=Paper=
{{Paper
|id=None
|storemode=property
|title=HealthIn: Toward a New Paradigm for Physician-Patient Communication
|pdfUrl=https://ceur-ws.org/Vol-984/paper7.pdf
|volume=Vol-984
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==HealthIn: Toward a New Paradigm for Physician-Patient Communication==
https://ceur-ws.org/Vol-984/paper7.pdf
HealthIn: Toward a New Paradigm for Physician-Patient
Communication
Ellen A. A. Jaatun1,2, Kari Sand2, Martin Gilje Jaatun3
1
University of Edinburgh, Edinburgh, UK
2
European Palliative Care Research Centre, Department of Cancer Research and Molecular
Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim,
Norway
3
SINTEF ICT, Trondheim, Norway
Abstract. Communication in health care is dominated by oral communication
which is not supported by the EHR systems. Patient work is segmented, and
involves several partners in a collaboration where the network of partners is
loose and invisible. In this paper we argue that an Electronic Health Record
system structured along the principles of current social network applications
would both make these interconnections more visible, and improve
collaboration for all involved parties along the patient trajectory.
1 Introduction
Internet-based technology is to a great extent available to the general population. In
daily life, letters and postcards have been replaced by email and SMS. The healthcare
profession has gone through a major development on the electronic frontier.
Healthcare is sub-specialized, and each worker is able to look up detailed information
on each patient or illness in the blink of an eye. Patients also have more knowledge
about their illness which to a large extent is acquired through internet search. Today's
patients and health care workers would appear to be a perfect match, where both have
abundant health-related knowledge that can be used to cure or alleviate illness.
However, there are several factors that make this collaboration less efficient than
desired.
Even though modern hospitals and health care institutions have based much of
their communications around electronic devices, it seems like their potential is still
not close to be exploited. In modern health care electronic health records and
computers are available to a large extent, nevertheless oral communication between
colleges has proved to be the most common way of acquiring data and getting
information about patients. The same study also pointed out how the high frequency
of communication caused interruption in daily work and chain of thoughts for the
health care provider who was being called upon [1].
Regarding e-communication between health care workers there is still no evidence
for use, benefit or effect [2]. The clinical benefit of use of email between patients
/caregivers and health care professionals was reviewed in a recent Cochrane review,
included nine trials with a total of 1733 patients [3]. This study proved some benefit
of use but for most studies it was hard to gain evidence. On the other hand there are a
high number of studies where different electronic systems have been used for
Copyright © 2013 by the paper's authors. Copying permitted for private and academic purposes.
In: H. Gilstad, L. Melby, M. G. Jaatun (eds.): Proceedings of the European Workshop on Practical Aspects
of Health Informatics (PAHI 2013), Edinburgh, Scotland, UK, 11-MAR-2013, published at
http://ceur-ws.org
68
assessment or communication in research, where a clinical effect has been proven in
the research setting [4-6] .
There seems to be support for the notion that technological methods of
communication among health care providers and between health care providers and
patients would be profitable[7].To a large extent, the equipment necessary is available
and has been so for many years, but still we are not capable of getting the systems
into daily practice and benefit from the possible advantages they might give us. The
aim of this article is to describe the challenges when changing how we communicate
with patients and between colleagues from “face to face” to e-communication
systems, by highlighting the most common communication channels currently utilized
in the Norwegian and Scottish health care systems. We also want to explore the
challenges of traditional communication. A secondary objective is to identify relevant
future communication channels in the health care systems, and identify the challenges
which may be caused by e-communication systems. The question is to identify which
factors might be influenced by the change from traditional communication to e-
communication within a health care setting?
1.1 Traditional communication in health care
The term communication stems from the latin word communicare which means “to
make common”. Through verbal and non-verbal interaction, the participants in a
communication cooperate to make common understanding or meaning of the topic of
interest. In clinical work more than 50 % of all communication between health care
professionals is face to face [8]. It is likely that communication between health care
workers and patients is close to 100% face to face. This communication is
characterized by the possibility of immediate turn taking and immediate feedback, the
possibility to repair misunderstandings and the support from non-verbal cues. The
face to face communication is also regarded as the best way of creating and
maintaining a social relationship. A consultation is an example of professional
communication, i.e., that one of the interactants take part in the interaction as part of
his/her job, that there are specific professional tasks that are going to be solved or
goals to be reached during the interaction, and that the professional party is the one
responsible for ensuring that the participants through cooperation reach these goals.
