Health information and communication technology in healthcare ...

Patient Education and Counseling 93 (2013) 359–362

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Editorial

Health information and communication technology in healthcare communication: The good, the bad, and the transformative

1. Introduction

2. General trends

Information and communication technology (ICT) have transformed our lives in banking, education, leisure, and human relationships. Health Information and communication technology (HICT) is no different; it is here to stay and there is no turning back. The presence of computers in the examination room has already transformed the traditional patient–doctor relationship from dyadic to triadic. It is now an interaction between the patient, the doctor and the computer [1]. Searching the World Wide Web for healthcare information is second only to searching for sites related to sex, while multiple forms of social media, now increasingly mobile, are challenging the limits of healthcare providers’ professionalism [2]. Information and knowledge are instantaneously accessible to patients, learners and care providers, adding an external brain or digital prosthesis to our cognitive capacity. In short, our use of computers and digital media has the potential to significantly shift the dynamics of health professions education, practice, and communication. The promise of HICT is to empower both patients and providers and, in so doing, improve health care delivery and outcomes. The reality of HICT is something else again. Care providers and patients have experienced multiple barriers to HICT ranging from the computer screen exerting a disabling influence on relationship formation to HICT-related mortality and morbidity [3]. How will healthcare providers respond to these challenges and what will the nature of conversations be in the brave new digital world? While very prominent in lay discourse about healthcare there is surprisingly little dialog about meeting these challenges in health professions education and practice [4]. As a result, healthcare providers are actually at risk of being relegated to a back seat in the digital healthcare revolution. As editors for this special issue, we have selected a sizeable group of papers that address some of the most important challenges in HICT impact on communication. Out of the many submissions, twenty-six (24 papers, a letter and a report) were chosen for their quality and scope to describe the cutting edge of research and practice in this arena. Multiple countries in four continents are represented here: North America (USA, Canada), Europe (UK, Norway, the Netherlands, Switzerland), Asia (China mainland, Hong Kong, Israel), and Australia. While multiple questions have been addressed by the authors others still remain, and new ones are sure to arise. In this editorial we provide an overview of the territory that is covered as well as some challenges for the future.

Multiple opportunities and barriers to using HICT to support healthcare communication are addressed by authors in this special issue [5–30]. Based on their research, we now know that a generation of providers and patients now exists, with no apparent age demarcation, which use and rely upon HICT. For example, Agur Cohen [5] describes a physician digital consultation (and support) network and George et al. [6] describe how iPads and Skype are being used in medical education. Other papers describe web-based patient support groups, information sites and patient oriented health interventions [7–11]. Willcox et al. [12, p.533], a North American group of authors, report on a human factors in computing systems conference that took place in the spring of 2013. Participants were researchers interested in the person/machine interface in clinical encounters. A workshop, research presentations and panel discussion demonstrated the multiplicity of modalities that have already been developed and tested as well as those that are, ‘‘increasingly facilitated, enriched, and mediated by new types of health technologies’’. The presentations at the conference underscored the need for closer collaboration and open dialog between the human factors communities and those interested in the real-time impact of technology on relationships, (e.g., the PEC readership), a view we fully endorse.

0738-3991/$ – see front matter ß 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.pec.2013.10.007

3. The impact of electronic health records (EHRs) on communication The opportunities and challenges of exam room computing are addressed from multiple perspectives. Attempts to improve providers’ skills in the computerized setting as well as instruments to support them are described. Frankel and Saleem [13, p.367], ‘‘use cockpit communication as an example of highly a coordinated complex activity during flight and compare it with providers’ communication when computers are used in the exam room’’. They conclude, ‘‘. . .that there is a great deal of room for improving the balance of interpersonal and technical attention that occurs in routine ambulatory visits in which computers are present in the exam room’’. Assis-Hassid et al. [14] review existing instruments for assessing exam room computing skills, concluding that new ones are needed, while Reis et al. [15] describe an intervention to enhance such skills. Kushnir and her group [16] demonstrate that cultural attitudes, (Bedouin as compared to Jews in southern Israel), do not play a significant role in patients’

