1 EHRs and the Doctor-Patient Relationship A Providers Perspective on EHR User Experience Presented by March 2013
1 EHRs and the Doctor-Patient Relationship The doctor-patient relationship is arguably one of the most fundamental components of healthcare. It is the medium through which a significant amount of health information is exchanged, and an important checkpoint for almost every major legal or medical decision in healthcare. As standards rise and the interaction between doctor and patient becomes increasingly customized and trustbased following recent trends in customer service and process engineering, EHR systems are poised to play an important role in facilitating coming changes in healthcare. This is particularly significant for a patient-centric model of care,where personalized data, customized services and the use of technology are changing traditional forms of practice. Given the increasing health information patients have access to and their ability to monitor their own progress, having the doctor in the traditional position of complete control makes less sense today than ever before. By emphasizing prevention and outsourcing parts of the healthcare process to individual patients, health organizations aim to create efficiencies and reduce costs. Stakeholders are counting on technology to keep up and set the pace for progress. Through our research we wanted to understand, from the point of view of medical practitioners, how EHR systems are supporting the evolving aspirations of patients and providers. In conversations with doctors from The Brigham and Women s Hospital, MGH, Cambridge Health Alliance, and other health organizations, we looked at how providers are adjusting to rapidly increasing standards for digital information in healthcare. In this report we explore a new wayof thinking about EHR systems based on the changing roles of Doctors and Patients, and their emerging needs for new and improved collaboration platforms. In our research, THE MEME found that in a teambased healthcare system, information management and exchange depend heavily on patterns of interaction from human relationships. The technologies that will rewrite the future of healthcare will be those that enable new forms of collaboration and eliminate existing barriers for engaging and productive doctor-patient communication. 2
2 Healthcare 2.0: Changing Roles for Practitioners and Evolving, Human-centered Aspirations In a model that increasingly puts the focus on prevention over treatment, today s doctors aspire to a highly nuanced form of positive intervention. As aspirations shift towards more holistic healthcare, prescribing treatment plans is not enough; a key goal of patient centric healthcare is sustainable behavioral change based on meaningful interactions with patients over time. The doctor s goal and the EHR s goal have gotten out of sync, and as a result, EHR systems are not well fitted to their current users. These are complex roles that differ from a historical legacy of doctor as director or exerciser of judgment. They are also more explicitly human-centered than the more recent role of doctor as coordinator of care. Most EHR systems were originally designed for information capture, data management, and medical coding, and meet efficiency requirements in those areas. But few systems were developed with a vision of the new roles to which doctors aspire. As a result, EHRs have not yet addressed new needs that are attached to human values and a specific rapport between people in the healthcare system. In our research, we found that doctors are aspiring to different roles such as: 1) Doctor as educator 2) Doctor as motivating mentor or coach 3
1) Doctor as Educator Danny is an endocrinology fellow at a large medical center. He spends his day rounding, teaching, providing consultations, and taking outpatient appointments in clinic. Danny is committed to preparing for his patient interviews, studying their profiles carefully before meeting to know what they have so he can focus on them during the exam. He also spends his energy educating them: If they know more about their own process, and they re more willing to take responsibility for their own health, the more I help them off the bat. The easier it is down the line. What can we learn from Danny? My job is to give patients the best options and let you make an educated decision. And if they feel like they can t, and want to defer to me, then I will try to give them what I think is the best option. Danny Danny participates in a people-centered process of learning and teaching, interested both in easing someone s confusion or concern and empowering them to have more agency. The goal of Danny s educational process is to improve someone s health by facilitating sustainable behavioral