Improving physician–patient communication

This chapter looks at improving physician–patient communicatio

Email for clinical communication between healthcare professionals

Email is one of the most widely used methods of communication, but its use in healthcare is still uncommon. Where email communication has been utilised in health care, its purposes have included clinical communication between healthcare professionals, but the effects of using email in this way are not well known. We updated a 2012 review of the use of email for two-way clinical communication between healthcare professionals

Email for clinical communication between healthcare professionals

Background Email is a popular and commonly-used method of communication, but its use in healthcare is not routine. Where email communication has been utilised in health care, its purposes have included use for clinical communication between healthcare professionals, but the effects of using email in this way are not known. This review assesses the use of email for two-way clinical communication between healthcare professionals. Objectives To assess the effects of healthcare professionals using email to communicate clinical information, on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information. Search methods We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists, contacting authors. Selection criteria Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information, and that took the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered. Data collection and analysis Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information. We report all measures as per the study report. Main results We included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment with usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement and/or osteoporosis medication) when compared with usual care. The evidence for its impact on patient behaviours/actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively: patients had a higher calcium intake, and two found no difference between the two groups. The study did not assess primary health service outcomes or harms. Authors' conclusions As only one study was identified for inclusion, the results are inadequate to inform clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research needs to use high-quality study designs that take advantage of the most recent developments in information technology, with consideration of the complexity of email as an intervention, and costs

The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente.

BackgroundPatient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited.MethodsThis paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development?ResultsWe identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design.ConclusionsThese findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs

Email for communicating results of diagnostic medical investigations to patients

<p>Background: As medical care becomes more complex and the ability to test for conditions grows, pressure on healthcare providers to convey increasing volumes of test results to patients is driving investigation of alternative technological solutions for their delivery. This review addresses the use of email for communicating results of diagnostic medical investigations to patients.</p> <p>Objectives: To assess the effects of using email for communicating results of diagnostic medical investigations to patients, compared to SMS/ text messaging, telephone communication or usual care, on outcomes, including harms, for health professionals, patients and caregivers, and health services.</p> <p>Search methods: We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 1 2010), MEDLINE (OvidSP) (1950 to January 2010), EMBASE (OvidSP) (1980 to January 2010), PsycINFO (OvidSP) (1967 to January 2010), CINAHL (EbscoHOST) (1982 to February 2010), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched July 2010). We used additional search methods: examining reference lists and contacting authors.</p> <p>Selection criteria: Randomised controlled trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies of interventions using email for communicating results of any diagnostic medical investigations to patients, and taking the form of 1) unsecured email 2) secure email or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.</p> <p>Data collection and analysis: Two review authors independently assessed the titles and abstracts of retrieved citations. No studies were identified for inclusion. Consequently, no data collection or analysis was possible.</p> <p>Main results: No studies met the inclusion criteria, therefore there are no results to report on the use of email for communicating results of diagnostic medical investigations to patients.</p> <p>Authors' conclusions: In the absence of included studies, we can draw no conclusions on the effects of using email for communicating results of diagnostic medical investigations to patients, and thus no recommendations for practice can be stipulated. Further well-designed research should be conducted to inform practice and policy for communicating patient results via email, as this is a developing area.</p&gt

What\u27s in a Message? The Impact of Patient-Clinician Email Message Content on Patient Health Outcomes and Healthcare Utilization

