Wei Wei Lee

Impact of Electronic Medical Record Use on the Patient–Doctor Relationship and Communication: A Systematic Review

ABSTRACTBACKGROUNDWhile Electronic Medical Record (EMR) use has increased dramatically, the EMR’s impact on the patient–doctor relationship remains unclear. This systematic literature review sought to understand the impact of EMR use on patient–doctor relationships and communication.METHODSParallel searches in Ovid MEDLINE, PubMed, Scopus, PsycINFO, Cochrane Library, reference review of prior systematic reviews, meeting abstract reviews, and expert reviews from August 2013 to March 2015 were conducted. Medical Subject Heading terms related to EMR use were combined with keyword terms identifying face-to-face patient–doctor communication. English language observational or interventional studies (1995–2015) were included. Studies examining physician attitudes only were excluded. Structured data extraction compared study population, design, data collection method, and outcomes.RESULTSFifty-three of 7445 studies reviewed met inclusion criteria. Included studies used behavioral analysis (28) to objectively measure communication behaviors using video or direct observation and pre-post or cross-sectional surveys to examine patient perceptions (25). Objective studies reported EMR communication behaviors that were both potentially negative (i.e., interrupted speech, low rates of screen sharing) and positive (i.e., facilitating questions). Studies examining overall patient perceptions of satisfaction, communication or the patient–doctor relationship (n = 22) reported no change with EMR use (16); a positive impact (5) or showed mixed results (1). Study quality was not assessable. Small sample sizes limited generalizability. Publication bias may limit findings.DISCUSSIONDespite objective evidence that EMR use may negatively impact patient–doctor communication, studies examining patient perceptions found no change in patient satisfaction or patient–doctor communication. Therefore, our findings should encourage providers to adopt the EMR as a communication tool. Future research is needed to better understand how to enhance patient–doctor- EMR communication. This research should correlate observed physician behavior to patient satisfaction, focus on physician communication skills training, and explore inpatient experiences.

Preparing for the primary care clinic: an ambulatory boot camp for internal medicine interns

Introduction Internal medicine (IM) interns start continuity clinic with variable ambulatory training. Multiple other specialties have utilized a boot camp style curriculum to improve surgical and procedural skills, but boot camps have not been used to improve interns’ ambulatory knowledge and confidence. The authors implemented and assessed the impact of an intern ambulatory boot camp pilot on primary care knowledge, confidence, and curricular satisfaction. Methods During July 2014, IM interns attended ambulatory boot camp. It included clinically focused case-based didactic sessions on common ambulatory topics as well as orientation to the clinic and electronic medical records. Interns anonymously completed a 15-question pre-test on topics covered in the boot camp as well as an identical post-test after the boot camp. The interns were surveyed regarding their confidence and satisfaction. Results Thirty-eight interns participated in the boot camp. Prior to the boot camp, few interns reported confidence managing common outpatient conditions. The average pre-test knowledge score was 46.3%. The average post-test knowledge score significantly improved to 76.1% (p<0.001). All interns reported that the boot camp was good preparation for clinics and 97% felt that the boot camp boosted their confidence. Conclusions The ambulatory boot camp pilot improved primary care knowledge, and interns thought it was good preparation for clinic. The ambulatory boot camp was well received and may be an effective way to improve the preparation of interns for primary care clinic. Further assessment of clinical performance and expansion to other programs and specialties should be considered.

Incorporating the human touch: piloting a curriculum for patient-centered electronic health record use

