Running Head: LITERATURE REVIEW 1 Improving Communication with Patients and Providers Using Health Information Technology Ingrid Valerio West Coast University LITERATURE REVIEW 2 Improving Communication with Patients and Providers Using Health Information Technology According to Ngo-Metzger et al. (2010) effective communication between patients and their care providers promotes positive patient outcomes. Patient outcomes are enhanced by the communication between the patients and healthcare providers. Ngo-Metzger et al. (2010) maintain that through communication care facilities can improve the quality of services provided to patients. Ngo-Metzger et al. (2010) sought to identify health information technology could be utilized to enhance the communication between patients and their care providers. In a bid to establish the impact of health information technology on communication and quality of care services, Ngo-Metzger et al. (2010) conducted research that reviewed literature centered on communication and health IT. Key informant interviews were utilized in the study to examine the current use of the health information technology. Also, the interviews enabled the research to understand how health IT influenced communication between providers and patients from diverse settings. Ngo-Metzger et al. (2010) concluded that communication between patients and providers could be improved by using technological innovations in care facilities which would, in turn, enhance care services for the people particular children from low-income families. How to Improve Communication in Healthcare Gordon, Deland, and Kelly, (2015) argue that care providers do not interact with each other enough. The claim is that all care providers including nurses, social workers, physicians and caregivers spend less time collaborating with each other and therefore spend minimal time interacting with patients. Gordon, Deland, and Kelly, (2015) suggests that interactions between LITERATURE REVIEW 3 the care providers and patients can be improved with the help of implementing communication strategies in the healthcare setting. One approach proposed by Gordon, Deland, and Kelly, (2015) is enhancing communication between the care teams. Improved communication among care teams helps to promote quality of care provided to the patients. Technology companies can also offer assistance to care facilities to help improve communication. Gordon, Deland, and Kelly, (2015) suggest that the technology companies can create new tools and initiatives that can enhance the communication between care providers and the patients to promote quality of care services. Gordon, Deland, and Kelly, (2015) also adds that technology plays a significant role in improving communication within the medical system since it enhances connectivity between the care teams and facilitates the flow of information. Implications of Communication in Healthcare Sloan and Knowles, (2013) claim that communication determines how healthcare providers administer treatment to their patients. For instance, they argue that the negative and positive communication acts dictate how medical providers conduct cancer diagnosis and the treatment phase for the patients. In their study, Sloan and Knowles, (2013) utilized interview methods to collect information on the impact of positive and negative communication. Data obtained from the study showed that care and respect were communicated through interactions and talks between the patients and providers. Additionally, data collected from the interviews show that there is minimal communication within healthcare that fails to accomplish the needs of patients. Sloan and Knowles, (2013) argue that care facilitates should make an effort to enhance communication LITERATURE REVIEW 4 within their setting. Further, their research emphasized on increased communication among care providers that deal with the treatment and diagnosis of cancer patients. All care providers should communicate either verbally or nonverbally regarding how they can enhance the health of patients and administer proper care and treatment for cancer patients. Importance of Improving Patient-Provider Communication Patak et al. (2009) argue that people with a problem in communication are at risk of poor medical outcomes. For instance, patients with communication impairment are exposed to medical errors since they are unable to express their needs clearly to the care providers. As such, patients are likely to end up receiving the wrong diagnosis of their illness. Additionally, other patients will also receive the wrong treatment because they fail to express their problems to the care providers. According to Patak et al. (2009), a call to action should be proposed within care organization to provide training to all the medical practitioners concerning improving communication in healthcare. The reason behind trying to enhance communication is to promote the safety of patients. Patak et al. (2009) claims that communication is an essential factor that influences patient care. Effective communication helps to meet the needs of the patients. On the contrary, poor communication in care facilities exposes patients to numerous medical risks. For instance, poor communication creates opportunities for medical errors, poor outcomes, and miscommunication that can result in a wrong diagnosis, treatment, and prescription. As such, healthcare providers will end up worsening the medical condition of their patients due to the poor communication. LITERATURE REVIEW 5 Patak et al. (2009) maintain that communication is important as it helps to improve the quality of care offered to the patients. Further, effective communication increases patient outcome and promotes their health. Care providers can understand the needs of the patients as well as their problems when they interact with them effectively. As such, Patak et al. (2009) propose a call to action that involves providing training to the care providers on how they can enhance the communication between them and the patients. In turn, improved communication will help to reduce risks and medical errors that can arise due to miscommunication. Communication and Patient Safety Loman, (2016) argues that communication is essential in healthcare