Family Physician Communication, Quality of Care and the use of Computer in the Consultation – The Patient's Perspective

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ScienceDirect Procedia Computer Science 100 (2016) 594 – 601

Conference on ENTERprise Information Systems / International Conference on Project MANagement / Conference on Health and Social Care Information Systems and Technologies, CENTERIS / ProjMAN / HCist 2016, October 5-7, 2016

Family physician communication, quality of care and the use of computer in the consultation – the patient’s perspective Dilermando Sobrala,b, Margarida Figueiredo-Bragaa,c* a

Dep Clinical Neurosciences and Mental Health, Medical Psychology Unit, Faculty of Medicine, University of Porto, Porto, Portugal; b Family Health Unit of Ramalde, Health Centres Grouping of Porto Ocidental, Porto, Portugal c i3S Instituto de Investigação e Inovação em Saúde

Abstract We evaluated the perceived impact of computer use on family physicians communication skills, empathy and quality of care. The study surveyed 106 family physicians and 392 patients. They were questioned regarding the utilization and impact of computer use in the consultation and its association with communication skills, physician’s empathy (Jefferson Scale of Physician Empathy - JSPE) and quality of care (QUOTE-COMM questionnaire). Physicians reported spending a considerable amount of time interacting with the computer during the consultation (42.4%±16.4 of the total length). They perceive the impact of computer use as negative, while patients have a general positive perception of computer use on patient-physician communication. According to the patients the ability to be more compassionate and understand patient’s perspective was not associated with the use of computer, but quality of care was negatively associated with time spent interacting with the computer. Interacting with the computer consumes a significant amount of clinicians' time during consultations and may represent a challenge to their communication ability and particularly to empathic attitudes. Patient’s perspectives regarding the use of the computer in the consultation, computer use skills and related quality of care are valuable, and will contribute to shape future educational interventions. byby Elsevier B.V.B.V. This is an open access article under the CC BY-NC-ND license © 2016 2016The TheAuthors. Authors.Published Published Elsevier (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of SciKA - Association for Promotion and Dissemination of Scientific Knowledge. Peer-review under responsibility of the organizing committee of CENTERIS 2016

Keywords: Attitude to computers; clinical communication; patient-centered care; physician-patient relations; primary health care.

* Corresponding author. Tel.: +351225513672; fax:+351225513673 E-mail address: [email protected]

1877-0509 © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer-review under responsibility of the organizing committee of CENTERIS 2016 doi:10.1016/j.procs.2016.09.200

Dilermando Sobral and Margarida Figueiredo-Braga / Procedia Computer Science 100 (2016) 594 – 601

1. Introduction Physicians’ communication skills are an essential tool in the diagnostic and therapeutic process, as they influence patients’ confidence, compliance, satisfaction and ultimately psychological and physical outcomes1-5. However, in the last decades, as electronic health records (EHR) became widely used6-9, the presence of a third actor in the consulting room, the computer, has threatened this therapeutic relationship10-13. Beyond all added values brought by the use of EHR (quick access to information; more efficient management of medical records; greater facility in prescribing; easy access to scientific information and to communication between members of the health care system, and with patients; active warning systems for preventive medicine, chronic disease management, and immunization)14,15, the presence of the computer in the consulting room still raises questions about its negative impact on the quality of patient-physician communication and relationships16-27. The use of the computer decreases the information disclosed by the patient and physicians responses to patients’ doubts22,25, and increases the mean time of the interview, without increasing patient satisfaction21,22. In addition, computer use appears to be related to a loss of eye contact and to less psychosocial information gathering19,21,22,27. In order to understand the patient and develop a therapeutic alliance enhancing quality of medical care, effective physician-patient and physician-patientcomputer communication is needed. Namely, the ability to active listening, maintain eye contact, and monitor patient’s nonverbal communication is crucial to the development of an empathic attitude. Clinical empathy has been associated with more positive clinical results28,29, improving patient's strength and ability to cope with the illness30 and patient's feeling of being supported and understood. Nevertheless, it has been shown that physicians’ baseline communication skills are amplified in the presence of the computer: physicians with good communication skills tend to better integrate the computer into the consultation, while physicians with poor baseline skills tend to create communication barriers when using the computer18. Also, specific communication skills have been identified in order to minimize the negative interference of the computer. These communication skills include out-of-consultation aspects (using mobile monitors, learning to type, reserving templates for documentation, separating routine data entry from patient encounters) and in-consultation aspects (start with patient’s concerns, look at the patient, tell patient what you are doing, point to the screen, integrate typing around patient’s needs and encourage patient’s participation in building his chart)19,31-33. In Portugal, widespread use of EHR in Primary Health Care network occurred only in the last decade, and concerns are still being raised about difficulties imposed by slow computer servers and unfriendly clinical software34. In one study, physicians identified the information system (integration, speed, performance, suitability for clinical practice, and outdated hardware) as the main source of dissatisfaction with the Portuguese primary health care (re)organization35. In a recent study27, Portuguese physicians reported a negative impact of computer use on patient-physician communication regarding the consultation length, confidentiality, maintaining eye contact, active listening to the patient, and ability to understand the patient. They also reported spending 42% of consultation time in contact with the computer and considered that the usual computer placement in their consultation room was significantly unfavourable to patient-physician communication. Research examining the effects of the utilization of computer reported a change in the interaction between physician and patient10,22 and a global transformation of both behavioural patterns. We confirmed that physician’s patient centeredness was negatively associated with the ability to look, listen and deliver information while using the computer27. As part of the same survey, we also analyzed the influence of physicians’ empathy, and physicians’ communication performance on this impact. This article details patients’ experience in communicating with their Family Physician (FP), and the relationship of perceived quality of care with empathic ability and the use of computer in FP consultations. 2.

