Effectiveness of a web-based, electronic medical records-integrated patient agenda tool to improve doctor-patient communication in primary care consultations: A pragmatic cluster-randomized controlled trial study

https://doi.org/10.1016/j.ijmedinf.2022.104761Get rights and content

Highlights

  • Patients with chronic disease entered pre-consultation agendas into an electronic medical record-linked website before seeing their doctors.

  • Compared to usual care, the use of the website did not affect patient satisfaction levels with the consultation.

  • However, the website arm showed slightly more agenda items were discussed in the same amount of time compared to usual care.

Abstract

Background

Doctors may struggle to identify patient agendas during busy primary care consultations. Therefore, an online patient agenda tool (the Values in Shared Interactions Tool- VISIT) was developed which allowed patients to enter their agenda items pre-consultation for doctors to view on their electronic medical records (EMR). This study aimed to measure the impact of this EMR-integrated website on patient satisfaction, number of agenda items discussed and consultation time.

Methods

An unblinded cluster-randomized controlled trial was conducted in a university-based primary care clinic between June-October 2019. Twenty-five family medicine trainees were randomized into using the VISIT tool (intervention) and usual care (control). Descriptive analysis showed significant differences between arms for age, occupation and mobile device proficiency scores. These were entered as covariates in trial analyses. Primary outcome was mean self-reported patient satisfaction score using the Healthcare Provider-Patient Communication (HCPPC) questionnaire, secondary outcomes were mean agenda items per consultation and mean consultation time.

Results

The intervention arm had 12 doctors and 109 patients; the control arm had 13 doctors and 137 patients. Participation rates were 25.5% for intervention vs 53.6% for control. There was no difference between arms for patient satisfaction scores (133.3, 95% CI: 130.67–135.88 intervention vs 134.0, 95% CI: 131.76–136.29 control, P =.680) and consultation duration (15.83 min, 95% CI: 13.66–17.99 intervention vs 15.45 min, 95% CI: 13.57–17.34 control, P =.805). Mean number of agenda items discussed was higher in the intervention arm (2.25 items, 95% CI: 2.06–2.44 intervention vs 1.94 items, CI 95%: 1.78–2.11, P =.024).

Conclusions

Integrating patient agendas into the EMR did not affect patient satisfaction compared to usual care but was associated with a slightly increased number of agenda items without an increase in consultation time. This shows it may be useful for a busy primary care setting with multiple comorbidities and short consultation times.

Introduction

An effective doctor-patient relationship is built on adequate two-way communication where the doctor can share their clinical expertise and the patient is able to voice their concerns and expectations freely [1]. However, there are considerable challenges in eliciting patient perspectives during medical consultations. These barriers include doctors’ lack of skills on how to discuss patients’ perspectives, prevailing attitudes such as paternalism, short consultation time and a lack of patient participation in consultations [2]. Indeed, there is often a ‘silent misdiagnosis of patient preferences’ whereby clinicians often make an assumption about their patients’ preferred options [3].

A number of interventions have been trialled to facilitate the articulation of patients’ unvoiced agendas. These include pre-consultation paper forms or websites which prompt patients to write or print an agenda list that can be brought into the consultation and handed to the doctor [4], [5], and workshops to increase doctors’ awareness of patient agendas [5]. Results from these studies reported that agenda tools increase consultation satisfaction at the expense of longer consultation times [5], [6].

This study aims to leverage the potential of the electronic medical records (EMR) platform as tool to communicate patient agenda to doctors via a patient agenda website (The VISIT Tool). This study was informed by shared decision making (SDM) as a theoretical framework [1]. In shared decision making, patient values clarification is an important component underpinning patient-doctor communication [1]. However, values clarification is often doctor-initiated and/or included as part of a decision aid; our study used a more open-ended form of values clarification by allowing patients to list concerns before their consultations. The detailed description of the VISIT website has been published elsewhere from the development phase [7]. Patients entered information about their concerns before the consultation, and these would be displayed on their doctor’s EMR screen [8]. In a pilot study, doctors said that knowing the patient agenda list beforehand helped them structure their consultation better [9]. Thus, VISIT differs from previous agenda studies as EMR integration allowed doctors to view agendas before the consultation, instead of during the consultation.