Professional interaction is characterized by clearer phases than informal interaction
between friends. The interaction is asymmetrical in the way that the health care
professional has to be in charge and responsible for the content, presentation of the
content and that the take home message is comprehended. The asymmetry is not an
obstacle for reaching the goals of the communication; it is rather a benefit, since it is
part of the genre expectations in the society that the conversation between a physician
and a patient is not symmetrical like a chat between friends. It is easier to reach the
professional goal (both the patient’s goal and the physician’s goal) if the structure of
the interaction is recognized [9].
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1.2 Work flow and communication flow in health care
Treatment of patients in a health care system is a complex process involving many
people. This system tends to be more complicated and involve more people the more
complex the situation is, e.g., a sore throat in a toddler is a matter between the patient,
parents and the GP; but pain treatment for a palliative care patient might involve the
patient, family, GP, community nurse, oncologist, radiologist and specialist pain
team. Tradition has formed the way we work and has a great influence on the com-
munication and collaboration between co-workers within a health care institution, and
communication to or from the health care institution. This tradition is based on the
evolution of the professions, and traits are quite visible even today. The way
physicians learn new skills and obtain knowledge and information in the medical
profession has not changed significantly with the electronic era. For physicians,
learning is related to work in a master/apprentice relationship. This means that the
apprentice will learn to categorize and treat patients from a more skilled co-worker [1,
10, 11]. The skilled physician ("master") will in this way be more interrupted in his
or her work, but through the relationship both will obtain more knowledge about the
medical practice. The master/apprentice relationship is also a very important
relationship in regard to sub-specialization of the medical care. In terms of com-
munication, it tends to form close bonding between each sub-specialty where
information is kept within the group. In this setting other co-workers might find it
hard to be integrated and participate in a wider communication [12]. Collaboration of
physicians from different subspecialties or levels of health care providers might have
some kind of master/apprentice relationship, but the commitment and relation
between the professionals are not always interpreted as collaboration. A recent study
assessed the evaluation of interaction between hospital physicians and general
practitioners in Norway, and found that a positively evaluated interaction was
strongly correlated with existence of face-to-face contact between the two physicians
[13].
Nursing has evolved from other traditions and other social circumstances. The
work and communication is more based on teamwork and collaboration in a more flat
structured way than among physicians. There is a well-defined line of responsibility
between the two professions which also influences the route of communication [12,
14].
In most hospitals, nurses work as gate keepers for the physicians. This is a virtue of
necessity in order to reduce the burden of inquiries to the physician on duty. To
communicate information is also within boundaries of each profession. The secretary
answers enquiries about the time for the patient's appointment, the nurse about more
general health or illness issues and the physician answers enquiries related to specific
information concerning each patient and specified patient illness issues.
Technology offers a possibility to include partners in a conversation or
collaboration in a way traditional methods don’t. In this setting patients could be more
involved. Patient involvement might also raise the consciousness about how each
individual can take an active part in their own healing process or maintaining a good
health by being a part of the collaborating team.
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1.3 Bringing health care communication into the 21st century
E-health systems are being developed at a high speed. A health care worker is
surrounded by technology, and very many procedures are either controlled by an
electronic device, or the procedure is performed by an electronic device, e.g.,
anesthesia during surgery and robot surgery for prostate cancer. During a regular
work day patients are registered and forms are filled in and health care workers are
dependent on a vast number of computer programs in order to do their work.
Nevertheless is communication still mainly performed the old fashioned way [1, 10,
11] . We will try to point at some reasons why we think this might be so.
2 Security issues and patient confidentiality
One of the problems related to paper and oral communication is the relation to
physical proximity and information sharing. Electronic communication would seem to
be a natural alternative, but sharing of sensitive health information is strongly
regulated and has become a major obstacle in the e-health setting. Data must be
treated in accordance with both EU legislation and the different national data
protection legislation standards [15].
One major challenge with information flow between patient and physician is that
virtually all communication, even that which in isolation would be considered
innocuous, turns into sensitive personal identifiable information governed by, e.g., the
European Privacy Directive [16].
Conventional email is not suited to communication of personal health information,
due to the lack of a proper security infrastructure. Secure email solutions such as
S/MIME or PGP provide more than sufficient security from a purely technical
perspective, but unfortunately the average user has demonstrated a lack of aptitude
when it comes to security software [17]. This implies that a patient is likely to
inadvertently send sensitive health information in clear text when contacting the
physician via email. Furthermore, the proliferation of malware on home computers
means that no patient can be sure that their computer does not contain backdoors and
spyware that may compromise their information [18]. In order to protect the patients
from themselves, the current consensus seems to be the development of portal
solutions, where no information is stored on the patient's computer.