Introduction In the upcoming chapters, we present our study findings as three papers ready for submission to peer-reviewed journals. The first paper describes the associations between taxa and the characteristics of the patients and clinic staff who exchange those messages. The second paper explores the associations between those taxa and patients’ healthcare utilization. The third paper presents associations between taxa and patient health outcomes for diabetes and hypertension. We conclude with how the three papers are related and highlight the importance of this research. Across the three papers, we reference a theory-based taxonomy we developed specifically for secure messaging. A number of researchers have created taxonomies to classify secure message content. Although these contained common themes, many were used only once or twice in published research and few classified content generated by clinic staff. We built our taxonomy upon commonly used themes from these existing classification systems. In contrast with other researchers, however, we leveraged theoretical constructs to group taxa and identify the concepts within messages that must be present for logical linkages between message content and patient outcomes. To identify why patients might outreach to clinicians during times of uncertainty, we referenced Mishel’s Uncertainty in Illness Theory (Mishel, 1988, 1999). We leveraged the framework developed by Street, Makoul, Arora, and Epstein (2009) to highlight patient task-oriented requests that might manifest in secure messages (e.g., to support self-care, satisfaction), and clinician-generated content that might support improved patient health outcomes. Our three papers present the first reports using this taxonomy and are the first to explore associations between taxa, patient outcomes, and the senders’ and receivers’ characteristics. We sampled patients with diabetes and/or hypertension to demonstrate that our taxonomy could be applied to different health conditions, and to highlight any differences in taxa use based on health condition. We included threads initiated and completed between January 1 and December 31, 2017. Our study included 2111 patients, of whom 49 percent initiated 7346 threads that included 10163 patient-generated messages and 8146 messages generated by 674 unique clinic staff (hereafter referred to as clinician-generated messages). Patient and Clinic Staff Characteristics Associated with Message Content In the first paper, we described the coding process and interrater and intrarater reliability derived from that process, and then presented our findings on the characteristics of the senders and receivers associated with selected taxa. We estimated both unadjusted and adjusted differences in characteristics associated with the use of each taxon. We assessed taxon use as a dichotomous variable that was positive if the patient or clinician sent or received at least one message coded with the selected taxon. For patient-generated taxa, we explored associations with the characteristics of the sender (which types of patients sent these taxa) and receiver (which types of clinic staff received these types of content). Similarly, we explored the associations between clinician-generated taxa and the characteristics of the sender (what types of clinic staff sent these taxa) and receiver (what types of patients were the recipients of this content). We created separate regression models for patient characteristics (demographic, geographic, health condition and status, and thread volume) and staff characteristics (staff type, specialty, and message volume). Our patient-level analyses included only the 1031 patients who initiated message threads using the patient portal. Our analyses found differences in taxa use by patients’ age, sex, race, health condition and status, and distance from clinic. Younger patients and females were less likely to share certain types of information with clinic staff (clinic updates among younger patients OR=0.77; 95% CI: 0.65-0.91; self-reporting biometrics by women OR=0.78; 95% CI: 0.62-0.98). Use of certain types of task-oriented requests varied by age (younger patients’ prescription refills OR=0.77; 95% CI: 0.65-0.90 and scheduling requests OR=1.41; 95% CI: 1.19-1.68) and race (black vs white requests for preventive care appointments OR=2.68; 95% CI: 1.30-5.51, requests for a new or changed prescription OR=0.72; 95% CI: 0.53-0.98, and laboratory or other diagnostic procedures OR=0.66; 95% CI: 0.46-0.95). Younger and uninsured patients were less likely to receive medical guidance from clinic staff (OR=0.84; 95% CI: 0.71-0.99 and OR=0.21; 95% CI: 0.06-0.72, respectively), but patients with public payers were two times more likely to receive medical guidance compared to patients with private payers (95% CI: 1.27-3.24). Females were less likely to receive confirmation that requests were fulfilled (OR=0.81; 95% CI: 0.68-0.97). These findings highlight differences in how patients used secure messaging to communicate with their clinic staff, which could result in differential access to care. Further, the differences in taxa use by clinic staff by patients’ characteristics might further exacerbate existing disparities in care and highlight opportunities for training and education to reduce these discrepancies. Healthcare Services Utilization Associated with Message Content The Street, Makoul, et al. (2009) framework highlights access to care as an intermediate outcome in the pathway between health outcomes and communication functions such as information exchange, enabling self-care, and making decisions. Patients reported that effective communication delivered through secure messaging prevented unnecessary appointments (Alpert, Markham, Bjarnadottir, & Bylund, 2019); however, prior studies that explored links between secure messaging and healthcare utilization only considered message volume, not what was said in those messages. Our second paper is the first to explore whether content is associated with healthcare utilization. We measured utilization in four ways: number of outpatient visits, number of emergency department visits, number of inpatient visits, and medication adherence. We created separate medication adherence dichotomous variables for diabetes and hypertension, based on having an average condition-specific medication possession ratio greater than 0.8 (Clifford, Perez-Nieves, Skalicky, Reaney, & Coyne, 2014; Khunti, Seidu, Kunutsor, & Davies, 2017; Krass, Schieback, & Dhippayom, 2015; Schulz et al., 2016). We measured our independent variables as the taxon prevalence among patient- or clinician-generated taxa, as appropriate. Our covariates included the patient characteristics described in the first paper. To estimate incidence rate ratios for the three visit dependent variables, we conducted