Therefore, this study aimed to measure the effectiveness of the EMR-integrated patient agenda tool (VISIT) on patient satisfaction, number of agenda items discussed and consultation time in a single-centre cluster randomized control trial.

Section snippets

Study design

We performed an unblinded single-centre cluster randomized trial to compare the effectiveness of using a website (VISIT) for patients to report their agenda before consultations against usual care.

Clinic setting

This study was conducted in an outpatient academic primary care clinic located in a busy urban area. Patients on chronic disease follow-up are given regular 3–6 monthly appointments. As far as possible they are assigned to see a regular doctor unless their usual doctor has been assigned to another

Results

Doctors’ and patients’ characteristics are reported in Table 1. There were 13 doctors in the control arm (usual care) and 12 in the intervention (VISIT). The participation rate was 25.5% for intervention vs 53.6% for control. There were significant differences between arms for age (trial patients were younger), occupation (the highest percentage of trial patients were employed, vs retired in the control), and MDPQ score (trial patients had higher mobile device proficiency) (Table 1). Patient

Discussion

This pragmatic trial aimed to measure the effect of a patient agenda website on consultation outcomes. For the primary outcome, there was no difference in patient satisfaction between arms. There was a possible ceiling effect as most patients were already satisfied with their care with scores for both arms skewed towards the upper limit of HCPPC scores which contrasts previous studies reporting low satisfaction levels [14] and poor doctor communication skills [15] in Malaysian outpatient

Acknowledgements

YKL, CJN, AMTF, PYL, AA, TKC and CL were involved in the design of the study. YKL, MRS, KK, AMY, and AMZ were involved in developing the VISIT website and EMR integration. MRS, YKL and AMTF were involved in the recruitment and data collection for the study. YKL, MRS, CJN, AMTF, PYL, AA, and TKC were involved in the analysis of the data. All authors reviewed and approved the manuscript for publication. Syazwina binti Mohamed Reza, Syahrir bin Zaini, Mohammad Najmi bin Mohammad Sazali and Nurul

Funding

This work was supported by the University of Malaya Faculty Research Grant (Grant number GPF006C-2018).

References (20)

  • F. Légaré et al.

    Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals' perceptions

    Patient Educ. Couns.

    (2008)
  • Y.K. Lee et al.

    Factors associated with level of shared decision making in Malaysian primary care consultations

    Patient Educ. Couns.

    (2020)
  • C. Charles, A. Gafni, T. Whelan, Shared decision-making in the medical encounter: what does it mean? (or it takes at...
  • A.G. Mulley et al.

    Stop the silent misdiagnosis: patients’ preferences matter

    BMJ: Br. Med. J.

    (2012)
  • J. Frost et al.

    Does a simple web-based intervention facilitate the articulation of patients' unvoiced agenda for a consultation with their diabetologists? A qualitative study

    BMJ Open

    (2019)
  • J.F. Middleton et al.

    Effect of patient completed agenda forms and doctors' education about the agenda on the outcome of consultations: randomised controlled trial

    BMJ

    (2006)
  • M. McLean et al.

    Eliciting patients' concerns: a randomised controlled trial of different approaches by the doctor

    Br. J. Gen. Pract.

    (2004)
  • Y.K. Lee et al.

    Addressing unmet needs of patients with chronic diseases: impact of the VISIT website during consultations

    J. Eval. Clin. Pract.

    (2017)
  • Y.K. Lee et al.

    Exploring patient values in medical decision making: a qualitative study

    PLoS ONE

    (2013)
  • Y.K. Lee, C.J. Ng, W.Y. Low, N. Atikah, K. Khaizura, M.A. Mohd Abrar, Pilot testing an innovative approach to identify...
There are more references available in the full text version of this article.
View full text