 Good afternoon. On behalf of the McLean Center and the Center for Health and Social Sciences and the Bucksburg Institute, David Meltzer and I are delighted to welcome you to today's lecture in the series on the present and future of the doctor-patient relationship. I'm delighted to introduce our speaker today, Dr. Wei Wei Li. Dr. Li is the assistant dean of students at Pritzker and an associate professor of medicine in the general medicine section. She earned her medical degree from New York University School of Medicine and a master's of public health from the Harvard School of Public Health. Upon receiving her medical degree, Dr. Li completed her residency in internal medicine at New York Presbyterian Hospital, Wild Cornell, where she served also as chief resident. At Pritzker, Dr. Li is the director of the Wellness Initiative and leads programs to improve physician and trainee well-being. As I said, Dr. Li is a primary care physician, a researcher, an educator, a national expert on the intersection of technology, patient experience, and physician well-being. She's written many papers in this area. I'll give you one example, a paper called Patient Perceptions of Electronic Medical Record Used by Faculty and Resident Physicians, a mixed-method study published a few years ago in the Journal of General Internal Medicine. In 2016, Dr. Li was one of the three faculty here at the university to be appointed as a Bucksbaum Institute Junior Faculty Scholar. She was selected for her dedication to patient care, collaborative decision-making, and clinical excellence. In addition, Dr. Wei Wei Li is a fellow of the Academy of Distinguished Medical Educators. Today, Dr. Li's talk is entitled, You, Me, and the Computer Make Three, The Doctor, Patient Relationship, and Electronic Medical Record. Join me in giving a warm welcome to Dr. Wei Wei Li. Thank you. Excellent. Can you hear me in the back? Yes? Excellent. Let me... Oh, no. Can you hear me now? Better? All right. So thank you, Mark, for that really kind introduction. I'm excited to be here today to talk a little bit about the research that I've been doing on the impact of EHR use on the patient-doctor relationship. And this is a topic that is near and dear to my heart. As Dr. Siegler mentioned, I am a primary care doctor, so I spend a lot of my work week in a patient room, face-to-face with the patient in the clinic, right? And I use that term face-to-face because I think there's a real tension in that. You know, the time I'm in the room with the patient, I'm also trying to manage the work that I'm doing in the EHR, right? Putting in the orders, reviewing the chart, and then documenting the notes that I don't leave the clinic day with, you know, 20 notes I need to finish at the end of the day, right? So that dilemma and that tension between paying attention and focusing and connecting and engaging with the patient in the room and being pulled away by the demands of the EHR are really what spurred me to kind of take a look into this as a research question. So I actually want to start off and set the stage. We're gonna watch this short video, which I'll start right now. Honey, look. He's playing doctor. Mm-hmm. How's it going, doc? Yeah. That's doctor, all right. We better leave him to it. So that's a funny little clip. That's actually part of a commercial for one of the EHR vendors out there, but I think it really does encapsulate a kernel of truth there, right? Our concern as physicians, that maybe we are paying more attention to that screen than the human being who's here to seek out our care in the clinic room, right? So let's dig a little bit deeper into that question. So what is the impact of EHR use on the patient-doctor relationship? So to help us answer that question, I do what most of our patients do when they have a question. I turn to Google, right? So let's go ahead and see what Google has to say about that. I put in the search terms electronic health record and patient-doctor relationship, right? And on that first page of hits, what I actually saw was that there were many pieces and articles that were written about the impact of that relationship, but actually most of it skewed negative, right? So let me share with you one article. This is one that was written by Danielle O'Frey and she is an internist at NYU and also does a lot of writing in the New York Times and has written several books. And she has a racy title to hers, right? The EHR has changed the doctor-patient duet into a menage-tois. And this is really, you know, she writes about that erosion of the patient-doctor relationship and communication. So she talks about doctors these days wrestling with the computer while the patient gazes at the supply cabinet. And she talks about her efforts to maintain eye contact, but she finds that it's really almost impossible with what she has to do with the EHR to get through her day, right? So, you know, she has written a couple of thought pieces about this type of work. Also, another, you know, sort of article or link that showed up on that Google hit was this recent survey conducted by Stanford Health, Stanford Medicine and Harris Poll, where they surveyed primary care doctors, right? And one of the main findings around how