical exam thought it was helpful to share the writing process, “I actually think room configuration, with a monitor and keyboard aligned for the that patients should have access to their notes. I see on one hand a clinician, project a sense of the computer belonging to the domain of Downloaded from https://academic.oup.com/jamiaopen/article-abstract/1/1/42/4980802 by Ed 'DeepDyve' Gillespie user on 07 November 2018 JAMIA Open, 2018, Vol. 1, No. 1 47 21,34 the clinician. While some patients voiced that they were curious and the potential to make use of the screen for patient interactions. would peek, others felt uncertain about the ethics and rules around The usability of EHRs presents well known challenges to clinicians, looking at the screen. Self-motivated and empowered patients are but also makes it challenging to clearly present data to the patient. more likely to regard the invitation to view their information on the Screens that focus on single tasks or enable a “focus” view may help screen as an act of transparency that might enhance the collabora- facilitate discussions. Despite these challenges, however, patients tive nature of the patient–clinician relationship as well as patient were able to identify benefits to viewing the record. Future iterations trust in clinicians. The simple presence of the second screen invited may also include dedicated “patient views” that simplify the tasks at all patients to participate. hand while enabling clinicians to access advanced options when A principal inference from our study is that patients gained con- needed. trol in the visit and in their relationship with their clinician, despite Our results must be interpreted within the confines of the study only being able to view what the clinician was doing or viewing. design and limitations. The study was done at a single site at an aca- Control over the data and narrative recorded in these EHRs still demic medical center. However, our participants were very diverse rests primarily with the clinician. In our study, patients voiced that in terms of age, race, and education. The sample size was modest, they felt more in control of visits, and the clinicians noted areas but within generally accepted ranges for qualitative studies focused where their control was ceded, such as enabling patients to pause on usability. As patients opted into the study, a selection bias favor- and reflect on what they see within the chart, and to see notes being ing the technology might have been present; we found, however, composed. We heard recurrently that patients had high trust in their while patient ratings were fairly high, not all patients found it imme- clinicians before the second screen, which was augmented further diately useful. through this access. Clinicians may also need to trust their patients, such that the distributed control will not interfere or distract with tasks but rather make the visits even more useful for patients. CONCLUSION As clinicians, practices, and hospitals seek to improve patient en- In conclusion, this study shows that designs providing patient access gagement, looking at the physical design of space and resources may to the EHRs during the visit may improve patient engagement. be very helpful. Our experience strongly suggests that patient en- According to respondents in our study, this type of design also might gagement can be positively facilitated by design that is unambigu- contribute to education, transparency, enhancing comprehension, ously inviting of their participation. Despite the majority of patients and improving trust. Finally, future studies should explore the best noting that their clinicians often share screens, our data show that ergonomic approach for various exam rooms layout as well as elimi- patients experience their dedicated screen in a fundamentally differ- nating clutter and making the information display in the second ent way. The second screen dispelled concerns about propriety of screen more patient-friendly. looking at the screen and also projected a sense that the patient was important and respected. It is difficult to not compare the experience to that of Open- Notes. In the OpenNotes study, patients valued access to their notes FUNDING far above the expectations of their clinicians, suggesting that clini- This study was funded by the Presidential Faculty Scholar Award and Re- cians may take data for granted but patients increasingly are seeing search and Education Program Fund, a component of the Advancing a direct access as valuable. It is therefore unsurprising that patients Healthier Wisconsin endowment at the Medical College of Wisconsin. also valued the ability to see the clinician create the note in real time. Also similar to OpenNotes is the concept that clinicians are de- Conflict of interest statement. None declared. veloping trust in their patients to engage without unduly or unneces- sarily hindering flow. Clinicians voiced some concerns about notes not being finished products, or typing in sensitive information. The CONTRIBUTORS future of OpenNotes is of shared note creation among patients and their clinicians. The second screen may facilitate such future O.A. conceived and designed the study, obtained funding, partici- endeavors. pated in data collection, analysis, and interpretation, drafted and re- vised the manuscript, and approved the final version for submission. B.C. assisted with study conception and design and data interpreta- tion, made critical manuscript revisions and approved the final ver- Concerns related to mirrored EHR displays sion for submission. J.T. assisted with data collection, and data Several caveats exist to mirrored screens that are important to men- analysis, and made critical manuscript revisions and approved the fi- tion. Clinicians commonly need to access other areas of the EHR or nal version for submission. other secured systems that could expose sensitive information, such as other patient names when accessing schedules. Being able to sup- press displays as necessary and outline workflows for rooming that address these important areas are needed. The literacy levels of ACKNOWLEDGMENTS patients, including health literacy and computer literacy specifically, We would like to thank all participating clinicians and patients for their valu- likely will impact benefits experienced by patients. We found evi- able insight. We also thank to Paul Iglar and Rabia Copuroglu for helping in dence, however, that patients perceived benefits despite the challeng- video coding. ing interface and jargon. Lastly, the second screen may indeed take away from a shared experience, such as with a large wall-mounted REFERENCES monitor for both clinicians and patients to use. 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JAMIA OpenOxford University Press

Published: Jul 1, 2018

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