and particularly within the field of psychiatry. Communication promotes the safety of patients in that it protects them from any harm. Communication enables care providers to carry out procedures that can prevent the occurrence of adverse events. Further, through interaction between patients and providers, it is easy to provide correct treatment procedures for the clients. On the contrary, poor communication is believed to cause integration of wrong procedures within healthcare. Loman, (2016) suggests that education has discovered communication to be an area that requires most improvement. Based on his research, it comes out that effective communication can contribute to positive treatment outcomes in healthcare. Further, effective communication leads to sustainable therapy relationship between patients and the care providers. Loman, (2016) maintains that care providers such as the psychiatry residents utilize communication tools that help them promote quality of care and enhance patient safety. Additionally, Loman, (2016) argues that communication is an essential component of healthcare for the mentally ill individuals. The therapeutic relationships between the caregivers LITERATURE REVIEW 6 and patients are formed through effective communication. These relationships help to improve the outcome of a patient. Communication enables care providers to interact with patients and understand their problems. In turn, the caregivers can keep patients safe and provide proper treatment for their illness. Components of Health IT Bauer et al (2014), notes that there are three common components of health IT which help ease communication between various channels. The Electronic Health Record (EHR) is the central component of health IT and can be defined as a person’s official digital health record that can be shared by multiple healthcare providers and agencies. This means that a patient does not require to go to their home hospital every time they are unwell because the medical records are there. With their permission, their EHR can be accessed by various healthcare providers, therefore, helping them get help no matter where they are without them necessarily cramming their medical history. The other key element is the Personal Health Record (PHR) which a person’s selfmaintained health record. As opposed to EHRs, PHRs are not necessarily professional but they help keep track of a person’s health. Using a PHR a patient can communicate well when they first started feeling unwell and what the symptoms were rather than guessing when the symptoms first appeared. A patient can also keep track of their medication using PHRs. Lastly, the Health Information Exchange (HIE), is composed of a group of healthcare organizations that enter an interoperability pact and agree to share information between their various health IT systems. HIE, mainly helps with research and transfers whereby if a patient has LITERATURE REVIEW 7 been transferred from one hospital to another, the records from the previous hospital can be made available through HIE. Impact of Health IT in Communication Using health IT communication barriers are decreased significantly. According to Diamantidis and Becker (2014), “ethnic and racial minorities are disproportionately affected and suffer worse outcomes than their white counterparts”. This means that access to proper healthcare becomes an issue to racial and ethnic minorities due to language barriers. While most minorities prefer being treated by ‘their own’ since they are more relatable, most specialists are not necessarily minorities. This, therefore, facilitates the need for proper communication channels as provided by health IT, therefore, ensuring that all people can get access to proper healthcare despite their background. Another reason for miscommunication between patients and health providers is ignorance on the end of the patients whereby patients may assume some symptoms as not important and only seek medical care when it is too late (Arnold & Boggs, 2015). Using telehealth, technology in health, which is a branch of health IT, patients are educated on health literacy so as to avoid last minute rushes to the hospital when their conditions are terrible when they could have been treated earlier. Telehealth also empowers patients to be their own care givers thus putting in preventive measures to some diseases. This is supported by Diamantidis amd Becker (2014) who posit, “Possibilities for Telehealth interventions are wide-ranging and include the delivery of telephone-based educational materials and prompts via landline, to video-conferenced clinical visits (also known as “Telenephrology”)”. LITERATURE REVIEW 8 The incorporation of HIE, HER, and PHR saves up on consultation time. One does not need to go through tests that had already been done previously not unless they are needed and one does not need to dig up family medical history each time or other common questions trying to deduct the problem. This time can be used in other ways but most importantly the version of the medical history will always be one that develops rather than a different story with each hospital visit. This aids also practitioners dealing with patients who have memory loss that is not advanced. E-prescriptions come in handy in that patients no longer have to rely on guess-work between their doctors and the pharmacists due to problems reading the handwriting. An eprescription is a typed prescription that can be read by both the patient and the pharmacists so there is nothing lost to translation (Hibbard & Greene, 2013). More so, an e-prescription cannot easily get lost, unlike the physical prescription. This makes it possible for patients to easily inform a doctor about their medical history including the medicines they used rather than just what they were suffering from. A doctor can also keep tabs on the medication given and how it has helped the patient. Also with the use of e-prescriptions, it becomes difficult to forge a fake prescription, therefore, reducing addiction problems (Hibbard & Greene, 2013). Transitioning into Health IT According to Kellermann and Jones (2013), heath IT has slowly started been implemented with hospitals making use of EHRs. However, the transition so far has just