doctors feel about the EHR was that they felt that the time they spent in the electronic medical record was having a potentially negative impact on their patient, right? And that they were spending more time in the EHR than they were with the patient. And about 70% of those doctors surveyed reported that the EHR increased the total number of hours that they were working, that it was contributing to burnout, and that using the EHR takes valuable time away from their patients, right? So, you know, there's, you know, Google is helping us identify some of the top themes that are rising up around this topic. Then there are other articles like this that come up, right? This is written by Atul Gawande, and this was published in The New Yorker, and the title also is a little provocative, right? Why doctors hate their computers. And, you know, I think this really gets to the heart of when EHR was rolled out, when we, you know, had, you know, the incentives to try and make sure we're digitizing medical care, there was a lot of promise, and, you know, promises to the profession and to patients that would increase efficiency and make things better in many ways. And in many ways it has, right? But he, you know, Atul Gawande also posed the question, are screens coming between doctors and patients? So what I wanna talk to you guys today about is, we'll move a little bit away from Google and we'll talk more about some of the research that's been done on EHR use and patient-doctor relationship. I really hope that you guys will walk away with some positive spin on this, about how we can integrate this technology that is here to stay, and in a way that we can actually use the EHR as a tool to engage our patients. And for us, I think, to really think about engaging our patients as partners, how can we empower our patients to help us engage better with the EHR when they're in the room with us? So I think in order to get an understanding of the impact of EHR use on patient-doctor relationship, we need to understand, well, what is the scope of the problem? How much are physicians actually using the EHR? And luckily yesterday in the Annals of Internal Medicine, there was a paper published on this, right? So you can get to see any from this. So this was published, and the title was Physician Time Spent Using the EHR During Outpatient Encounters. And this was quite a large study. This study included 100 million patient encounters from 155,000 physicians from 417 health systems. And the physicians here were using the CERNR EHR system. Okay? And so what they found was that the average time physician spent per patient encounter in the EHR was 16 minutes and 14 seconds, okay? So you can do the math and multiply that by the number of patients that you see in a typical day in your clinical practice. And that'll give you a sense of the amount of actual EHR work that's really contributing to that patient care. So let me ask you guys, so there's, you know, a range in these means, right? Of the times that physicians spend in the EHR per encounter, which specialties you think might have the higher end of that as far as spending more time in the EHR per patient encounter? Any thoughts? Primary care. Primary care. Any other thoughts? Radiology. Radiology, interesting. Other thoughts? Oncology, excellent. Okay, and what do you think the fields might be that maybe spend a lower amount of time on average in the EHR? Surgery, okay. Anything else? Psychiatry. So let's take a look. So I thought this is an interesting kind of piece of that as well. Highest meantime, 18 to 22 minutes from our gerontologists, right? Endocrine was spending some amount of time in the EHR, primary care, and internal medicine fields, right? The lowest meantime was actually the sports medicine, okay, and PM and R. So, you know, we can see that there was quite a lot of variation, obviously, in this data that they were able to find, but this is really the most comprehensive study out there to date, as of yesterday, about the time that really is involved with EHR use and patient-doctor interactions and communication and time spent. So let's think about this a little bit more, right? So, when we started off looking at this research question, 2012, 2013, our healthcare system here in the outpatient clinic was actually just rolling out the epic in our clinical practice. And we wanted to really understand, well, what is the impact? How can we expect to know what the repercussions are gonna be for EHR use and patient-doctor communication? And what we actually found was that we took a look at the literature, and there really wasn't a systematic review that took a look at this information. So we decided to go forth, and our first research question was, let's take a look at the literature and see what we can draw from the studies that have been done. So, a good number of these studies that we included in the review were actually observational studies. So these were studies where the researchers put a camera in an exam room and watched patients and doctors interact while they use the EHR, right? And then they had the researchers then code the different behaviors and sort of note what it is that happened during that encounter. So what was uncovered was that