With the HIMSS13 Conference next week we can expect to hear a lot about how health information technology (HIT) and e-Health is expected to challenge and change the way health care now and in years to come. To be sure great strides have been made in the adoption of electronic medical records, decision support, and patient web portals… with the promise of more to come. Health Apps, in spite of their painfully slow uptake by many consumers, press forward with innovative new tools.
Yet in order to realize the full promise of patient-facing like EMRs, PHRs, patient portals and the like, we need to be more mindful of the following “first principles.”
First Principles #1 – Health care delivery and healing occurs in the context of interpersonal relationships.
Today, as in the past, health care is delivered within the context of interpersonal relationships, e.g., the physician-patient relationship. Sir William Osler, the father of modern medicine, recognized this along with the importance of a clinician’s communication skills when he said “listen to the patient and they will tell you what is wrong.” Today, as in Osler’s time, encouraging patients to “tell their story” is the hallmark of good communication skills. Eliciting the patient’s story is also a hallmark of strong healing relationships…since the simple act of “talking” and “feeling heard” have been shown to have clear therapeutic benefits.
The same is true with the intensely interpersonal act of “laying on of hands.” “Touch” as a method of healing dates back to biblical times and beyond. Today, physicians like Abraham Verghese, MD continue to speak to about therapeutic value of touch as practiced during patient exams in both the hospital and ambulatory settings. These same physicians caution us against losing sight of the central role and value of the physician-patient relationship in the false belief that technology will one day be capable of replacing the personal physician.
First Principles #2 – HIT cannot compensate for weak physician-patient relationships or poor physician-patient communication skills.
We hear today about how primary care physicians are very busy…and getting even busier. EMR systems, e-visits, decision support tools, patient portals and the like are touted as solutions for saving time, increasing quality, etc. While all this may be true, a great EMR system or secure e-mail visits cannot turn a physician with sub-optimal patient communication skills into a patient-centered Marcus Welby, MD. It will probably make things worse.
Absent strong, physician-patient relationships and equally strong patient-centered communication skills, such HIT investments are like building castles upon sand.
Another hallmark of patient-centered communication is a “meeting of the minds” between patients and their physicians regarding issues like the visit agenda, the accuracy and severity of the diagnosis and which treatment options will work best. Unfortunately since many physicians today continue to employ a physician-directed style of communicating with patients…the patient’s perspective is seldom sought…and a meeting of the minds never has a chance to occur. Even if EMRs accommodated the patient’s perspective, the clinician first has to ask the patient…and that just isn’t happening.
First Principles #3 – Beware of unintended consequences
Many HIT professionals will quickly dismiss the above first principles cited above in the name of improving physician productivity. After all, given today’s shortage of primary care physicians we have no choice but to layer on more HIT like EMRS and self-help patient portals. But as with anything, one needs to be prepared for the consequences. And there are always consequences.
In addition to improving productivity, health care professionals cite patient engagement as yet another reason to invest in HIT. But is that really the case?
We have all seen the research citing how patients would “like” secure e-mail with their doctor, online appointment scheduling, access to their doctor’s notes, etc. Who in their right mind would not like this? But liking is not the same as using. Of perhaps more importance is the finding that the vast majority of patients (85%) want to know that they will still have the ability to see their doctor face-to-face when needed after they have access to the above conveniences . People aren’t dumb. We/they know that technology is increasingly getting in between us/them and our/their physician. Provider organizations that try and channel patients into substituting web portals and PHRs for physician office visits run the risk of pushing patients/members into the waiting arms of their competitors.
A recent study of decision support tools underscores yet another unintended consequence – loss of trust in their physician. Interestingly, certain patients saw the use of computer decision support tools as a reflection of their physician’s clinical knowledge. That is, physicians that used decision support tools were perceived as being less knowledgeable than physicians that didn’t employ them. Since clinical skills are a driver of patient trust, the risk of encouraging physicians to “engage” patients by using decision support tools is that you may well be disengaging them by increasing their distrust.
So What’s The Take Away?
We need to recognize that there are fundamental first principles concerning the delivery of healing and health care. To that extent that HIT professionals and those that write the checks for HIT understand these principles one has a better chance of meeting their expectations.
Here are three questions that need to be considered when evaluating any patient-facing HIT solution:
- Does technology support or detract from the physician-patient relationship in a meaningful way?
- Does the technology presuppose the presence of strong physician-patient relations and physician-patient communication skills?
Do you even know what kind of patient communication skills your physicians have?
- What are the potential unintended consequences of adopting the proposed technology?
That’s what I think…what’s your opinion?
Agarwa, R. et al. If We Offer it, Will They Accept? Factors Affecting Patient Use Intentions of Personal Health Records and Secure Messaging. Journal of Medical Internet Research 2013;15(2):e43.