been in a bid to go paperless. Physicians have complained that the move is making them underused. Most patients, on the other hand, think that this is just hospitals trying to be fancy. They do not understand that the move is meant to help them. For the proper transition to health IT I would LITERATURE REVIEW 9 recommend awareness of what the program aims to achieve. In doing so, the health IT system does not become underused. Practitioners would be taught that the new system does not allow for breaches of protocol but it is just meant to help. Patients would be made to understand that their records would still be private and that they would be contacted if anyone needed to access the EHRs. Patients and practitioners would see the benefits of the system and use them to reap as much as they possibly can from the system. The transition can also be done slowly with a hybrid system of the old and the new health IT system being run simultaneously until people ease into the new health IT system. This would be having the patients recount their medical history as they would in a normal hospital visit and the practitioner looking it up on the system. If differences arise from the two it would be a good time to seal loopholes whereby tests would be run on the patient to determine the correct version of the history. The hybrid system may start up as expensive but it would then ease into a cheaper means in the end. An offline system could also be considered for people who do not have internet access (Kellermann & Jones, 2013). This would also be helpful to people who travel a lot, both healthcare providers and patients. This would enable one to simply post data without internet connectivity that can be backed up later over the internet rather than have a person try to remember something later when they get access to the internet. With increased cyber-crimes, hospitals implementing health IT would need to closely work with IT specialists to come up with proper measures to safeguard information. This should not necessarily translate to a complicated user interface. A simple design that can be used by all practitioners but have measures to access the information such as a key log that would show who LITERATURE REVIEW logged on to retrieve files or view or even delete them and a proper firewall would be enough security. In conclusion, the world is making major leaps in terms of technology and the sooner people adapt the easier it becomes. Health IT is meant to help both healthcare givers as well as patients and as illustrated above would prove very meaningful to help bridge gaps in communication. This translates to progress and covers grounds especially in terms of misdiagnosis. 10 LITERATURE REVIEW 11 References Arnold, E. C., & Boggs, K. U. (2015). Interpersonal Relationships-E-Book: Professional Communication Skills for Nurses. Elsevier Health Sciences. Bauer, A. M., Thielke, S. M., Katon, W., Unützer, J., & Areán, P. (2014). Aligning health information technologies with effective service delivery models to improve chronic disease care. Preventive medicine, 66, 167-172. Gordon, J. E., Deland, E., & Kelly, R. E. (2015). Let’s talk about improving communication in healthcare. Col Med Rev, 1(1), 23-27. Diamantidis, C. J., & Becker, S. (2014). Health information technology (IT) to improve the care of patients with chronic kidney disease (CKD). BMC nephrology, 15(1), 7. Hibbard, J. H., & Greene, J. (2013). What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs. Health affairs, 32(2), 207214. Kellermann, A. L., & Jones, S. S. (2013). What it will take to achieve the as-yet-unfulfilled promises of health information technology. Health affairs, 32(1), 63-68. Loman, R. (2016). Improving Communication Between Patients and Providers Surrounding the Legal Basis for Admission. American Journal of Psychiatry Residents' Journal, 11(11), 3-5. Ngo-Metzger, Q., Hayes, G. R., Chen, Y., Cygan, R., & Garfield, C. F. (2010). Improving communication between patients and providers using health information technology and LITERATURE REVIEW other quality improvement strategies: focus on low-income children. Medical Care Research and Review, 67(5_suppl), 246S-267S. Patak, L., Wilson-Stronks, A., Costello, J., Kleinpell, R. M., Henneman, E. A., Person, C., & Happ, M. B. (2009). Improving patient-provider communication: a call to action. The Journal of nursing administration, 39(9), 372. Sloan, A. G., & Knowles, A. (2013). Improving communication between healthcare providers and cancer patients: A pilot study. Journal of Communication in Healthcare, 6(4), 208215. 12 Running Head: IMPROVING COMMUNICATION WITH PATIENTS AND PROVIDERS Improving Communication using Health Information Technology West Coast University Ingrid Valerio 1 IMPROVING COMMUNICATION WITH PATIENTS AND PROVIDERS 2 It is imperative to understand that any suffering experienced by patients as a result of lack of proper quality care is a violation of human dignity. According to Katie Erickson’s nursing model, nurses are expected to practice care services with love and charity. Katie’s theory in nursing is recognized as Caritative Caring which comprises of aspects such as love, charity, and respect for human dignity and holiness. The theory also argues that nurses should make an effort to follow nursing ethics which provide a guideline concerning the capacity of nurses to make certain decisions in their profession. It is evident from this nursing model that the priority of nurses is to offer quality and proper care to the patients to avoid any suffering. As such, any decisions or changes made in the care facilities should be veered towards improving the health of the patients. Nursing profession faces various challenges that prevent the delivery of quality care to patients. Thus, although the nursing models expect nurses to offer care services with love, charity and respect for dignity certain barriers hinder effective delivery. Communication is a crucial aspect of the nursing profession since it influences the outcome of care services. For instance, patients are having trouble sharing their problems with the nurses as a result of communication barriers. On the other hand, nurses are also having trouble administering proper treatment and care services