there was a lot of behaviors that detracted away from patient-doctor communication and relationship, right? They saw through these video studies that the physicians often had their back to the patients. Poor eye contact definitely results from that, right? When docs are looking up information in the health record, there could be long silences. And hence, Danielle O'Fries talking about patients staring off at the cabinets, right? The screen is often not visible to the patient, so there's not a lot of transparency in what the doctor is doing in the chart. When patients were bringing up sensitive topics during the visit, the physician could be seen typing in the computer, so doing work that doesn't signal that they are fully engaged in what the patient is saying. And then there's this idea of computer-guided questioning, right? This is sort of not having a human-level conversation with a patient in an exam room. It's more using like a checklist to make sure that your view systems of back pain is sort of covered, right? So these were some of the concerns that sort of came up along the way as far as behaviors that could impede patient-doctor relationship and communication. It wasn't all that though, right? A lot of these video studies actually showed positive behaviors that could help improve patient-doctor relationship. And some of them were just, you know, physicians who were very intentional about sharing the screen and inviting the patients in to engage in understanding their trends over time by, you know, graphing results or wage or BMI, really incorporating the tools that are built in to our EHRs, things like shared decision-making tools to help people better understand what their treatment options and what might be a good fit for them and their values, right? The simple act of explaining what you're doing while you're doing it, so talking out loud so you avoid some of those awkward silences that happen when you're looking for material and information in the chart, and then really proactively using that computer-engaged patients, right? But I also wanna go back to our central question for the systematic literature review, which was taking a look at, you know, what can we glean from the research that's been done already on this topic? And I want you to remember, we did this study starting in 2012, 2013. So we were looking backwards in the literature at EHR use and patient-doctor relationship. And this was really before the widespread, you know, massive adoption of EHR. And right now in the US, we are at adoption rates in outpatient clinics well above 90, 95%, right? The error that these studies were done in was really much more in the sort of beginning of the integration of EHR. So there's still, I think, a lot more that we can probably learn from taking a look at the recent literature on this as well. But as far as our studies concerned, we included 53 studies that met our inclusion criteria. And we were really interested and saw and found that there were only 22 studies out of those that actually evaluated and asked about patient satisfaction with patient-doctor relationship or, you know, communication out of that. And of those, it was actually, there was a neutral impact for the most part. Most of the patient results showed that they felt there was no change in the relationship or communication or that even, you know, five reported a positive impact, right? So there's a little bit of a, you know, kind of dissonance there because a lot of the observations and some of the patient and physician comments and feedback about EHR and interference with communication and relationship wasn't necessarily being reflected in that patient satisfaction piece when you look at the studies. But remember, you know, these are a very small number of studies done before there was, you know, much more widespread use. So this is, take this with a grain of salt, right? So, you know, I thought that was, you know, pretty encouraging to start with. So we decided to then actually dig a little bit deeper and take a look at our own healthcare system here, right? And as I sort of mentioned earlier, 2012 was around the time that we were implementing Epic EHR into our outpatient clinic. And so this was actually a perfect time for us to kind of study our patient perceptions of integration of EHR. So what we were able to do was we interviewed patients of faculty and residents in the primary care clinics or internal medicine residents and asked them a series of questions about the EHR and their relationship and communication, right? And we did this by doing a phone call with patients about a year after the EHR was rolled out. So what did we find, right? Of these 108 interviews that we conducted, we found that, again, overall the patients were non-plussed about it. They told us, you know what, you know, we like the EMR big picture. We love that. It really simplifies some of the clinical functions, right? Patients told us they can see all the notes from the other doctors and they really work together as a team. I love it, right? So they could see the benefit of having an EHR in the clinic by allowing their physicians to work together and have access to information easily. But many of the negative comments that emerged