Methods

The study followed a descriptive cross-sectional design and included physicians and patients from the Health Centers Grouping of Porto Ocidental (HCGPO). Ethical approval was obtained from North Regional Health Administration’s Ethics Committee and all participants were informed about the study objectives and procedures and provided a written informed consent.

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The study protocol and an invitation to participate were presented to the coordinators of the 15 Family Health Units (FHU) integrating the HCGPO (Fig. 1). Thirteen FHUs (87%) agreed to participate. All 142 family physicians (92 specialists and 50 trainees) working in the participating FHUs were informed about the aims and procedures and personally invited by one of the authors (DS), during December 2013. A population of 172,298 patients was registered in the HCGPO. A sample of 392 adult patients from the 13 participating FHUs was recruited to participate in the survey during the months of May and June 2014. The invitation was presented by the receptionists and willingness to participate was the unique criteria for entering the study. Patients completed the survey in the waiting room before the consultation and delivered it back to the receptionists. The sample size needed (383) was calculated using Sample Size Calculator (http://www.surveysystem.com/sscalc.htm), for a 95% confidence level and a 5% confidence interval. Participants flow and study procedures are detailed in Figure 1. HCGPO: Health Centers Grouping of Porto Ocidental FHU: Family Health Unit FP: Family Physician Sp: Specialist; Tr: Trainee

HCGPO - 15 FHU 156 FP 172.298 Pt

13 FHU accepted (87% response rate)

142 FP (92 Sp + 50 Tr)

106 FP completed the survey (75% response rate)

2 FHU refused

159.580 Pt registered

392 Pt completed the survey (convenience sample)

Fig. 1. Flow diagram of the study population and data collection procedures.

An original self-administered questionnaire, partially based on previous studies20,21,26, was developed to evaluate sociodemographic and professional characteristics of physicians, their general perspectives on the use of the computer during the consultation and its impact on patient-physician communication, and physicians’ empathy. The impact of computer use was evaluated regarding consultation length, confidentiality and ability to maintain eye contact, listen, collect and provide information, and understand the patient, using a five-point Likert-type scale, ranging from -2 (very negative) to +2 (very positive). To measure physicians’ empathy, the Portuguese version36 of the Jefferson Scale of Physician Empathy (JSPE)37,38 was used. This instrument contains 20 items, rated according to a seven-point Likert-type scale (1 = strongly disagree, 7 = strongly agree). It has three components: “Perspective Taking”, “Compassionate Care” and “Standing in the Patient’s Shoes”, which is consistent with the notion of the multidimensionality of empathy37. The Portuguese version36 was validated and presented good internal consistency, with a Cronbach’s alpha coefficient = 0.79, and the exploratory factor analysis defined three factors accounting for approximately 38% of the total variance, similar to those of the original version (0.81 e 36%)37. A similar self-administered questionnaire evaluated patient’s sociodemographic characteristics, their general perspective on the use of the computer during the consultation and its impact on the physician’s communication strategies “(ability to look at the patient, active listening, ability to talk and to provide information to the patient and