to patients due to miscommunication. Thus, the use of health information technology has been recommended as an alternative solution that can help to enhance the communication between care providers and their patients (Ngo-Metzger, Hayes, Chen, Cygan and Garfield, 2010). Health information technology has been proposed as an approach that can improve communication in care organizations. For example care facilities can implement health IT tools to educate and engage patients as well as collect data about a client to help enhance IMPROVING COMMUNICATION WITH PATIENTS AND PROVIDERS 3 communication during a visit to the organization. Further, the health IT tools can improve communication in that they can enhance face-to-face interactions between providers and patients. Some of the health IT tools that can be utilized in healthcare include tablets, cellular phones and smartphones among others (Miller and Himelhoch, 2013). These tools can be utilized to provide health services to the public. Further, the technology tools can be implemented by healthcare organizations to deliver significant information about healthcare to the patients. In a bid to effectively implement the health IT tools within healthcare, it is imperative to establish how the approach can be utilized in the organizations. Jean Watson’s nursing model argues that human beings should be seen and treated as valuable persons. Jean claimed that human beings should be cared for and nurtured while in care facilities ("Jean Watson Nursing Theory - Nursing Theory," n.d.). Further, Jean adds that the people deserve respect and understand to assist them in accomplishing their needs. As such, while trying to implement the change concerning the introduction of health IT tools in health care, it is imperative to understand what the human beings want and expect from the care facilities. According to Jean Watsons’ theory health is associated with activities that are aimed at mitigating illness and the suffering of patients. In a bid to reduce patient suffering, care organizations should thus adopt health IT approach to enhance the communication between providers and patients. In turn, effective communication enables a patient to share their problems with the providers without any misunderstanding, whereas the providers can administer effective treatment approaches to the clients. IMPROVING COMMUNICATION WITH PATIENTS AND PROVIDERS 4 References Jean Watson Nursing Theory - Nursing Theory. (n.d.). Retrieved from http://nursingtheory.org/theories-and-models/watson-philosophy-and-science-of-caring.php Miller, C. W., & Himelhoch, S. (2013). Acceptability of mobile phone technology for medication adherence interventions among HIV-positive patients at an urban clinic. AIDS research and treatment, 2013. Ngo-Metzger, Q., Hayes, G. R., Chen, Y., Cygan, R., & Garfield, C. F. (2010). Improving communication between patients and providers using health information technology and other quality improvement strategies: focus on low-income children. Medical Care Research and Review, 67(5_suppl), 246S-267S. Running head: INTRODUCTION 1 A Systematic Review Of The Literature Examining The Use Of Electronic Devices Enhance The Communication Between Patient And Provider Ingrid Valerio, RN, CCM West Coast University Master’s in Science in Nursing (Advanced Generalist) NURS 690B Culminating Experience II 201803SPIIOL OL-3 Dr. Susan Gonda, RN April 8th, 2018 2 INTRODUCTION Introduction and Background The patient's perception of quality care from health care providers is directly proportionate to the communication between patient/provider. Good communication improves patient outcomes. Communication relies on the ability of patients and medical professionals to consistently provide convenience to the patient. It is, however, worth noting that the current communication systems between the patients and medical experts do not offer the desired levels of convenience and flexibility (Abdullah, Rashid, Abou-ElNour, & Tarique, 2015). The clinical experience provided significant information regarding the deplorable state of communication infrastructure between medical professionals and the outpatients in healthcare facilities. The primary focus of the change project is, therefore, to establish appropriate systemic implementations through text messages and emails that would ensure the physicians can attend to patients with increased efficiency and convenience (Abdullah et.al, 2015). The change project introduces the use of mobile devices in the healthcare environment in a bid to improve the efficiency and convenience of communication between the patients and the medical experts. The background information reveals a limited application of mobile clinical application programs in the communication process in clinical facilities (Silva, Rodrigues, Torre Díez, & Saleem, 2015). The result is that the rate of communicating critical information and health matters is low and inconvenience to both the patients in the out-patient category and the medical professionals. The change project would, therefore, introduce necessary transformation in the clinical communication infrastructure. Through the introduction of mobile communication technology INTRODUCTION 3 through emails and text messages, the patients and medical personnel would be able to relay and receive crucial data from healthcare professionals. The change project would also enhance operations over long distances without the necessity of physical meeting between the patients and the healthcare professionals (Ventola, 2014). The intention of the change project would also be an effort to provide meaningful education to both the medical professionals and the patients on the significance of applying mobile communication technologies in their communication. Through staff meetings and seminars, the research findings would be relayed to the stakeholders in a move to ensure a vibrant way of communication to improve healthcare service provision. Considering the positive impact that the change project would bring to the medical facilities in the study area, it is worth researching and implementing the mobile communication applications to transform service delivery to the outpatients. The essential elements of change that need