ABSTRACT Background: Integrating electronic health records (EHRs) into clinical care can prevent physicians from focusing on patients. Despite rapid EHR adoption, few curricula teach communication skills and best practices for patient-centered EHR use. Objective: We piloted a ‘Patient-centered EHR use’ curriculum, consisting of a lecture and group-observed structured clinical examination (GOSCE) for second-year students (MS2s). Design: During the lecture, students watched a trigger tape video, engaged in a reflective observation exercise, and learned best practices. During the GOSCE, one of four MS2s interacted with a standardized patient (SP) while using the EHR. Third-year students (MS3s) received no formal training and served as a historical control group by completing the same OSCE individually. All students completed post-GOSCE/OSCE surveys. The SP evaluated GOSCE/OSCE performance. Results: In 2013, 89 MS2s participated in the workshop and GOSCEs during their required Clinical Skills course and 96 MS3s participated in individual OSCEs during their end of year multi-station formative GOSCE exercise. Eighty MS2s (90%) and 88 MS3s (92%) post-GOSCE/OSCE surveys were analyzed. Compared to MS3s, significantly more MS2s rated their knowledge (19% vs 55%) and training (14% vs 39%) as good (≥4/5 point scale, P < .001 for both). Most learners (85% MS2s and 70% MS3s) thought training should be required for all students. SP ratings on GOSCE/OSCE performance was higher for the 20 MS2s compared to the 88 MS3 controls (73.5 [SD = 4.5] vs 58.1 [SD = 13.1] on 80 point scale, P < .001). Conclusions: A short workshop and GOSCE were effective in teaching patient-centered EHR use. This curriculum is now a permanent part of our Clinical Skills course. Clerkship students who did not receive our curriculum may have been exposed to negative role-modeling on the wards. To address this, training residents and faculty on patient-centered EHR use skills should be considered. Abbreviations: EHR: Electronic health record; EHR: Electronic health record; SP: Standardized patient

Medical student resilience and stressful clinical events during clinical training

ABSTRACT Background: Medical students face numerous stressors during their clinical years, including difficult clinical events. Fostering resilience is a promising way to mitigate negative effects of stressors, prevent burnout, and help students thrive after difficult experiences. However, little is known about medical student resilience. Objective: To characterize medical student resilience and responses to difficult clinical events during clinical training. Design: Sixty-two third-year (MS3) and 55 fourth-year (MS4) University of Chicago medical students completed surveys in 2016 assessing resilience (Connor Davidson Resilience Scale, CD-RISC 10), symptoms of burnout, need for resilience training, and responses to difficult clinical events. Results: Medical student mean resilience was lower than in a general population sample. Resilience was higher in males, MS4s, those without burnout symptoms, and students who felt able to cope with difficult clinical events. When students experienced difficult events in the clinical setting, the majority identified poor team dynamics among the most stressful, and agreed their wellbeing was affected by difficult clinical events. A majority also would prefer to discuss these events with their team later that day. Students discussed events with peers more than with attendings or residents. Students comfortable discussing stress and burnout with peers had higher resilience. Most students believed resilience training would be helpful and most beneficial during MS3 year. Conclusions: Clinical medical student resilience was lower than in the general population but higher in MS4s and students reporting no burnout. Students had some insight into their resilience and most thought resilience training would be helpful. Students discussed difficult clinical events most often with peers. More curricula promoting medical student resilience are needed.

Patient-Centered Technology Use: Best Practices and Curricular Strategies

Abstract This chapter addresses the practical dilemma clinicians’ face today to be both efficient with the EMR while engaging in meaningful patient-centered interactions. It starts by outlining best practices and strategies for patient-centered computer use with patients and details barriers encountered in implementing these techniques. We describe curricular approaches to teach these skills and evaluation tools to assess learners. In addition, we highlight an institutional model for a longitudinal curriculum. Lastly, challenges to curriculum implementation are discussed, including the need for institutional support and required training across the continuum of learners in order to ensure sustained positive behavioral change.This chapter addresses the practical dilemma clinicians’ face today to be both efficient with the EMR while engaging in meaningful patient-centered interactions. It starts by outlining best practices and strategies for patient-centered computer use with patients and details barriers encountered in implementing these techniques. We describe curricular approaches to teach these skills and evaluation tools to assess learners. In addition, we highlight an institutional model for a longitudinal curriculum. Lastly, challenges to curriculum implementation are discussed, including the need for institutional support and required training across the continuum of learners in order to ensure sustained positive behavioral change.

The Impact of EMRs on Communication Within the Doctor-Patient Relationship

This chapter addresses the impact of electronic medical record (EMR) use on the patient–doctor relationship and communication. It starts by defining the principles of patient–centered care, explores the phenomena of treating the “iPatient” on the screen while ignoring the real patient, and discusses the myth of multitasking in the context of EMR use with patients. The chapter summarizes current research findings on how EMR use alters the patient–doctor interaction and outlines physician behaviors that may have a positive or negative impact on the clinical encounter and patient perceptions. In addition, the chapter presents evidence-based best practices to foster patient-centered communication, promote patient engagement, education, and shared decision making. Lastly, strategies to teach best practices as well as an institutional model for a longitudinal curriculum of EMR-based communication skills is provided.