Dilermando Sobral and Margarida Figueiredo-Braga / Procedia Computer Science 100 (2016) 594 – 601

ability to understand the patient)”. The patient’s perspective about their physicians’ communicational style, regarding their experience in the previous year was also assessed. Patients’ experience regarding physicians’ communicational style was measured by a Portuguese experimental version of the QUOTE-COMM questionnaire39. This is a 4-point Likert-type scale, with 13 items. The items can be divided into two categories: an affect-oriented scale of seven communication aspects and a task-oriented scale of six communication aspects. Affect-oriented communication consists of attentive and empathic behaviour by the doctor (“doctor gave me enough attention”; “doctor listened well to me”; “doctor took enough time for me”; “doctor was friendly”; “doctor was frank with me”; “doctor took my problem seriously”; and “doctor was empathic towards me”). Task-oriented aspects include exchanging information and advice, diagnosing and problem solving (“doctor diagnosed what’s wrong”; “doctor explained well what’s wrong”; “doctor informed me well on the treatment”; “doctor gave advice on what to do”; “doctor helped me with my problem”; and “doctor examined me”). Pilot studies were undertaken for both questionnaires to test recruitment, feasibility, study procedures and instruments. Consultation room layout was evaluated as its characteristics may influence patient-physician communication. All physician use in their daily practice a desktop computer with an adjustable (17 inch) monitor. Usual and ideal location of the computer and other tool (table, chairs) in the consultation room were evaluated and are described in a previous article27. 3. Results A total of 106 family physicians (75% response rate) completed the survey (65 specialists and 41 trainees). From the 106 respondents, aged between 26 and 64 years old (mean 42.6, SD 14.2), 73% were female. Years of professional experience varied between 1 to 39 years (mean 15.3, SD 13.1) and computer experience in consultation between 1 to 20 years (mean 6.9, SD 4.7). Physicians worked on average 39.9 hours per week, and performed 18.5 consultations per day, with a mean length of 19.6 (SD 4.4) minutes. These characteristics are representative of Portuguese family physicians40. The 392 patients who answered the survey were aged between 18 and 93 years old (mean 46.9, SD 15.9), and 67% were female. One hundred and nineteen (30.6%) had completed 12 years of school, 200 (51.0%) were professionally active, and 253 (63.8%) lived with a spouse. They were registered at the current doctor for 12.9 years (SD 10.0) and had 3.5 consultations (SD 3.1) last year, on average. Table 1: Use of the computer in the consultation. Physicians (n=106) b

a c

d

Patients (n=392)

pa

Before the patient enters the office At the beginning of the consultation At any time during the consultation At the end of the consultation After the patient leaves the office To consult patient data b To record patient data To prescribe To refer the patient to another health professional To carry out research on the internet To internal communication To give health information to the patient Explains to the patient what is registering on the computer? b Shows the patient what is writing on the computer? Time spent in interaction with the computer c

4.32 (1.038) 3.53 (1.395) d 3.98 (1.023) 4.46 (0.948) 3.91 (1.238) 4.75 (0.518) 4.94 (0.270) 4.99 (0.097)

N. A. 4.17 (1.197) d 4.00 (1.174) 4.31 (1.090) N. A. 4.35 (1.063) 4.52 (0.942) 4.61 (0.956)

0.000 0.881 0.186 0.000 0.000 0.000

4.80 (0.653)

4.34 (1.227)

0.000

3.96 (1.162) 3.60 (1.547) 2.98 (1.414)

2.45 (1.485) 2.40 (1.532) 2.84 (1.517)

0.000 0.000 0.410

3.25 (1.178)

3.41 (1.556)

0.301

2.08 (1.188)

2.33 (1.459)

0.111

42.39 (16.3)

35.16 (20.7)

0.001

Independent-Samples T Test, 95% Confidence Interval. Minutes; d Mean (Standard Deviation).

b

Values ranging from 1=rarely to 5=almost always;

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Physicians reported using the computer predominantly at the end of the consultation and before the patient enters the office, to prescribe and to record patient data. Lower ratings were found in giving health information and in sharing their notes with the patient. Patients’ perceived that physicians used the computer less than physicians did, regarding most of the tasks performed with the computer (Table 1). A negative impact of the computer on the duration of consultation (-0.31, SD 1.2); confidentiality (-0.38, 1.1); ability to look at the patient (-1.12, 0.9); ability to listen to the patient (-0.72, 0.8); and ability to understand the patient (-0.03, 0.7) was reported by the physicians. On the other hand, patients’ mean ratings were positive for all items, with significantly higher ratings (p=0.000) when compared with physicians in several domains of computer use impact (Table 2). Table 2: Impact of computer use during consultation. Physicians (n=106) b

On duration of the consultation On confidentiality On ability to look at the patient On ability to listen to the patient On ability to talk to the patient and collect information On ability to provide information to the patient On ability to understand the patient a c

Independent-Samples T Test, 95% Confidence Interval. Mean (Standard Deviation).

b

Patients (n=392) c

pa

c

-0.31 (1.174) -0.38 (1.060) -1.12 (0.902) -0.72 (0.837)

+0.72 (1.039) +0.83 (0.984) +0.57 (1.222) +0.64 (1.107)

0.000 0.000 0.000 0.000

+0.92 (1.079)

+0.70 (1.124)

0.085

+1.08 (0.852) -0.03 (0.736)

+0.98 (1.017) +0.81 (1.068)

0.338 0.000

Values ranging from -2=very negative impact to +2=very positive impact.