change. Improved exchange between doctor and patient can lead to a better foundation of knowledge upon which to act. When it comes to optimizing a human body, Danny, the expert, trained in medical information and experience for years, knows he knows best. However, something about the doctor-patient relationship dynamic makes him hesitant to declare a given strategy too soon. He would rather the patient learn, think, and choose their own way forward. Danny s goal is to facilitate a back-and-forth rapport of shared decisions. He wants the patient to ask him questions specifically meaningful or targeted questions that facilitate an educational process. My role is to help educate them, so they know what s going on. Danny gets excited when he thinks about all the ways a mobile, integrated EHR could help him in his role of educator, a common thought amongst many practitioners. He recently purchased an ipad hoping it would serve as a mobile platform for his EHR and image-display systems, helping him boost patient involvement and information sharing on rounds. When I m the patient, if I had imaging done I d like to see it So when I m in clinic with my patients, I ll review their images with them. If it s the ultrasound that I did I ll pull it up and show it to them. In his mind, this technology represents the ability for real time communication of medical data, which means meaningful understanding. An aha moment from a patient is Danny s reward. It becomes clear that by empowering patients with knowledge and establishing a highly educational relationship, doctors increase trust and the chances of patients getting involved, participating in their care and improving their wellbeing. An EHR that aids a doctor in his or her aspiration as educator will be well-fitted to Danny s aspirations, and many others like him. 4
2) Doctor as Mentor, Coach Linda is a general internist working at a primary care practice. She takes patient motivation seriously, and asserts that good listening skills are key for the motivational process. Despite the trend towards doctors and patients spending less time together, Linda sees in-person appointments as invaluable for building relationships and setting up rapport, and essential to keeping doctors and patients on the same page in terms of health strategies: It s 20 minutes of dedicated time that I have with somebody to go over something. What can we learn from Linda? I d say motivation is just understanding the patient, where they are, and what the barriers for success are, and (finding) different moments when you can talk about them. Linda Talking to Linda, we heard a need for sensitive communication. A doctor must often choose language carefully and act with caution, needing both to both respect patient privacy and maintain medical credibility in context. Similarly, a patient has a need for sensitivity about their health situation; they are vulnerable to social liability that may arise from negative labels or stigmatized diagnoses. Sometimes you get patients that say, I don t want that diagnosis on my problem list. I don t like that other people are seeing that diagnosis. And then you have to explain to them that: this is important, people need to know that you drink alcohol, or that you had syphilis when you were 20. But then you have to think to yourself also, maybe it s not important. Or I can change the way I say it, like history of a metabolic issue. The sensitivity in this quote is about much more than being a medical expert. It s about being a mentor, and an agent of positive change in a person s relationship with themselves and their health. Linda sees her work as an opportunity to have the difficult yet important conversations necessary for both lasting behavioral change and a healthy medical perspective. Sometimes it s a chance to really explain to somebody that, if you drink heavily for 15 years it puts you at risk for other cancers, and you need to put that on your list, and it doesn t define you, it s just part of who you are and the risks you carry into the future. She also indicates complex aspirations about the extent to which she wishes to motivate her patients: There s a whole world of motivational interviewing tactics. It s really just a matter of listening to people and seeing where they are and what they care about. 5 Linda s aspiration to mentorship calls for leadership capabilities. She needs her EHR system to facilitate the clarity she requires to plan. Linda wants to know: What have been the patient s historical milestones? Where is the patient at the present moment? What matters most next? An EHR with features designed to provide doctors who plan for patient motivation with clear, relevant overviews and goal-setting or progresstracking tools would be well suited to Linda s needs.