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Editorial / Patient Education and Counseling 93 (2013) 359–362

experience of examination room computer use by primary care physicians; both groups were concerned with the same handicap – time lost due to providers’ typing speed. The message from these papers is loud and clear: clinicians need to better balance the interpersonal and technical, and foster both, so that the promise of EHRs is fulfilled without a degradation of patients’ experiences of care. For this purpose frameworks and tools are already available and need to be implemented together with further development and rigorous evaluation. 4. Patient empowerment and social media Websites that target patients’ decision making and information-seeking often include testimonials of patients’ experiences. An interesting endeavor by Kelly et al. [22, p.433] used an objective impact assessment questionnaire to gauge and bridge the presentation of purely subjective patient experiences of health information websites. Through theme identification, item generation, expert and patient refinement – their item pool was created and validated. Having been validated through community consensus, the questionnaire ‘‘will be used in a randomized controlled trial examining the effects of online patients’ experiences’’. This is a fine example of a mixed methods inquiry chain. Nes et al. [7] in a bi-national (Norway and the Netherlands) paper examine support and feedback for patients’ self-management of their chronic diseases through comparison of three web-based CBT-grounded interventions. Three complicated chronic conditions were addressed: inflammatory bowel syndrome, chronic widespread pain, and type 2 diabetes mellitus. The interventions which included E-diaries and feedback via PDAs/smart phones appear feasible, acceptable and supportive. Sillence et al. [10] report on patient experience-based websites that serve asthma patients and caregivers in the UK. Patients found the sites containing useful information that refreshed their knowledge and provided them with an opportunity to reflect on the role of asthma in their lives. In Canada, Bender et al. [9, p.472] compared the perspectives of former patients who are now facilitators of online support groups for breast cancer patients, with their experience of face-to-face meetings. The investigators’ conclusion is that, ‘‘respondents used online communities to address unmet needs during periods of stress and uncertainty. Online communities have the potential to fill gaps in supportive care by addressing the unmet needs of a subgroup of breast cancer survivors’’. In joint work conducted in Hong Kong and the UK, Mo and Coulson [11] describe online support groups for individuals living with HIV/ AIDS. Results from an online survey showed that the more patients used on-line support, the better their psychological health was. Shaw et al. [28] remind us that the first HICT device was the telephone, which still plays a central role in patient helplines. A multiplicity of ways in which patients are empowered by HICT is obvious. How should providers be made more aware of these powerful therapeutic modalities? And should they be prescribed? Patients will probably turn more and more to the World Wide Web for making sense of their symptoms, check on their providers, and seek support for self-management and emotional well-being. How this development will impact outcomes and health professionals’ roles is unclear at present. Equally important, and poorly understood, is providers’, learners’ and patients’ increasing use of informal digital networks, and how this will impact care, education and society. The use of social media in healthcare, health education, and health promotion is somewhat under-represented. While generational issues in YouTube use by patients is addressed, building and sustaining clinical relationships using social media is not, nor are the challenges of professionalism that have been raised in the media and by ethicists and others responsible for maintaining

professional standards. Mazanderani et al. [17] describe how the World Wide Web (You Tube in this instance) provides novel but unfiltered sources of information that influence patients’ decision making. Healthcare professionals need to become familiar with the various modalities patients use so that they can acquire the skills necessary to address potentially harmful decisions based on unsubstantiated evidence. This challenge will continue to become more complex as additional channels of web-based information become available and skills for managing conversations with patients about the potentially harmful effects will become more important over time. 5. IT as healthcare infrastructure Healthcare interventions, as well as tools and models that seek to improve patient outcomes abound. Linn et al. [8, p.387], for example, describe a multimedia intervention to improve medication adherence in Inflammatory Bowel Syndrome patients. The intervention seeks to synergize interpersonal and technologicallymediated strategies. Based on an MRC (UK Medical Research Council) framework, the intervention was developed based on theory, existing evidence and extensive modeling. It consists of communication skills training for nurses administered using an online preparatory assessment of patients’ barriers to adherence, tailored interpersonal communication and tailored text messaging. Its feasibility was tested and found instructive, applicable and acceptable. The approach ‘‘could therefore serve as a guide for the development of other health interventions’’. In a ground breaking paper, Van Gurp et al. present a rigorous analysis of one of the most challenging areas of communication, palliative care [18, p.512]. Intuitively, IT-supported communicative modalities such as telecare would seem to challenge the notion that patients requiring palliative care need the proximity, empathy, and face-to-face contact that define human relationships. The authors model how such a profound concern may be approached rationally, yet with a full-fledged affective and ethical premise, producing valuable results for the future implementation of technology. These are highlighted through exploration of how ‘cold’ technologies can enable ‘warm’ relationships and how ‘care at a distance’ may interfere with the inner motivation of care professionals to deliver the necessary commitment, engagement and mutual recognition that make end of life care effective and meaningful. Their analysis highlights how ‘time as a commodity’ is transformed through telecare, making the care team available and present in a radical new way that need not need to take away from limited face-to-face provider availability. Some questions raised by this study are: ‘‘Can telecare technologies provide their users with an environment where they can learn each other’s states of mind, address cues about intimate topics and build a shared care upon?’’. In a somewhat different vein, Ruiz et al. [19] hypothesized that icon arrays in cardiovascular risk presentation might increase patients’ understanding, recall, perception of risk, and behavioral intent as compared with numerical information. However, their conclusion is that it does not. Botnga˚rd et al. [20, p.389] studied parent’s information needs in acute pediatric care and showed that multimedia-based health information was no better than verbal information. ‘‘However, after discharge the parents were more satisfied with the multimedia approach’’. Rubinelli et al. [21, p.463] investigated the potential for websites powered by health organizations to become interactive especially in the context of Web 2.0. They studied a website for patients with spinal cord injury and concluded that, ‘‘Interactions between different categories of users can make these websites important platforms for promoting self-management of chronic conditions, organizational innovation, and participatory research’’. Finally, Patrick-Miller