According to their perceptions, physicians spent, in average, 42.4% (SD 16.4) of consultation time in contact with the computer, corresponding to 8.3 minutes in average (mean consultation length 19.6 minutes). Patients’ perception of the time spent by their physicians interacting with the computer during the consultation was significantly lower (6.9 minutes; p=0.001). Physicians’ empathy, assessed with JSPE, presented a mean total score of 119.7 (SD 10.5). Perspective Taking showed a mean score of 61.1 (SD 5.0), Compassionate Care presented a mean score of 37.7 (SD 5.10) and Standing in the Patient’s Shoes a mean score of 20.9 (SD 4.0) (Table 3). Table 3: Jefferson Scale of Physicians Empathy (JSPE). Total score of JSPE has a maximum of 140. Total (n=106) Perspective Taking Compassionate Care Standing in Patients’ Shoes Total Empathy a

61.10 (5.071) a 37.72 (5.102) 20.88 (3.963) 119.70 (10.467)

Mean (Standard Deviation).

Empathy total score (r=-0.354; p=0.000), Compassionate Care (r=-0.454; p=0.000) and Standing in the Patient’s Shoes (r=-0.299; p=0.002), showed to have a significant negative correlation with physicians’ age. No correlations were found between JSPE scores and physicians’ perceived impact of computer use on patient-physician communication. Physicians’ communication performance, measured by the QUOTE-COMM questionnaire, showed a mean score of 3.59 (SD = 0.514), with a minor difference between affect-oriented and task-oriented scores. The affect-oriented scale had a mean score of 3.61 (0.517) and the task-oriented scale a mean score of 3.57 (0.550). Overall, patients reported a high ability of FP’s to communicate. Total QUOTE-COMM score, as well as affect-oriented scale and task-oriented scale were positively correlated with patients’ perceived impact of computer use (Figure 2).

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Total score / Impact of computer use Ϯ ϭ Ϭ ϭ Ͳϭ

Ϯ ZϸсϬ͕ϭϯϱϮ

ϯ

ϰ

ͲϮ Fig. 2. QUOTE-COMM Score and patients’ perceived impact of computer use.

Furthermore, FP communication capacity was negatively associated with time spent interacting with the computer during the consultation, although patients perceived the use of the computer by their physician as a positive asset. No differences were found regarding patient gender and only the affect-oriented scale showed to be positively correlated with patients’ age. No association was found between number of years with their FP and QUOTE-COMM score, but a positive correlation was observed between number of consultations in the previous year and QUOTE-COMM score. 4. Discussion and conclusions Computer has become an essential tool in primary care consultations, and quality of care is expected to benefit from the use of the computer, by means of active warning systems and follow-up planning for preventive medicine, chronic disease management and immunization. Electronic health records have a positive impact on adherence to guidelines, allow an easy access to scientific information and facilitate the communication between members of the health care system but also challenge patient-physician communication. Communication skills remain essential to all stages of diagnostic and therapeutic process, as they influence patients’ confidence, compliance, and satisfaction, and, ultimately, the disease outcome. Clinicians must concurrently or alternately communicate with the patient and the computer to provide medical quality care. Empathy, as a core component of clinical communication, is recognized to promote the quality of care and the clinical relationship, and to improve clinical outcomes41. We found a noteworthy ability of cognitively understand patient’s perspective, a capacity to communicate this understanding42, and the ability to put themselves in the patient's position, among the population of family physicians studied. Representing just patients and physicians perception of time spent, physicians reported to interact with the computer for a meaningful length of time during the consultation, similarly to a multi-channel video study, from Kumarapeli and collaborators43. Patients perceived this interaction as shorter, eventually corresponding to a fluid integration of computer use in the consultation. In the present study, physicians and patients reported different perspectives on the utility and impact of computer use in family medicine. Physicians are more apprehensive and perceive the use of technology as a possible threat to the quality of the communication. Nevertheless, studies addressing patient’s satisfaction and opinion on how their physician’s computer use affected their visit repeatedly report little or no interference of a computer in general practice26,44-49. Physicians regard the computer as a helpful tool for specific demands but a challenge for time management and an obstacle to actively listen and understand patients, and patients look at the computer as a useful tool in the consultation room, benefitting clinical communication. As this study suggests, however better communication skills are related to a more positive impact of computer use by FPs, explaining how physician maintain an empathic approach albeit spending considerable time interacting with the computer. Quality of care evaluated by the QUOTE-COMM, as well as affect-oriented scale and task-oriented scale were positively correlated with patients’ perceived impact of computer use. In a paired sample of patients and their doctors