Poisson regressions with robust variance estimation (Hilbe, 2014). We estimated the odds of medication adherence associated with each taxon using logistic regression. In unadjusted analyses, we found that patients who initiated message threads had higher numbers of outpatient visits (p\u3c0.0001) and better hypertension medication adherence (p\u3c0.01), compared to patients who did not initiate threads. Among patients who initiated message threads, we identified a positive association between emergency department visits and prevalence of request denials from clinic staff (IRR=1.18; 95% CI: 1.03, 1.35) and patients’ requests for follow-up appointments (IRR=1.15; 95% CI: 1.07-1.23), as well as between clinic non-response and the number of outpatient visits (IRR=1.02; 95% CI: 1.00, 1.03). We identified an inverse association between hypertension medication adherence and patients’ appointment reschedule requests (OR=0.87; 95% CI: 0.79-0.96). These findings highlight opportunities for future research about the use of secure messaging to influence care delivery and access to care. Patient Health Outcomes Associated with Message Content Patients whose uncertainty in their illness is addressed experience less stress, leading to better health outcomes (Mishel, 1988). Through appropriate communication functions with clinicians, patients develop better understanding of their condition and how to manage it and may have improved access to care and self-care skills, which leads to better outcomes (Street, Makoul, et al., 2009). Our third paper describes the first study to assess the types of message content associated with improved health outcomes. We examined changes in patients’ glycemic index (A1C) for patients with diabetes and changes in diastolic (DBP) and systolic blood pressure (SBP) among patients with hypertension, comparing patients who sent or received messages with selected taxa to (1) those who sent other types of messages and (2) those who did not initiate threads in 2017. We measured outcome changes as the difference between baseline (the last measured value in 2016) and endpoint (the first measured value reported in 2018) measures. Similar to the analyses conducted for Paper 2, our independent variables were the prevalence of each taxon by patient, where the denominator was the number of patient- or clinician-generated taxa, as appropriate for the selected taxon. Analyses included only patients with the selected condition: 811 patients with diabetes only, 787 patients with hypertension only, and 513 patients with both conditions. We used linear regression to identify associations between the outcomes and each taxon. In unadjusted analyses, we found that patients who initiated threads had lower endpoint A1Cs (p=0.01) compared to patients who did not initiate threads. We observed improvements in A1C among patients who sent information seeking messages (b=-0.07; 95% CI: -0.13, -0.00). We also observed improved SBP associated with clinic non-response to patients’ threads (b=-0.30; 95% CI: -0.56, -0.04), staff acknowledgement and fulfillment of patients’ requests (b=-0.30; 95% CI: -0.58, -0.02), and patients’ complaints (b=-4.03; 95% CI: -7.94, -0.12). Poorer outcomes were associated with information sharing messages among patients with diabetes (b=0.08; 95% CI: 0.01, 0.15), and deferred information sharing by clinic staff among patients with hypertension (SBP b=1.29; 95% CI: 0.4-2.19). In addition, among patients with either condition, we observed positive associations between outcome and patient- and clinician-generated appreciation and praise messages with effect sizes ranging from 0.4 (A1C) to 5.69 (SBP). These findings demonstrate associations between outcomes and message content and further emphasize the need for training and education of clinic staff on appropriate use of secure messaging to prevent exacerbation of health disparities due to differential communication delivered through this modality. Conclusion We identified patient characteristics associated with patients’ use of taxa; not surprisingly, patients’ use of taxa varied by age, sex, and race. Taxa use varied by clinic staff characteristics consistent with the triage systems employed by most healthcare organizations (Heyworth et al., 2013; Ozkaynak et al., 2014; Wooldridge, Carayon, Hoonakker, Musa, & Bain, 2016). We also identified differences in staff’s taxa use based on the characteristics of the patient to whom they were sending the message. We further identified associations between taxa and healthcare utilization and health outcomes. If certain types of patients use taxa less frequently, and these taxa are associated with better outcomes or more appropriate utilization, then that presents opportunities to target those populations for education to shift their use of secure messaging. Further, if clinician-generated message content is associated with improved outcomes and clinic staff are not equitably sharing that content with all patients, there is an opportunity for education and training. Our research is a set of first-of-its-kind analyses that highlight differences in taxa use by both patients and clinicians and demonstrates the associations between those taxa and patient outcomes. Healthcare administrators and clinic staff should be aware of these associations and consider mitigation strategies to improve equitable secure messaging use by their staff and across their patient populations. The studies shared several limitations discussed in more detail in the papers themselves. These limitations included a need for more specificity in the taxa definitions and more rigorous coding processes, the lack of temporal indicators in the analysis, and limited patient and clinical characteristics. The analyses that incorporated A1C measurements suffered from significant missing data. Sample size for some taxa was limited so that the algorithms did not converge. The analyses were based on single taxa, which represented only one component of the overall thread discussion. Finally, our message sample included only those messages saved to patients’ charts, which likely led to an underrepresentation of taxa and clinic non-response. We highlighted a number of opportunities for future research across the three studies. Consideration should be given to refining taxa definitions and applying more rigorous coding practices, incorporating temporal elements into the analyses to provide context and support assessments of causality, adding relevant covariates such as message reading level or patients’ health literacy levels, and exploring other proximal and intermediate outcomes identified in the Street, Makoul, et al. (2009) framework. We also strongly recommend examining the impact of taxa pairings: analyses that consider the call-and-response nature of the full conversation occurring within the thread