Year-End Clinic Handoffs: A National Survey of Academic Internal Medicine Programs

BackgroundWhile there has been increasing emphasis and innovation nationwide in training residents in inpatient handoffs, very little is known about the practice and preparation for year-end clinic handoffs of residency outpatient continuity practices. Thus, the latter remains an identified, yet nationally unaddressed, patient safety concern.ObjectivesThe 2014 annual Association of Program Directors in Internal Medicine (APDIM) survey included seven items for assessing the current year-end clinic handoff practices of internal medicine residency programs throughout the country.DesignNationwide survey.ParticipantsAll internal medicine program directors registered with APDIM.Main MeasuresDescriptive statistics of programs and tools used to formulate a year-end handoff in the ambulatory setting, methods for evaluating the process, patient safety and quality measures incorporated within the process, and barriers to conducting year-end handoffs.Key ResultsOf the 361 APDIM member programs, 214 (59%) completed the Transitions of Care Year–End Clinic Handoffs section of the survey. Only 34% of respondent programs reported having a year-end ambulatory handoff system, and 4% reported assessing residents for competency in this area. The top three barriers to developing a year-end handoff system were insufficient overlap between graduating and incoming residents, inability to schedule patients with new residents in advance, and time constraints for residents, attendings, and support staff.ConclusionsMost internal medicine programs do not have a year-end clinic handoff system in place. Greater attention to clinic handoffs and resident assessment of this care transition is needed.

Impact of a brief faculty training to improve patient-centered communication while using electronic health records

OBJECTIVE Despite rapid EHR adoption, few faculty receive training in how to implement patient-centered communication skills while using computers in exam rooms. We piloted a patient-centered EHR use training to address this issue. METHODS Faculty received four hours of training at Cleveland Clinic and a condensed 90-minute version at the University of Chicago. Both included a lecture and a Group-Objective Structured Clinical Exam (GOSCE) experience. Direct observations of 10 faculty in their clinical practices were performed pre- and post-workshop. RESULTS Thirty participants (94%) completed a post-workshop evaluation assessing knowledge, attitude, and skills. Faculty reported that training was important, relevant, and should be required for all providers; no differences were found between longer versus shorter training. Participants in the longer training reported higher GOSCE efficacy, however shorter workshop participants agreed more with the statement that they had gained new knowledge. Faculty improved their patient-centered EHR use skills in clinical practice on post- versus pre-workshop ratings using a validated direct-observation rating tool. CONCLUSION A brief lecture and GOSCE can be effective in training busy faculty on patient-centered EHR use skills. PRACTICE IMPLICATIONS Faculty training on patient-centered EHR skills can enhance patient-doctor communication and promotes positive role modeling of these skills to learners.

Enterprise Microblogging to Augment the Subinternship Clinical Learning Experience: A Proof-of-Concept Quality Improvement Study

Background Although the Clerkship Directors in Internal Medicine (CDIM) has created a core subinternship curriculum, the traditional experiential subinternship may not expose students to all topics. Furthermore, academic institutions often use multiple clinical training sites for the student clerkship experience. Objective The objective of this study was to sustain a Web-based learning community across geographically disparate sites via enterprise microblogging to increase subintern exposure to the CDIM curriculum. Methods Internal medicine subinterns used Yammer, a Health Insurance Portability and Accountability Act (HIPAA)–secure enterprise microblogging platform, to post questions, images, and index conversations for searching. The subinterns were asked to submit 4 posts and participate in 4 discussions during their rotation. Faculty reinforced key points, answered questions, and monitored HIPAA compliance. Results In total, 56 medical students rotated on an internal medicine subinternship from July 2014 to June 2016. Of them, 84% returned the postrotation survey. Over the first 3 months, 100% of CDIM curriculum topics were covered. Compared with the pilot year, the scale-up year demonstrated a significant increase in the number of students with >10 posts (scale-up year 49% vs pilot year 19%; P=.03) and perceived educational experience (58% scale-up year vs 14% pilot year; P=.006). Few students (6%) noted privacy concerns, but fewer students in the scale-up year found Yammer to be a safe learning environment. Conclusions Supplementing the subinternship clinical experience with an enterprise microblogging platform increased subinternship exposure to required curricular topics and was well received. Future work should address concerns about safe learning environment.