et al. [29, p.413] describe yet another controversial technology supported practice i.e. the delivery of BRCA 1/2 test results by a genetic counselor telephone rather than face to face, showing that it ‘‘may not be associated with negative cognitive and affective responses among willing patients’’. In summary, the prediction that the World Wide Web will become the central venue for information retrieval, as well as the infrastructure for healthcare [31] is taking shape through patient portals, telemedicine, multimedia, web based interventions and more as described by this issue’s authors. 6. Disparities and digital disparities Concern about how HICT could be used to level the playing field for disadvantaged communities, provide greater access and address issues of low health literacy are fairly obvious. The complexities of digital equity, however, are much more than just socioeconomic. Xiao et al. [23], for example, address the mismatch between the number healthcare institutions and relative rarity of pharmacies in China and propose ‘‘bridging’’ solutions. These solutions are already available in China, but have not yet been harnessed for this particular purpose. Their paper raises the compelling argument that smart phone, Weibo (the Chinese version of twitter) and QQ (instant messenger), rather than increase the digital divide (a concern expressed by many), may actually reduce it especially in developing countries. Berger et al. [24, p.480] in the US, examine whether disparities can be addressed through public reporting. Having conducted a systematic review the authors found a lack of evidence for the impact of public reporting on reducing disparities. However, lack of effect is not available either. The review calls for better and more extensive ‘‘information collection on patient-relevant outcomes. . .. A research gap exists regarding. . .outcomes and public reporting’’. Reporting on US data too, Gleason-Comstock et al. [25, p.464] ‘‘explore the feasibility and short term outcomes of using an interactive kiosk integrated into office flow to deliver health information in a primary care clinic’’ serving a disadvantaged population. In a randomized control trial, ‘‘although there were no differences between groups. . .using a kiosk within a clinic setting is a feasible method of providing health information and selfmonitoring. Multi-session educational content can provide beneficial short term outcomes in overweight adults. A kiosk with attached peripherals in a clinic setting is a viable adjunct to provider education, particularly in medically underserved areas’’. Miller et al. [30, p.488] use the telephone for improving Pap Smear adherence in the underserved and conclude that: ‘‘Dissemination of barriers counseling into ongoing telephone reminder calls and contacts may decrease disparities in cancer outcomes, especially among women with less than postsecondary education’’. Clearly, more research is needed in the area of HICT and health equity as well as the impact of social media on processes and outcomes of care. 7. The e-doc and HICT in Health professions education Much has been reported in literature about the need for health professionals to develop, an e-persona, i.e. a professional virtual presence that skilfully takes advantage of the new options offered by HICT. A salient example is already mentioned earlier (van Gurp et al. [18]) concerning telecare in end of life care, another by Bravender et al. [28] addresses training of physicians to better communicate with teenagers through a web-based intervention. Agur Cohen [5] as already mentioned, describes what already is turning to a common practice: physicians professional networks utilizing social media (there are emerging reports of such networks utilizing mobile devices for point of care fast consultations).