Technically, securing the communication channel between a patient's computer
and the physician's server is straightforward; solutions like SSL, while not flawless,
have served to protect online shopping and internet banking (although some argue
that our health data is more sensitive than our banking data [19]), and is considered to
work reasonably well for most purposes.
However, there are currently legal hurdles which restrict the extent of digital
communication. Primarily, it is the privacy regulations that limit this, but more
specific national laws are making this even more difficult; currently it is not even
permitted to transmit patient information across local health authority boundaries.
71
3 Traditional work flow in transition
Some claim that EMR systems developed are merely a copy of the paper record
transferred to a computer, implying that the potential benefits are far from being
realized. Ideally, we want to standardize care, investigation and treatment in order to
improve and measure the cost/benefit ratio. Many good systems have been
developed, e.g. decision support systems, but the benefit of these systems has been
very difficult to evaluate [20, 21]. One reason is that the systems change the way we
work, and the set of variables increases beyond what a sensible statistical method can
measure. Decision support systems would also change the pattern of communication
within a health care group, and challenge the master/apprentice relationship [22] The
health care provided will presumably be more standardized, and it will be more easy
to compare. In case the master/apprentice relationship is good and prosperous (i.e.,
the “master” has a lot of knowledge to pass on to the “apprentice”), minimizing this
relationship might reduce the quality of health care. In the opposite case, where the
master / apprentice relationship doesn’t work well, a change might be a better
alternative. By standardizing, health care decisions, such decisions might to a larger
extent be based on evidence, rather than making decisions based on experience or
local tradition. A decision support system would thus need to be developed from
medical evidence; whereas decisions made by a master/apprentice system might be
evidence-based, they might also be based on tradition and experience. Traditional
decision making is made through discussion and with support from peers. This type of
work is also a part of the collaboration in health care. The technological decision
making is based on individuality with support from evidence.
4 EHR systems
Studies of communication patterns in an emergency unit have suggested that 90 % of
the information transfer is performed orally. Even with a working EHR system in a
high density communication area like the emergency unit, the information transfer is
not passed on using the EHR system [23, 24]. This might be related to the tradition of
information transfer, but it also indicates that the properties of the EHR does not
support quick information transfer, and one can possibly also claim that the EHR used
today is merely an instrument for putting information into, and not flexible enough for
extracting information in all given settings. From this train of thought it is hard to
understand how giving patient’s access to the EHR should improve health care
communication and information transfer.
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Fig. 1: Example of EHR Social Network Application
4.1 The EHR as a communication system
Technology seems to change the way we work, and technology challenges the
traditional way of learning. It also widens the possibilities of communication. In many
other fields we have exploited new possibilities offered by technology; e.g., in
banking, physical proximity between customer and bank is no longer considered
necessary. In health care we have access to the same technology, but we are not able
to exploit its full potential. In different settings there are different needs. The
operation theatre or the emergency room does not afford extensive reading and
writing in order to communicate the needed information. The needs for
communication in this setting will be different than in the Lung clinic where patients
will have a follow-up for years, where both GP and hospital will be involved. The
EHR system will have to be flexible enough to serve both purposes and yet have a
level of conformity in order to be understood and usable by personnel crossing
between the different departments.
The EHR should also promote face-to-face contact and be able to identify
participants in a collaboration or conversation. There should also be an option to
identify potential collaborators as available or occupied and the physical location
should also be revealed. Patients accessing this network should be based on invitation.
The system should also encourage short messages or short statements but also provide
options for extensive reports, video or audio recording/messages for further
information. A feedback system for participant interaction in the media, task or
message should also be implemented.
These are all options available in different social media today. Social networks are
identified and made accessible or inaccessible in all social media concepts. Skype has
73
an option for face to face communication with an already established network; you
also have chat function for short messages. Twitter challenges the short message or
statement option, and LinkedIn provides a professional network of the kind that might
be suitable for rolling out decision support systems. All these functionalities should be
implemented in one system accessible either from home (patients), in hospitals or a
GP practice.
5 Conclusion
Current communication paradigms in the health care sector have not been
significantly adjusted with the introduction of modern technology, and the full
potential of the new technology is not being reached. We believe that Electronic
Health Records could have been extended with features borrowed from various social
networks. This way we might be able to provide easier and more accessible
communication for health care professionals, a more flexible and usable health care
record, give patients better information, and facilitate closer collaboration for all
participants within a patient trajectory.
Acknowledgments Photos used in Figure 1 courtesy of flickr users edenpictures,
MattJhsn, Arian Zwegers
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