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further analyses could furthermore reveal the relationship between physician’s experience and mastery of computer use in the consultation and the patients perspectives regarding its impact in clinical communication. The negative perception referred by physicians is more related to many aspects of the EHR that are frustrating (inefficiencies of EHR design, sudden crashes, different software that don't talk to each other) than with their ability to integrate computer use in patient-physician communication50. Specific training on integrated computer and communication skills during FP internship and across clinical practice may enhance physicians’ communication ability and lead to a positive impact of computer use on patient-physician communication. 5. Practice implications The enhancement of consultation support technologies is one of the priorities in Family medicine, in order to make electronic medical record an efficient tool in the consultation, reducing the amount of time spent interacting with the computer. The computer in the consultation is not perceived as negative by the majority of patients, however it is worthwhile to enhance physicians’ competence in integrating the computer in their daily practice in order to protect patient centeredness and empathy. Effective clinical communication skills, including specific computer use skills may influence physicians’ efficiency and reduce their own negative perception. More studies are needed to establish how patients evaluate their FP ability to communicate in a computerized environment and how they value specific communicational approaches. References 1. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49:796-804. 2. Epstein RM, Franks P, Shields CG, Meldrum SC, Miller KN, Campbell TL, Fiscella K. 2005. Patient-centered communication and diagnostic testing. Ann Fam Med. 2005;3:415–421. 3. Harmon G, Lefante J, Krousel-Wood M. Overcoming barriers: the role of providers in improving patient adherence to antihypertensive medications. Curr Opin Cardiol. 2006;21:310–315. 4. Brinkman WB, Geraghty SR, Lanphear BP, Khoury JC, Gonzalez del Rey JA, Dewitt TG, Britto MT. Effect of multisource feedback on resident communication skills and professionalism: a randomized controlled trial. Arch Pediatr Adolesc.2007;161:44–49. 5. Williams SL, Haskard KB, DiMatteo MR. The therapeutic effects of the physician-older patient relationship: Effective communication with vulnerable older patients. Clin Interv Aging. 2007;2:453–67. 6. Schoen C, Osborn R, Huynh PT, Doty M, Peugh J, Zapert K. On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries. Health Affairs. 2006;25:w555-71. 7. Protti D, Johansen I, Perez-Torres F. Comparing the application of Health Information Technology in primary care in Denmark and Andalucia, Spain. Int J Med Inform. 2009;78:270-83. 8. Protti D. A Comparison of How Canada, England, and Denmark are Managing their Electronic Health Record Journeys. In: Rodrigues J, editor. Health Information Systems: Concepts, Methodologies, Tools, and Applications: IGI Global. 2009;402-27. 9. Balicer RD, Shadmi E, Lieberman N, Greenberg-Dotan S, Goldfracht M, Jana L, et al. Reducing health disparities: strategy planning and implementation in Israel's largest health care organization. Health Serv Res. 2011;46:1281-99. 10. Pearce C, Dwan K, Arnold M, Phillips C, Trumble S. Doctor, patient and computer - a framework for the new consultation. Int J Med Inform. 2009;78:32-8. 11. 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;18:138-42. 12. Pearce C, Trumble S, Arnold M, Dwan K, Phillips C. Computers in the new consultation: within the first minute. Fam Pract. 2008;25:202-8. 13. Ventres W. How Do EHRs Affect the Physician-Patient Relationship. Am Fam Physician. 2007;75:1385-90. 14. Ho CH, Wene HC, Chu CM, Wu YS, Wang JL. Importance-satisfaction analysis for primary care physicians' perspective on EHRs in Taiwan. Int J Environ Res Public Health. 2014;11:6037-51. 15. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742-52. 16. Mitchell E, Sullivan F. A descriptive feast but an evaluative famine: systematic review of published articles on primary care computing during 1980-97. BMJ 2001;322:279-82. 17. Noordman J, Verhaak P, Beljoow I, Dulmen S. Consulting room computers and their effect on general practitioner-patient communication. Fam Pract 2010. 2010;27:644-51. 18. Frankel R, Alfschuler A, George S, Kinsman J, Jimison H, Robertson NR, et al. Effects of Exam-Room Computing in Clinician-Patient Communication. J Gen Intern Med. 2005;20:677-82.

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