Message Deleted? Resolving Physician-Patient E-mail through Contract Law

This article examines the impact of e-mail on the physician-patient relationship, and how contract law can resolve the uncertainties incumbent in this nascent form of communication. Significantly, courts have yet to indicate when the physician-patient relationship begins by e-mail, or to what extent e-mail affects the duties of the relationship. Instead of waiting for judicial guidance, physicians and patients can employ specialized contracts to clarify the role that e-mail plays in their relationship. As a result, more physicians and patients will regard e-mail correspondence as a valuable means of communication, and a tool for improving the quality of health care as well

Patient Centeredness in Electronic Communication: Evaluation of Patient-to-Health Care Team Secure Messaging

BACKGROUND: As information and communication technology is becoming more widely implemented across health care organizations, patient-provider email or asynchronous electronic secure messaging has the potential to support patient-centered communication. Within the medical home model of the Veterans Health Administration (VA), secure messaging is envisioned as a means to enhance access and strengthen the relationships between veterans and their health care team members. However, despite previous studies that have examined the content of electronic messages exchanged between patients and health care providers, less research has focused on the socioemotional aspects of the communication enacted through those messages. OBJECTIVE: Recognizing the potential of secure messaging to facilitate the goals of patient-centered care, the objectives of this analysis were to not only understand why patients and health care team members exchange secure messages but also to examine the socioemotional tone engendered in these messages. METHODS: We conducted a cross-sectional coding evaluation of a corpus of secure messages exchanged between patients and health care team members over 6 months at 8 VA facilities. We identified patients whose medical records showed secure messaging threads containing at least 2 messages and compiled a random sample of these threads. Drawing on previous literature regarding the analysis of asynchronous, patient-provider electronic communication, we developed a coding scheme comprising a series of a priori patient and health care team member codes. Three team members tested the scheme on a subset of the messages and then independently coded the sample of messaging threads. RESULTS: Of the 711 messages coded from the 384 messaging threads, 52.5% (373/711) were sent by patients and 47.5% (338/711) by health care team members. Patient and health care team member messages included logistical content (82.6%, 308/373 vs 89.1%, 301/338), were neutral in tone (70.2%, 262/373 vs 82.0%, 277/338), and respectful in nature (25.7%, 96/373 vs 33.4%, 113/338). Secure messages from health care team members sometimes appeared hurried (25.4%, 86/338) but also displayed friendliness or warmth (18.9%, 64/338) and reassurance or encouragement (18.6%, 63/338). Most patient messages involved either providing or seeking information; however, the majority of health care team member messages involved information provision in response to patient questions. CONCLUSIONS: This evaluation is an important step toward understanding the content and socioemotional tone that is part of the secure messaging exchanges between patients and health care team members. Our findings were encouraging; however, there are opportunities for improvement. As health care organizations seek to supplement traditional encounters with virtual care, they must reexamine their use of secure messaging, including the patient centeredness of the communication, and the potential for more proactive use by health care team members

Using Intervention Mapping to Develop an Efficacious Multicomponent Systems-Based Intervention to Increase Human Papillomavirus (HPV) Vaccination in a Large Urban Pediatric Clinic Network

Background: The CDC recommends HPV vaccine for all adolescents to prevent cervical, anal, oropharyngeal, vaginal, vulvar, and penile cancers, and genital warts. HPV vaccine rates currently fall short of national vaccination goals. Despite evidence-based strategies with demonstrated efficacy to increase HPV vaccination rates, adoption and implementation of these strategies within clinics is lacking. The Adolescent Vaccination Program (AVP) is a multicomponent systems-based intervention designed to implement five evidence-based strategies within primary care pediatric practices. The AVP has demonstrated efficacy in increasing HPV vaccine initiation and completion among adolescents 10-17 years of age. The purpose of this paper is to describe the application of Intervention Mapping (IM) toward the development, implementation, and formative evaluation of the clinic-based AVP prototype. Methods: Intervention Mapping (IM) guided the development of the Adolescent Vaccination Program (AVP). Deliverables comprised: a logic model of the problem (IM Step 1); matrices of behavior change objectives (IM Step 2); a program planning document comprising scope, sequence, theory-based methods, and practical strategies (IM Step 3); functional AVP component prototypes (IM Step 4); and plans for implementation (IM Step 5) and evaluation (IM Step 6). Results: The AVP consists of six evidence-based strategies implemented in a successful sequenced roll-out that (1) established immunization champions in each clinic, (2) disseminated provider assessment and feedback reports with data-informed vaccination goals, (3) provided continued medical and nursing education (with ethics credit) on HPV, HPV vaccination, message bundling, and responding to parent hesitancy, (4) electronic health record cues to providers on patient eligibility, and (5) patient reminders for HPV vaccine initiation and completion. Conclusions: IM provided a logical and systematic approach to developing and evaluating a multicomponent systems-based intervention to increase HPV vaccination rates among adolescents in pediatric clinics