Letters
1. National Technical Information Service. NINDS t-PA Stroke Study data set (on CD-ROM). http://www.ntis.gov. Accessibility verified October 3, 2013.
Author Affiliations: Yale University School of Medicine, New Haven, Connecticut.
2. Zinkstok SM, Engelter ST, Gensicke H, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke. 2013;44(4):1080-1084.
Corresponding Author: Yunsoo A. Kim, AB, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 (
[email protected]).
3. Winbeck K, Bruckmaier K, Etgen T, von Einsiedel HG, Röttinger M, Sander D. Transient ischemic attack and stroke can be differentiated by analyzing early diffusion-weighted imaging signal intensity changes. Stroke. 2004;35(5):1095-1099.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. White A, Danis M. Enhancing patient-centered communication and collaboration by using the electronic health record in the examination room. JAMA. 2013;309(22):2327-2328.
Patient-Physician Interactions and Electronic Health Records 1
To the Editor In their recent Viewpoint, Drs White and Danis discussed using the electronic health record (EHR) to enhance patient-physician interactions. Whereas others have argued that the EHR can hinder patient-physician communication,2 the authors hold a more optimistic view that expanded uses (such as inviting patients to participate in EHR viewing during the clinical encounter) are untapped tools for patient activation. We share the optimism of White and Danis for health care information technology. During an era of technology innovation and adoption in all aspects of daily life, patients as well as medical professionals are, in general, becoming increasingly familiar with computer use during the clinical encounter. Current EHR systems, however, can be awkward to use, and there is a lack of standardized data structure for true integration of patient data across different EHR platforms.3 These issues are technical and will likely be overcome through innovations in EHR technology, allowing expanded EHR use to further enhance patient care. Additionally, there is a growing repertoire of technologybased tools for patient activation that can complement the EHR. The relatively nascent web-based patient portals allow patients to securely log in and access their personal health information. The portal pulls data from the patient’s EHR and can support items such as screening reminders and patient-physician messaging. One study showed that patient portals in conjunction with an EHR may improve patient engagement.4 Health care–focused social networks also offer a platform for patient activation. Patients can post questions online about their health condition. Physicians registered with the network can then post answers, which can be peer reviewed by other registered physicians. As medical students, we believe proper EHR usage instruction during medical education is important. Patientphysician communication is a part of the standard curriculum at most medical schools. For example, during our preclinical years, we learned a patient-centered model of patient interviewing. These interviews can serve as opportunities for students to practice using the EHR in a way to enhance the interaction. Appropriate use of the EHR to enhance patient activation can thus be taught concurrently with patient communication.2,5 Ultimately, EHR education in medical school will train physicians to become skilled users of this tool. Daniel X. Yang, BS Yunsoo A. Kim, AB jama.com
2. Lown BA, Rodriguez D. Commentary: lost in translation? how electronic health records structure communication, relationships, and meaning. Acad Med. 2012;87(4):392-394. 3. Mandl KD, Kohane IS. Escaping the EHR trap—the future of health IT. N Engl J Med. 2012;366(24):2240-2242. 4. Wright A, Poon EG, Wald J, et al. Randomized controlled trial of health maintenance reminders provided directly to patients through an electronic PHR. J Gen Intern Med. 2012;27(1):85-92. 5. Peled JU, Sagher O, Morrow JB, Dobbie AE. Do electronic health records help or hinder medical education? PLoS Med. 2009;6(5):e1000069.
