Time to Listen More and Talk Less

Submitted as Invited Editorial response to Singh Ospina et. al. Eliciting the Patient’s Agenda – Secondary Analysis of Recorded Clinical Encounters. In 1984, Elliot Mishler published a book called the Discourse of Medicine in which he argued that patients and providers bring different stories to a clinical encounter—the former reflecting the world in which the patient manages their health and illness and the latter reflecting the biomedical definitions of disease and treatment. He showed that providers far too often interrupt the patient stories in favor of a more biomedical version of the person in front of them. It was the beginning of reflections on the need to bridge these two stories in order to foster better communication and patient-centered care

The temporal nature of social context: Insights from the daily lives of patients with HIV

BACKGROUND: Patients\u27 life contexts are increasingly recognized as important, as evidenced by growing attention to the Social Determinants of Health (SDoH). This attention may be particularly valuable for patients with complex needs, like those with HIV, who are more likely to experience age-related comorbidities, mental health or substance use issues. Understanding patient perceptions of their life context can advance SDoH approaches. OBJECTIVES: We sought to understand how aging patients with HIV think about their life context and explored if and how their reported context was documented in their electronic medical records (EMRs). DESIGN: We combined life story interviews and EMR data to understand the health-related daily life experiences of patients with HIV. Patients over 50 were recruited from two US Department of Veterans Affairs HIV clinics. Narrative analysis was used to organize data by life events and health-related metrics. KEY RESULTS: EMRs of 15 participants documented an average of 19 diagnoses and 10 medications but generally failed to include social contexts salient to patients. In interviews, HIV was discussed primarily in response to direct interviewer questions. Instead, participants raised past trauma, current social engagement, and concern about future health with varying salience. This led us to organize the narratives temporally according to past-, present-, or future-orientation. Past-focused narratives dwelled on unresolved experiences with social institutions like the school system, military or marriage. Present-focused narratives emphasized daily life challenges, like social isolation. Future-focused narratives were dominated by concerns that aging would limit activities. CONCLUSIONS: A temporally informed understanding of patients\u27 life circumstances that are the foundation of their individualized SDoH could better focus care plans by addressing contextual concerns salient to patients. Trust-building may be a critical first step in caring for past-focused patients. Present-focused patients may benefit from support groups. Future-focused patients may desire discussing long term care options

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

Assessing Patients\u27 Perceptions of Clinician Communication: Acceptability of Brief Point-of-Care Surveys in Primary Care

BACKGROUND: Improving patient-centered (PC) communication is a priority in many healthcare organizations. Most PC communication metrics are distal to the care encounter and lack clear attribution, thereby reducing relevance for leaders and clinicians. OBJECTIVE: We assessed the acceptability of measuring PC communication at the point-of-care. DESIGN: A brief patient survey was conducted immediately post-primary care appointments at one Veterans Affairs Medical Center. Audit-feedback reports were created for clinicians and discussed in qualitative interviews. PARTICIPANTS: A total of 485 patients completed the survey. Thirteen interviews were conducted with clinicians and hospital leaders. MAIN MEASURE(S): Measures included collaboRATE (a 3-item tool measuring PC communication), a question about how well needs were met, and overall visit satisfaction. Data were analyzed using descriptive statistics to characterize the mean and distribution of collaboRATE scores and determine the proportion of patients giving clinicians a top score on each item. Associations among responses were examined. Interviews focused on the value of measuring PC communication and were analyzed using a framework approach. KEY RESULTS: The proportion of patients giving PC communication top scores ranged from 41 to 92% for 16 clinicians who had \u3e /= 25 completed surveys. Among patients who gave top scores for PC communication, the odds of reporting that needs were completely met were 10.8 times higher (p \u3c .001) and the odds of reporting being very satisfied with their care were 13.3 times higher (p \u3c .001) compared with patients who did not give top scores. Interviewees found clinician-specific feedback useful; concerns included prioritizing this data when other measures are used to evaluate clinicians\u27 performance. Difficulties improving PC communication given organizational structures were noted. Recommendations for interventions included peer-to-peer education and mentoring by top-scoring clinicians. CONCLUSIONS: Assessing provider communication at the point-of-care is acceptable and useful to clinicians. Challenges remain to properly incentivize and support the use of this data for improving PC communication

Incorporating African American Veterans\u27 Success Stories for Hypertension Management: Developing a Behavioral Support Texting Protocol