consideration are environmental aspects, technological preparedness of the staff/employees, and current systems in the healthcare facilities (Silva et al., 2015). The master’s capstone project focuses on the impact of electronic correspondence and the influence that it plays in communication between patients and healthcare providers in the outpatient setting. The principal objectives of this scholarly brief are to outline current research and to introduce the project plan. 4 INTRODUCTION References Abdullah, A., Ismael, A., Rashid, A., Abou-ElNour, A., & Tarique, M. (2015). Real time wireless health monitoring application using mobile devices. International Journal of Computer Networks & Communications (IJCNC), 7(3), 13-30 Silva, B. M., Rodrigues, J. J., de la Torre Díez, I., López-Coronado, M., & Saleem, K. (2015). Mobile-health: A review of current state in 2015. Journal of biomedical informatics, 56, 265-272. Ventola, C. L. (2014). Mobile devices and apps for health care professionals: uses and benefits. Pharmacy and Therapeutics, 39(5), 356. Rationale Aims and Objective Design: A systematic review of the literature. Method: Thirty-four interventions published in peer-reviewed journals before July 2010, employing short message service (SMS) and/or multimedia message service to address healthrelated behavioral change, were reviewed. Results: Five interventions utilized SMS alone, 18 employed SMS/Internet, and 11 utilized SMS, Internet, and other strategies. Intervention length ranged from 4 weeks to 1 year. Twenty interventions (59%) were evaluated using experimental designs, and most resulted in statistically significant health behavioral changes. Conclusion: Surveillance of mHealth interventions’ role in facilitating behavioral change is a judicious parallel activity for health education and health behavior authorities. The effect of electronic devices use on Patient-Provider Communication has limited research information available. As data accumulate, the purpose of this article is to review the literature on electronic devices on patient and healthcare provider, to identify recurring themes and to offer preliminary guidelines and future directions for healthcare education and research. To perform a systematic review of the literature concerning behavioral mobile health (mHealth) and summarize points related to heath topic, use of theory, audience, purpose, design, intervention components, and principal results that can inform future health education applications. Method A retrospective systematic review of literature utilizing a database search was conducted and 20 articles that met inclusion criteria published in the past ten years, empirical investigations, direct assessment of the impact of electronic devices impact on patient– healthcare provider communication were chosen for review. A qualitative theory was utilized to analyze the data. Results The use of electronic devices often has a positive impact on information exchange but exerts a negative influence on patient-centeredness. Some patient characteristics such as lack of electronic devices skills and negative stigma may be perceived as a negative influence. Conclusion, The use of electronic devices, employs both positive and negative impacts on healthcare provider-patient relationships. The negative results can be overcome by some simple means as well as better technology and training on the importance of bridging the communication gap by utilizing electronic devices to enhance communication. Communication training may facilitate patient and healthcare provider in computerized. Despite these apparent benefits, there are also disadvantages of the use of electronic devices in healthcare settings have also been reported. It has been demonstrated that the use of electronic devices hindered critical thinking resulting in possible loss of information and miscommunication. Other unintended consequences of the use of electronic devices also created additional processes which in turn created more work for healthcare staff and clinical workflow. Introduction Electronic Medical Records (EMRs) are increasingly used in healthcare organizations in general and ambulatory settings in particular. Their use is being promoted by President Bush’s administration in the USA [1], and organizations such as the National Health Service (NHS) in the UK, Canada Health Infoway, the US Institute of Medicine (IOM) and the American Medical Informatics Association (AMIA). A number of countries, among them Denmark, Canada and Israel develop strategies towards integrative national health record systems [2–4]. The potential benefits of electronic devicesization in healthcare have been discussed extensively [1,5–8]. These include comprehensive documentation of a patient’s medical history, easy access to medical data from remote sites, improved communication among the various providers involved in health care, easy access to medical information and state of the art resources over the Internet (e.g. medical journals, guidelines, Evidence-based Medicine databases, medication databases, etc.) and clinical decision support. A recent systematic literature review suggests that the use of information technology improves healthcare by increasing adherence to guidelines or protocol-based care, reduction of medical errors, and clinical monitoring and data aggregation which are not feasible with paper [9]. A growing concern is the influence of electronic devices use on patient– doctor communication during the patient visit. Communication is one of the ‘most powerful, encompassing, and versatile instrument[s] available to the physician.’ [14]. It is currently widely accepted and evidence-based that patient–doctor communication is perhaps the most significant component of the healthcare © 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 641–649 visit, with ramifications for patient satisfaction [15–17], compliance/adherence [18], conflict- resolution [19] and clinical outcomes [17,20]. A growing literature linking patient and healthcare provider to a host of important patient outcomes has broadened definitions of medical care quality to include physicians’ interpersonal skills in the medical interview [21]. Such outcomes have ranged from reports of improved physical and emotional health status, and better performance in activities of daily living, to enhancements in markers of disease control such as Haemoglobin A1C and blood pressure and finally to specific disease states such as Myocardial Infarction [17,22,23]. It has been suggested that information systems have the potential to help sharing understanding between doctors and patients, thereby educate and empower both and make the patient–doctor encounter more effective [5,6]. However, the actual influences of EMR use on patient and healthcare provider are just beginning to be realized. The purpose of this paper is to review the existing research on the effect of EMR on patient and healthcare provider, which accumulated during the last decade. As the existing included literature is largely qualitative, the paper’s goal is to report the results of a narrative analysis resulting in synthetic recurring themes, adjustment of proposed best practices [24] and delineation of present knowledge gaps. Potential implications for the design of EMRs, educational interventions and future research are subsequently discussed. Methods Paper selection Asearch of peer-reviewed medical, nursing, and professional journals, full-text articles, abstracts, thesis, dissertations, and reviews with publications within the last 10 years (20082018). The following electronic databases were accessed to retrieve electronic articles from CINAHL, Health Business, Health Source, LexisNexis Academic, Opposing Viewpoints in Context, ProQuest Nursing & Allied Health Source, ProQuest ProQuest Health & Medical Complete, SPORTDiscus with Full Text, WorldCat.org, Google Scholar. The proposed search terms include but are not limited to “communication”, “patient”, “provider”, and “electronic communication”. Search results were limited to papers in English, published in the past 10 years. The database search yielded a total of 75 controlled trials of people that had an intervention 67 articles as of 2008. The titles and abstracts of the papers retrieved were manually screened. Papers meeting the following inclusion criteria were selected for the final analysis: empirical investigations (quantitative or qualitative); direct assessment of the use of electronic devices and the impact on patient–healthcare provider communication. Data analysis A qualitative–interpretive approach to analysis of the data was used. Following the general principles of qualitative data analysis, researchers first familiarized themselves with the data by reading through the selected articles and reflecting on them (e.g. by margin notes). Then, open coding – the process of ‘selectively attach[ing] meaningful tags to words, phrases, events, situations, and so forth, naming what is potentially important about them and distinguishing them from the rest of the data’ [25] was employed. Next, thematic categories were developed and relationships between categories were determined. An analytic induction [26] process was employed to reach interpretation. Finally, emergent themes were compared and contrasted with the tips provided by Ventres et al. [24] to modify and provide potential extensions to those tips. The researchers identified 75 studies that compare the outcomes of patients who do and do not receive an intervention. The use of electronic devices for communication between patienthealthcare providers. Twenty-six studies researched the use of electronic devices to change health behaviors, 59 investigated their use in chronic conditions, special needs populations and disease management, most were not specific or unable to establish a pattern. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lowerquality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases. What Do These Findings Mean? These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using electronic devices. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a highincome setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other electronic devices–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further research are undertaken to establish their clinical benefits. Results A total of 14 papers met the inclusion criteria. In 11 of them [27–37], the effect of electronic devices usage on patient–doctor communication was the primary scope. One study [38] was aimed at developing a methodology to transcribe data regarding electronic devices– patient– doctor communication and one study [39] investigated patient–doctor communication in general. However both these studies describe some results concerning the effect of electronic devicess on patient–doctor communication and therefore, were included in this review. Another study compared physicians’ satisfaction with using desktop and mobile electronic devicess, and included patient–doctor communication as one of the dependent variables [40]. The methodological approaches of the various studies included in this review are summarized in Table 1. The majority of studies used videotape recording of clinical encounters as a primary data collection method, sometimes in combination with interviews or observation. A qualitative approach to data analysis was taken in the majority of these studies; specific methods include ethnography, grounded theory and conversation analysis. Two studies, however, analysed videotaped encounters quantitatively using a checklist of communication tasks [30] and the Roter Interaction Analysis System (RIAS) [34]. Other studies used physician and/or patient satisfaction written questionnaires or patient telephone structured interviews for data collection [27,36,37,40]. Our review suggests four major themes discussed by the literature on patient–doctor–electronic devices communication. These are: electronic devices use, effect of EMR use on patient and healthcare provider, factors affecting patient and healthcare provider in computerized settings and classification of physicians’ behaviour. Electronic devices use Five papers discussed issues related to electronic devices use. Electronic devicess were employed for various purposes: general review of patients’ medical record, checking medications taken by the patient, retrieving test results, entering information, writing prescriptions and letters, and, occasionally, displaying