Research paperElectronic-clinical evaluation exercise (e-CEX): A new patient-centered EHR use tool
Introduction
As healthcare providers integrate Electronic Health Records (EHRs) into patient care, maintaining a patient-centered and not technology-centered focus is critical [1], [2]. Literature on the impact of EHR use on patient-nurse, patient-nurse practitioner, and patient-physician communication has identified a number of behaviors that can negatively impact the patient-provider relationship, for example typing during sensitive discussions or not sharing the screen [3], [4], [5], [6], [7], [8], [9]. When providers exhibit these behaviors, the computer can be viewed negatively as an obtrusive “third party” that impedes patient-provider communication [1], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Patient concerns have also arisen over a lack of transparency regarding provider computer use, “They’re looking at the computer constantly when I’m in the room. I know they’re not on Facebook but I don’t know what they are doing” as well as issues regarding focus of attention, “I just want my doctor’s undivided attention, so I can tell him what’s going on…the computer takes them away from focusing on you” [14].
Conversely, when providers use the EHR in a patient-centered manner, they have the opportunity to enhance communication, empower patients and promote patient education and shared-decision making [4], [5], [6], [7], [8], [9], [15], [16], [17], [18], [19], [20], [21]. Patients appreciate the ability to use the computer and its resources as a starting point for dialogue, “We talk and look at results together in the computer…we had an intelligent conversation about my progress” and have noted when there is transparent, collaborative computer usage that it benefits their care, “He’s telling you all along…what he’s doing. This improves the quality of my care” [14]. Our group and others have identified EHR-related behaviors that enhance patient-provider interactions and these represent a set of best practices [3], [7], [22], [23], [24], [25], [26]. With the global movement toward patient-centered care, and the World Health Organization’s (WHO) Global Strategy on People-Centered and Integrated Health Services calling for improved people-centered care that empowers, educates and engages individuals and incorporates technology in an efficient and effective manner, it is critical for healthcare providers of all types and training levels to be aware of and employ these best practices [27].
With regard to specific mandates for physician providers, in the United States (US), the American Medical Association (AMA) recommends educating doctors on these behaviors and soliciting patient feedback on physician EHR use [28]. In addition, the Alliance for Clinical Education (ACE) recommends medical schools formally train students on a “clear set of competencies” related to EHR use to ensure preparation for clinical practice [29]. The United States is not alone in advocating for the need to educate practicing and trainee physicians in best communication practices as it relates to the EHR. For example, the Royal College of Physicians and Surgeons of Canada developed the CanMeds framework for improving patient care by enhancing physician training [30]. This framework highlights the importance and global call for health care providers to communicate effectively as they use EHRs, and recommend sharing information with patients in a manner that enhances understanding.
Despite the existence of best practices and mandates for health care providers to educate and engage individuals with technology, most practicing providers and trainees receive no formal training or evaluation on these key patient-centered EHR communication behaviors [3], [23], [24], [25], [29], [31], [32], [33]. Although validated tools to assess overall health care provider communication skills exist, for example the widely used SEGUE tool, most were developed prior to widespread EHR adoption and do not take into account the effects of EHR use while interacting with a patient [34], [35]. There are currently two tools that assess physicians’ communication skills in the computerized setting using checklists of behaviors and communication tasks, however neither tool has been formally validated [35], [36]. If health care providers of all types, particularly trainees during their formative learning years, are not properly trained and evaluated in best practices, they may learn improper behaviors resulting in not only poor communication outcomes but also a missed opportunity to use the EHR to enhance the relationship and better educate and empower patients.
To address this gap, we aimed to develop and test the validity and reliability of the electronic-Clinical Evaluation Exercise tool (e-CEX) to assess the quality of health care provider communication skills while using the EHR. The e-CEX has the potential to augment EHR communication curricula and facilitate ongoing assessment and feedback to improve the quality of EHR communication.
Section snippets
Development of e-CEX
The e-CEX was modeled on the widely used mini-CEX for real-time observation of history and exam skills for internal medicine trainees [37]. While the mini-CEX was initially developed and studied in a resident population, the mini-CEX format has since been studied with different types of health care providers and trainees including medical students, nurses, nurse practitioners, social workers, pharmacists, and practicing physicians and has been found to be a practical and helpful evaluation tool
Results
Seventy students were rated using the e-CEX: 20 trained MS2s, and 50 untrained MS3s.The mean e-CEX scores for all 70 students was 47.8 (SD 12.9, score range 22–68, max score 72) and the mean SP checklist score was 61.2 (SD 12.6, score range 24–79, max score 80).
Discussion
As EHR adoption becomes increasingly widespread, appropriate EHR use to foster patient-provider communication is a critical part of any health care provider or trainee’s education and practice. Anyone who uses an EHR with patients (i.e., nurses, nurse practitioners, social workers, physical therapists, pharmacists, and physicians as well as trainees of each provider type) must learn how to manage their EHR work demands while making the interaction as meaningful, engaging and educational as
Conflict of interest
All authors listed have contributed sufficiently to the project to be included as authors, and all those who are qualified to be authors are listed in the author byline. To the best of our knowledge, no conflict of interest, financial or other, exists. We have included acknowledgements, conflicts of interest, and funding sources after the discussion.
Funders
Funding for this work was made possible by grants from the Alliance for Academic Internal Medicine and Clerkship Directors of Internal Medicine iInTime Small Grants Program to Promote Educational Scholarship (Grant number FP058012-01), the University of Chicago Academy of Distinguished Medical Educators Medical Education Grants Program (Grants number DD45671 and DD35051), and theArnold P. Gold Foundation Research Institute “Mapping the Landscape, Journeying Together” Project (Grant number
Prior presentations
This study was presented as an oral presentation at the AAMC Central Group of Education Affairs (CGEA) Conference in Ann Arbor, MI on April 2016 and was awarded the “Best Medical Education Scholarship Research and Evaluation (MESRE) Oral Presentation”, and was presented as an oral abstract at the AAMC Annual Meeting in Seattle, WA in November 2016. This work was also presented as a poster at the Society of General Internal Medicine (SGIM) Annual National Meeting in Hollywood, FL in May 2016,
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