BACKGROUND: Peer narratives engage listeners through personally relevant content and have been shown to promote lifestyle change and effective self-management among patients with hypertension. Incorporating key quotations from these stories into follow-up text messages is a novel way to continue the conversation, providing reinforcement of health behaviors in the patients\u27 daily lives. OBJECTIVE: In our previous work, we developed and tested videos in which African American Veterans shared stories of challenges and success strategies related to hypertension self-management. This study aims to describe our process for developing a text-messaging protocol intended for use after viewing videos that incorporate the voices of these Veterans. METHODS: We used a multistep process, transforming video-recorded story excerpts from 5 Veterans into 160-character texts. We then integrated these into comprehensive 6-month texting protocols. We began with an iterative review of story transcripts to identify vernacular features and key self-management concepts emphasized by each storyteller. We worked with 2 Veteran consultants who guided our narrative text message development in substantive ways, as we sought to craft culturally sensitive content for texts. Informed by Veteran input on timing and integration, supplementary educational and 2-way interactive assessment text messages were also developed. RESULTS: Within the Veterans Affairs texting system Annie, we programmed five 6-month text-messaging protocols that included cycles of 3 text message types: narrative messages, nonnarrative educational messages, and 2-way interactive messages assessing self-efficacy and behavior related to hypertension self-management. Each protocol corresponds to a single Veteran storyteller, allowing Veterans to choose the story that most resonates with their own life experiences. CONCLUSIONS: We crafted a culturally sensitive text-messaging protocol using narrative content referenced in Veteran stories to support effective hypertension self-management. Integrating narrative content into a mobile health texting intervention provides a low-cost way to support longitudinal behavior change. A randomized trial is underway to test its impact on the lifestyle changes and blood pressure of African American Veterans. TRIAL REGISTRATION: ClinicalTrials.gov NCT03970590; https://clinicaltrials.gov/ct2/show/NCT03970590. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29423

Communicating with providers about racial healthcare disparities: The role of providers’ prior beliefs on their receptivity to different narrative frames

Objective Evaluate narratives aimed at motivating providers with different pre-existing beliefs to address racial healthcare disparities. Methods Survey experiment with 280 providers. Providers were classified as high or low in attributing disparities to providers (HPA versus LPA) and were randomly assigned to a non-narrative control or 1 of 2 narratives: “Provider Success” (provider successfully resolved problem involving Black patient) and “Provider Bias” (Black patient experienced racial bias, which remained unresolved). Participants' reactions to narratives (including identification with narrative) and likelihood of participating in disparities-reduction activities were immediately assessed. Four weeks later, participation in those activities was assessed, including self-reported participation in a disparities-reduction training course (primary outcome). Results Participation in training was higher among providers randomized to the Provider Success narrative compared to Provider Bias or Control. LPA participants had higher identification with Provider Success than Provider Bias narratives, whereas among HPA participants, differences in identification between the narratives were not significant. Conclusions Provider Success narratives led to greater participation in training than Provider Bias narratives, although providers’ pre-existing beliefs influenced the narrative they identified with. Practice implications Provider Success narratives may be more effective at motivating providers to address disparities than Provider Bias narratives, though more research is needed

Use of electronic personal health record systems to encourage HIV screening: an exploratory study of patient and provider perspectives

<p>Abstract</p> <p>Background</p> <p>When detected, HIV can be effectively treated with antiretroviral therapy. Nevertheless in the U.S. approximately 25% of those who are HIV-infected do not know it. Much remains unknown about how to increase HIV testing rates. New Internet outreach methods have the potential to increase disease awareness and screening among patients, especially as electronic personal health records (PHRs) become more widely available. In the US Department of Veterans' Affairs medical care system, 900,000 veterans have indicated an interest in receiving electronic health-related communications through the PHR. Therefore we sought to evaluate the optimal circumstances and conditions for outreach about HIV screening. In an exploratory, qualitative research study we examined patient and provider perceptions of Internet-based outreach to increase HIV screening among veterans who use the Veterans Health Administration (VHA) health care system.</p> <p>Findings</p> <p>We conducted two rounds of focus groups with veterans and healthcare providers at VHA medical centers. The study's first phase elicited general perceptions of an electronic outreach program to increase screening for HIV, diabetes, and high cholesterol. Using phase 1 results, outreach message texts were drafted and then presented to participants in the second phase. Analysis followed modified grounded theory.</p> <p>Patients and providers indicated that electronic outreach through a PHR would provide useful information and would motivate patients to be screened for HIV. Patients believed that electronic information would be more convenient and understandable than information provided verbally. Patients saw little difference between messages about HIV versus about diabetes and cholesterol. Providers, however, felt patients would disapprove of HIV-related messages due to stigma. Providers expected increased workload from the electronic outreach, and thus suggested adding primary care resources and devising methods to smooth the flow of patients getting screened. When provided a choice between unsecured emails versus PHRs as the delivery mechanism for disease screening messages, both patients and providers preferred PHRs.</p> <p>Conclusions</p> <p>There is considerable potential to use PHR systems for electronic outreach and social marketing to communicate to patients about, and increase rates of, disease screening, including for HIV. Planning for direct-to-patient communications through PHRs should include providers and address provider reservations, especially about workload increases.</p