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As the discourse of current health professions education includes flipped classrooms, web based portfolios, telementoring and more, HICT will necessarily have a greater presence and impact in this field. One important and unaddressed question for health professions education is the extent to which training that has traditionally been based on face to face interactions, e.g. gross anatomy, teaching interviewing skills, and physical diagnosis can be enhanced or replaced by HICT. Websites like Doc.Com (webcampus.drexelmed.edu/doccom/user) and others use hybrid models (some face to face interaction and some virtual interaction) to teach interviewing skills. Whether HICT can be used as a ‘‘stand alone’’ modality to teach these skills is an interesting and open question. George et al. [6] as well as Reis et al. [15] inform this discussion in this issue. 8. Conclusions Healthcare is experiencing a flood of HICT based modalities that are already transforming the way providers and patients think about, access, and act upon digitally supplied healthcare information. In many cases the transformation has already had a profound impact on clinical encounters, rendering the traditional face to face patient encounter only one of many options, and often not the preferred one. The office visit of yesterday is rapidly being transformed into medical care ‘‘to go,’’ that is, care that takes advantage of digital devices such as smart phones, and applications such as texting, email, and Skype. Integrated systems are making instantaneous information sharing a reality in a growing number of countries and institutions. At this juncture, patients seem to be way ahead of providers in terms of their use of digital technology to access health information. The healthcare professional community is slowly catching up. HICT communication-related posters and podium presentations at professional meetings have increased from practically zero a year ago, to about 10–15% in the last year. This is a positive development; however, we are still left with a number of questions: What are the skills and competencies providers will need to be effective in a HICT-based universe? How can providers’ fears of HICT adding additional responsibilities and commitments of time to provider tasks be assuaged? Will the High tech – High touch promise of HICT be fulfilled and, if so, what role will providers have in making it happen? We invite you, as readers, to reflect on these questions (and others) raised in this special issue, and become part of the solution to making HICT-mediated healthcare a tool for improving health and healing across the lifespan. References [1] Pearce C, Dwan K, Arnold M, Phillips C, Trumble S. Doctor, patient and computer—a framework for the new consultation. Int J Med Inf 2009; 78:32–8. [2] Gholami-Kordkheili F, Wild V, Strech D. The impact of social media on medical professionalism: a systematic qualitative review of challenges and opportunities. J Med Internet Res 2013;8:e184. [3] Shachak A, Reis S. The computer-assisted patient consultation: promises and challenges. In: Kabene SM, editor. Healthcare and the effect of technology: developments, challenges and advancements. Med Inform Science; 2010 . http://dx.doi.org/10.4018/978-1-61520-733-6. [4] Shachak A, Hadas-Dayagi M, Ziv A, Reis S. Primary care physicians’ use of an electronic medical record system: a cognitive task analysis. J Gen Intern Med 2009;24:341–8. [5] Agur Cohen D, Levy M, Cohen Castel O, Karkabi K. The influence of a professional physician network on clinical decision making. Patient Educ Couns 2013;93:496–503. [6] George P, Dumenco L, Dollase R, Taylor JS, Wald HS, Reis SP. Introducing technology into medical education: two pilot studies. Patient Educ Couns 2013;93:522–4. [7] Nes AA, Eide H, Kristjańsdo´ttir OB, van Dulmen S. Web-based, self-management enhancing interventions with e-diaries and personalized feedback for persons with chronic illness: a tale of three studies. Patient Educ Couns 2013;93:451–8.

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Shmuel Reis* Bar Ilan University, Faculty of Medicine in the Galilee, Israel Adriaan Visser Rotterdam University for Applied Sciences, Knowledge Centre Innovations in Health Care, Rotterdam, The Netherlands Editor, Patient Education and Counseling Richard Frankela,b,c Medicine and Geriatrics, Indiana University School of Medicine, USA b Mary Margaret Walther Center for Palliative Care Research and Education, IU/Simon Cancer Center, USA c Center for Implementing Evidence Based Practice, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN 46202, USA

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*Corresponding author at: Bar Ilan University Faculty of Medicine in the Galilee, Henrietta Sold 8 St, Safed, Israel. Tel.: +972 7202644944/524892535; fax: +972 49800210 E-mail address: [email protected] (S. Reis)