changes in clinical data over time to patients and printing educational material for them [28–31]. The intensity of electronic devices use is discussed in two studies. In one of them, usage intensity during the visit was low, and paper records were used to a greater extent than EMR. In the other, physicians screen Rationale Aims and Objective The effect of electronic devices use on Patient-Provider Communication has limited research information available. As data accumulate, the purpose of this article is to review the literature on electronic devices on patient and healthcare provider, to identify recurring themes and to offer preliminary guidelines and future directions for healthcare education and research. Method A database search was conducted and 14 articles that met inclusion criteria (published in the past ten years, empirical investigations, direct assessment of the impact of electronic devices impact on patient–healthcare provider communication were chosen for review. A qualitative theory was utilized to analyze the data. Results The use of electronic devices often has a positive impact on information exchange but exerts a negative influence on patient-centeredness. Some patient characteristics such as lack of electronic devices skills and negative stigma may be perceived as a negative influence. Conclusion, The use of electronic devices, employs both positive and negative impacts on healthcare provider-patient relationships. The negative results can be overcome by some simple means as well as better technology and training on the importance of bridging the communication gap by utilizing electronic devices to enhance communication. Communication training may facilitate patient and healthcare provider in computerized. Despite these apparent benefits, there are also disadvantages of the use of electronic devices in healthcare settings have also been reported. It has been demonstrated that the use of electronic devices hindered critical thinking resulting in possible loss of information and miscommunication. Other unintended consequences of the use of electronic devices also created additional processes which in turn created more work for healthcare staff and clinical workflow. Introduction Electronic Medical Records (EMRs) are increasingly used in healthcare organizations in general and ambulatory settings in particular. Their use is being promoted by President Bush’s administration in the USA [1], and organizations such as the National Health Service (NHS) in the UK, Canada Health Infoway, the US Institute of Medicine (IOM) and the American Medical Informatics Association (AMIA). A number of countries, among them Denmark, Canada and Israel develop strategies towards integrative national health record systems [2–4]. The potential benefits of electronic devicesization in healthcare have been discussed extensively [1,5–8]. These include comprehensive documentation of a patient’s medical history, easy access to medical data from remote sites, improved communication among the various providers involved in health care, easy access to medical information and state of the art resources over the Internet (e.g. medical journals, guidelines, Evidence-based Medicine databases, medication databases, etc.) and clinical decision support. A recent systematic literature review suggests that the use of information technology improves healthcare by increasing adherence to guidelines or protocol-based care, reduction of medical errors, and clinical monitoring and data aggregation which are not feasible with paper [9]. A growing concern is the influence of electronic devices use on patient– doctor communication during the patient visit. Communication is one of the ‘most powerful, encompassing, and versatile instrument[s] available to the physician.’ [14]. It is currently widely accepted and evidence-based that patient–doctor communication is perhaps the most significant component of the healthcare © 2009 The Authors. Journal compilation © 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 15 (2009) 641–649 visit, with ramifications for patient satisfaction [15–17], compliance/adherence [18], conflictresolution [19] and clinical outcomes [17,20]. A growing literature linking patient and healthcare provider to a host of important patient outcomes has broadened definitions of medical care quality to include physicians’ interpersonal skills in the medical interview [21]. Such outcomes have ranged from reports of improved physical and emotional health status, and better performance in activities of daily living, to enhancements in markers of disease control such as Haemoglobin A1C and blood pressure and finally to specific disease states such as Myocardial Infarction [17,22,23]. It has been suggested that information systems have the potential to help sharing understanding between doctors and patients, thereby educate and empower both and make the patient–doctor encounter more effective [5,6]. However, the actual influences of EMR use on patient and healthcare provider are just beginning to be realized. The purpose of this paper is to review the existing research on the effect of EMR on patient and healthcare provider, which accumulated during the last decade. As the existing included literature is largely qualitative, the paper’s goal is to report the results of a narrative analysis resulting in synthetic recurring themes, adjustment of proposed best practices [24] and delineation of present knowledge gaps. Potential implications for the design of EMRs, educational interventions and future research are subsequently discussed. Methods Paper selection Asearch of peer-reviewed medical, nursing, and professional journals, full-text articles, abstracts, thesis, dissertations, and reviews with publications within the last 10 years (20082018). The following electronic databases were accessed to retrieve electronic articles from CINAHL, Health Business, Health Source, LexisNexis Academic, Opposing Viewpoints in Context, ProQuest Nursing & Allied Health Source, ProQuest ProQuest Health & Medical Complete, SPORTDiscus with Full Text, WorldCat.org, Google Scholar. The proposed search terms include but are not limited to “communication”, “patient”, “provider”, and “electronic communication”. Search