To the Editor The Viewpoint by Drs White and Danis1 illustrated some of the ways in which using the EHR can enhance patient-physician collaboration and patient activation. We would like to point out some additional issues. First, patient-centeredness requires consideration of the patient’s perspective. Not only do the styles of physicians using the EHR vary, but so do the reactions of patients to the computer. For some patients and physicians, sharing the screen may be distracting.2 Physicians need to pay attention to patient cues and how this practice affects the encounter. It can be very easy for the interaction to become driven by the computer rather than supported by it.3 Second, sharing the monitor with the patient is just one of the ways to overcome the potentially negative effect of EHR use on communication. One study identified a range of strategies, best practices, and enabling factors that physicians used,4 which are largely consistent with tips for effective use of EHRs in the examination room from Ventres et al.5 These range from spatial organization of the office to improving technical skills, such as typing and computer navigation, to information management and documentation practices (eg, using standard templates when possible), and management practices for patient encounters (eg, starting with patient concerns and dividing the encounter into patient- and EHR-focused stages). We encourage physicians to familiarize themselves with and adopt these best practices. As frameworks for describing the new EHR-related skills and enhancing their acquisition become available, we hope they will become part of the training of health professionals. Aviv Shachak, PhD Shmuel Reis, MD, MHPE Christopher Pearce, PhD, MFM, MBBS Author Affiliations: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (Shachak); Bar-Ilan University Faculty of Medicine in the Galilee, Safed, Israel (Reis); Inner East Melbourne Medicare Local, Melbourne, Australia (Pearce).
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Letters
Corresponding Author: Aviv Shachak, PhD, University of Toronto, 155 College St, Toronto, ON M5T 3M6, Canada (
[email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. White A, Danis M. Enhancing patient-centered communication and collaboration by using the electronic health record in the examination room. JAMA. 2013;309(22):2327-2328. 2. Pearce C, Arnold M, Phillips C, Trumble S, Dwan K. The patient and the computer in the primary care consultation. J Am Med Inform Assoc. 2011;18(2):138-142. 3. Kumarapeli P, de Lusignan S. Using the computer in the clinical consultation; setting the stage, reviewing, recording, and taking actions: multi-channel video study. J Am Med Inform Assoc. 2013;20(e1):e67-e75. 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(3):341-348. 5. Ventres W, Kooienga S, Marlin R. EHRs in the exam room: tips on patient-centered care. Fam Pract Manag. 2006;13(3):45-47.
In Reply Mr Yang and Ms Kim thoughtfully suggest some complementary tools for patient activation, emphasize the importance of user-friendly EHR design, and underscore the need for medical education that prepares trainees to incorporate computers and other forms of technology into the clinical encounter. Dr Shachak and colleagues offer further strategies for effective EHR use in the examination room. We agree that these additional elements are useful to consider, especially as the EHR becomes increasingly prominent in the patientphysician interaction. Shachak and colleagues highlight the need to maintain patient-centeredness when interacting with patients who may wish to avoid computer screen viewing; we agree that this is an important issue for further consideration. A patient’s reluctance to engage in screen viewing during the encounter could stem from a number of distinct or overlapping factors, including a general lack of familiarity with computer technology, apprehension about viewing his or her own health trends, a desire to focus solely on building a face-to-face rapport with the clinician, a perception that monitor viewing is somewhat distracting, or other relevant concerns. In some cases, particularly when patients hesitate to gaze at the screen due to limited computer skills, there may be opportunities over the course of the patient-physician relationship to slowly demystify aspects of the technology that may have prevented them from accessing helpful information in the
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past. On the other hand, even patients with adequate computer navigation skills may prefer to limit computer-related activities during the clinical encounter. Our optimism about the utility of the EHR for enhancing collaboration in the examination room presupposes that clinicians offer the invitation but respect patient preferences when that invitation is declined. We propose that this invitation to engage in EHR collaboration, if offered in an appealing and nonjudgmental way, is a means of emphasizing the patientcenteredness of the clinical encounter. Amina A. White, MD Marion Danis, MD Author Affiliations: Department of Bioethics, National Institutes of Health, Bethesda, Maryland. Corresponding Author: Amina A. White, MD, National Institutes of Health, 10 Center Dr, Bldg 10, Room 1C118, Bethesda, MD 20892 (
[email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Disclaimer: This letter reflects the views of the authors and not necessarily the policies of the National Institutes of Health or the US Department of Health and Human Services.
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