3 Evolving Roles in Healthcare Suggest Additional Requirements for Communication These increasing communication requirements on both sides of the doctor-patient relationship are fundamentally linked to evolving roles in healthcare; the ways in which doctors and patients communicate and expect to communicate have changed due to the changing roles of both players. Ineffective communication in healthcare leads to decreased patient involvement and decreased adherence to treatment plans, threatening the quality and effectiveness of care, particularly as the emphasis in healthcare systems shifts towards the patient. Unfortunately, communication challenges are often exacerbated by interacting with an EHR system. In our research, THE MEME found that: 1) Trust from transparency drives meaningful communication. 2) Doctors and patients are overwhelmed by information. 3) Doctors and patients take different approaches to information exchange. 4) Both sides need enhanced communication channels. 6
1) Trust from Transparency Drives Meaningful Communication While the future lies in increasing patient access to information, there are still barriers limiting the level of communication with patients. Doctors talk about a patient differently than how they talk to a patient. If patients could access doctors notes about themselves, they may not understand, be offended, or overwhelmed. A more transparent doctorpatient relationship would have to involve more than allowing patients in, it would need to change the way doctors present information. Sometimes I have to write in my notes that I m not changing the patient s medications because I don t think they re following their treatment plan. That may come off as judgmental, but it s not about blame. I wonder, if the patient read that, how would the patient feel about it? 2) Transparency in terms of medical records, though sometimes a liability for doctors, can build trust. But the less transparency there is in the doctor patient relationship, the more the balance shifts toward the provider. We saw a need from providers to balance maintaining credibility and medical professionalism with building more transparent channels to create a trusting rapport with their patients. Doctors and Patients are Overwhelmed By Information EHR systems need to consider innovative solutions to manage efficiently increasing doctor and patient information needs. Otherwise they run the risk of replicating existing fragmented and overwhelming information sharing practices. Information transfer within the healthcare system can result in a flood of materials that require time and resources to sort. In some cases, too much unintelligible information can both cause a patient stress and slow a provider s workflow. Patients will sometimes bring in a full CAT scan and want every word explained to them. It can take up a lot of your time and offer nothing to the patient in terms of their understanding of their health overall. An EHR note may be pages long, and some systems may resend the entire document as a notification, without highlighting changes. Interoperability and effective record exchange remain a challenge for EHR systems, but even within traditional methods the problem prevails. Sometimes I need to track a patient s history and end up having to call different hospitals to talk to their medical records departments, asking for very specific information. Otherwise they re going to fax me 80 pages of things I don t need. Methods to search and selectively retrieve relevant information are still a fundamental unsatisfied need for doctors that could change the way they communicate and collaborate efficiently with patients and other providers. 7
3) Lack of a Common Language Hinders Doctor-Patient Information Exchange Without resources to connect information to patients in a way that is clear to them, different levels of understanding between patient and provider can lead to fear, mistrust, or feelings of discomfort. 4) Both Sides Need Enhanced Communication Channels New expectations require coordinating communication throughout the medical process and sharing informative resources where possible. Doctors and patients use a different language to talk about the same medical history, symptoms and treatment plans. Doctors spend a long time familiarizing themselves with specialized terminology and use it regularly, creating a barrier that puts patients at a disadvantage. To bridge this gap, doctors are using existing available resources that facilitate translation and help build a common language. Let s say a patient has a new onset of hyperthyroidism and asks, what is it? I can pull it up on Up-to-date and click the patient view, and it will have a description of the disease, process, management, etc. -- but it would be in simpler language, in layman s terms, so people can understand. EHR systems should provide tools that help doctors understand the way patients interpret medical information and are capable to understand its context, meaning and how to make appropriate decisions. People request their record and get mad because they are called obese in the doctors notes. It s a medical term, but people get upset. You have to think about how it sounds to somebody who is non-medical. Given the increasing exchange between doctors and patients, both sides have a stronger need for coordinating their position with the other. If a patient ventures off in independent research and arrives at a disconnected conclusion, it may require additional energy from a provider to track back through the process and undo misunderstandings. However, given the prevalence of medical information on the internet, a patient may also discover and introduce previously unconsidered information. In that case, a provider may be the one to who needs to adjust their position. Sometimes I ll ask them, where did you find this information? This is not something that I know of. And Well I read about it on a blog. I don t know who s blogging about it. I tell them to the best of my knowledge, this is what I know. I refer them to a website. If it s something I really don t know, I ll tell them that. But what I ll do is I ll look it up and get back to you Sometimes the thing they say really is true, something new for me to learn. 8