results were limited to papers in English, published in the past 10 years. The database search yielded a total of 75 controlled trials of people that had an intervention 67 articles as of 2008. The titles and abstracts of the papers retrieved were manually screened. Papers meeting the following inclusion criteria were selected for the final analysis: empirical investigations (quantitative or qualitative); direct assessment of the use of electronic devices and the impact on patient–healthcare provider communication. Data analysis A qualitative–interpretive approach to analysis of the data was used. Following the general principles of qualitative data analysis, researchers first familiarized themselves with the data by reading through the selected articles and reflecting on them (e.g. by margin notes). Then, open coding – the process of ‘selectively attach[ing] meaningful tags to words, phrases, events, situations, and so forth, naming what is potentially important about them and distinguishing them from the rest of the data’ [25] was employed. Next, thematic categories were developed and relationships between categories were determined. An analytic induction [26] process was employed to reach interpretation. Finally, emergent themes were compared and contrasted with the tips provided by Ventres et al. [24] to modify and provide potential extensions to those tips. The researchers identified 75 studies that compare the outcomes of patients who do and do not receive an intervention. The use of electronic devices for communication between patienthealthcare providers. Twenty-six studies researched the use of electronic devices to change health behaviors, 59 investigated their use in chronic conditions, special needs populations and disease management, most were not specific or unable to establish a pattern. In one high-quality trial that used text messages to improve adherence to antiretroviral therapy among HIV-positive patients in Kenya, the intervention significantly reduced the patients’ viral load but did not significantly reduce mortality (the observed reduction in deaths may have happened by chance). In two high-quality UK trials, a smoking intervention based on text messaging (txt2stop) more than doubled biochemically verified smoking cessation. Other lowerquality trials indicated that using text messages to encourage physical activity improved diabetes control but had no effect on body weight. Combined diet and physical activity text messaging interventions also had no effect on weight, whereas interventions for other conditions showed suggestive benefits in some but not all cases. What Do These Findings Mean? These findings provide mixed evidence for the effectiveness of health intervention delivery to health-care consumers using electronic devices. Moreover, they highlight the need for additional high-quality controlled trials of this mHealth application, particularly in low- and middle-income countries. Specifically, the demonstration that text messaging interventions increased adherence to antiretroviral therapy in a low-income setting and increased smoking cessation in a highincome setting provides some support for the inclusion of these two interventions in health-care services in similar settings. However, the effects of these two interventions need to be established in other settings and their cost-effectiveness needs to be measured before they are widely implemented. Finally, for other electronic devices–based interventions designed to change health behaviors or to improve self-management of chronic diseases, the results of this systematic review suggest that the interventions need to be optimized before further research are undertaken to establish their clinical benefits. Results A total of 14 papers met the inclusion criteria. In 11 of them [27–37], the effect of electronic devices usage on patient–doctor communication was the primary scope. One study [38] was aimed at developing a methodology to transcribe data regarding electronic devices– patient– doctor communication and one study [39] investigated patient–doctor communication in general. However both these studies describe some results concerning the effect of electronic devicess on patient–doctor communication and therefore, were included in this review. Another study compared physicians’ satisfaction with using desktop and mobile electronic devicess, and included patient–doctor communication as one of the dependent variables [40]. The methodological approaches of the various studies included in this review are summarized in Table 1. The majority of studies used videotape recording of clinical encounters as a primary data collection method, sometimes in combination with interviews or observation. A qualitative approach to data analysis was taken in the majority of these studies; specific methods include ethnography, grounded theory and conversation analysis. Two studies, however, analysed videotaped encounters quantitatively using a checklist of communication tasks [30] and the Roter Interaction Analysis System (RIAS) [34]. Other studies used physician and/or patient satisfaction written questionnaires or patient telephone structured interviews for data collection [27,36,37,40]. Our review suggests four major themes discussed by the literature on patient–doctor–electronic devices communication. These are: electronic devices use, effect of EMR use on patient and healthcare provider, factors affecting patient and healthcare provider in computerized settings and classification of physicians’ behaviour. Electronic devices use Five papers discussed issues related to electronic devices use. Electronic devicess were employed for various purposes: general review of patients’ medical record, checking medications taken by the patient, retrieving test results, entering information, writing prescriptions and letters, and, occasionally, displaying changes in clinical data over time to patients and printing educational material for them [28–31]. The intensity of electronic devices use is discussed in two studies. In one of them, usage intensity during the visit was low, and paper records were used to a greater extent than EMR. In the other, physicians screen
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