4 Moving Forward: Build Your Platform Around the Doctor- Patient Relationship EHRs are well established as electronic medical charts and as practice management solutions. How can they become a more transparent, personalized and trusted communication platform for doctors and patients? We saw a variety of ways in which an EHR system can support the human relationship and education process at the center of the healthcare experience. In our research, we found 3 areas of opportunity for the management and presentation of electronic health information: 1) Capitalize on EHR as translator. Build a common language and a common understanding between doctor and patient. 2) Allow for selective information formats. Reduce the complexity of data to decrease cognitive load, improve clarity and customize access to relevant data. 3) Plan for Collaboration and Verification. Take advantage of EHR as a collaboration and coordination platform. THE MEME believes that the best healthcare solutions are built around the collaborative doctor-patient relationship. EHR systems can ease barriers brought about by a lack of clarity or trust, supporting exchange between doctor and patient as more explicitly humancentered, communicationrequiring roles continue to develop. 9
1) EHR as Translator: Build a Common Language Both Educator and Mentor rely on communicating corroboratively with patients. Visual formats and educational resources can provide an interactive means to check in on mutual understanding. Translating medical information and trends into intuitive graphics and displays for patients can relieve unnecessary stress that might result from a misunderstanding of raw medical data. Intuitive visual formats can facilitate clear understanding of normal and abnormal ranges for tests, expected changes, and next steps for treatment. Reduce the complexity of data with look and feel to decrease cognitive load and improve clarity. Well-summarized, relevant patient information can help doctors avoid being distracted or lost in the data during their important patient interviews. Allowing patients to describe symptoms in advance in their own language to help doctors prepare creates the option to compare terms during the medical interview. Provide conversational tools that support doctor-patient interactions, both in real-time during consultation as well as remotely. Providing simple educational material with clear visual information and using simple language can help patients and doctors discuss diagnosis, diseases, medication or test results. Hosting direct links to trusted and recommended external resources for medical information that doctors can monitor and supervise can encourage patients to learn more about their conditions or lab results on their own, increasing transparency and trust. 10
2) Allow for Selective Information Formats Mentor and Educator both strategize and tailor their educational instruction or action plans to their patients. An EHR can facilitate clarity during a provider s planning process, selectively presenting the most relevant information as well as time-based overviews. Support different levels of understanding by creating enhanced communication channels for doctors and patients. This can include interactive UI features that simplify search and retrieval of specific information. Allow sorting features for doctors to prioritize reliable sources of information while maintaining flexibility for additional content. Provide a customized experience using patient personal data to adjust the system. Doctors and patients can set preference options to specific levels of detail for shared information. Allow customized reporting using different graphics, pictures, numeric data or simple text summaries. Give a system the ability to adjust to age or physical limitations to guarantee accessibility to all information, allowing variation in text size, voice over options or other universal design solutions. 11
3) Plan for Collaboration and Verification The goal of both Mentor and Educator is sustainable behavioral change for the patient. Increased patient engagement with the EHR platform, besides being a government mandated component of the future of healthcare, strongly supports this goal. Chronological or time-based views of patient data can give a patient insight into how medication, treatment or behavior patterns are affecting their progress and overall wellness. This is especially valuable for elderly patients or people with chronic conditions, who may require continuous monitoring and care. Doctors can generate simple reminders or establish ways to motivate and encourage positive behavior and better habits. According to treatment schedule, the system can support doctors and patients achieve planned goals with communication channels, custom alerts, and recording and displaying patient response. Doctor can act as mentor by engage the circle of care: patients and family members can give feedback, post updates, or collect and enter requested medical history information. Consider allowing entry of patient s self-tracked medical information (blood pressure, glucose levels, symptoms, etc), providing an optional view of patient behavior, and creating a credible health-monitoring space to engage the patient. 12
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