from these interviews that we were able to code were around communication, right? And about physical focus, right? So one patient told us, I mean, I know they are not on Facebook, right? But I don't know what they're doing, right? This idea of transparency being important to our patients is key, right? They wanna know that when you are typing away at the screen there, but you're doing something that's helping them in their patient care and they are really asking for more of that transparency and screen sharing, right? So in thinking about this and looking at the results from the literature review and taking a look at the results from our patient perspective study here, I think what we walked away with was the idea that there's a real gap here. There are some negative behaviors that emerge from the studies of observing patient doctors and EHRs, but there's also a lot of positive behavior that's not being emphasized, not being taught. And there was no curricular training that we were aware of that helped trainees, students, residents and faculty really sort of integrate these best behaviors of communication with EHR. So we set out to develop that, right? And we did that because we wanted to avoid a situation like this, right? So this is an article that was written in 2012 in JAMA as a perspective piece and it's entitled The Cost of Technology, right? So this was actually a drawing that was made by a pediatric patient and the patient gave this to this pediatrician at her next visit, right? And the pediatrician in this case is actually a trainee and a resident who was practicing at Brown at that time who was actually seen as a humanistic role model to many of his colleagues, as someone who was incredibly empathetic, who had really great patient communication skills and patients really loved him. When the resident got this picture, he was devastated, right? Because what do you see here? You see this beautiful child who's in to see her doctor. She's sitting on the exam table there. She's got really awesome, colorful, maybe mermaid dress on, right? Her family's sitting behind her in that purple chair. She's got a younger sibling, maybe a mom there. And then there he is. There's a primary care doctor. What is he doing? What's he doing? He's on the computer. He's got his back to them, right? And she's put him in the position of typing and working furiously away at that computer there, right? So these things are important. These optics are incredibly important to our patients. This is what a child has taken away from her visit with her doctor, who she has a really good relationship with, right? So in thinking about the education opportunities that we can teach these skills, I think we can really think about using those positive findings we found from the literature of you to build these curricula. That also got us to thinking about patient-centered care, right? What does patient-centered care look like in the digital age? And this is the National Academy of Medicine's definition of patient-centered care, right? Care that's respectful and seeing patients as individuals with preferences and values that guide their clinical decisions. How can we as a cadre of physicians and medical educators really think about infusing this into our clinical interactions with our patients, right? And it's important because patient-centered care has been found to improve not just patient satisfaction and adherence to medications, but also health systems factors like resource utilization or cost or risk of litigation, right? So this is an important and timely question for us as a medical education community. So we wanted to move away from the idea that patient-centered care means, you know, docs under devices in the patient, you know, sort of in the middle there as we kind of tend to our EHR work, right? So that got us to really think about this idea of bedside manner, right? So doctors across, you know, many, many years have asked themselves, how is your bedside manner? How is my bedside manner? How do patients feel that I engage with them? How do I communicate with them? How do I connect with my patients? And how do I make them feel, right? When I am seeing them and working with them on their health. So I want you guys to really think about how we interact with doctors and patients, you know, in our modern age. We have a doctor, one of my favorite doctors here from the ER days, and you have a lovely patient, right? In the exam room waiting to see you and having concerns they want to talk about with you together. But you always now these days have an EHR as well, right? So in updating this concept, I really think that we need to ask ourselves, what is your computer side manner, right? So what is it in our day and age in the digital age with EHR use? How patients see you is going to have a lot to do with how well you can navigate the work and the important things you're doing in EHR with the communication and the integration of the patient into that visit and to be able to provide the education that they need on the health conditions and the advice that they have come to seek you out for, right? So the computer side manner becomes an incredibly important concept I think as we move forward in thinking about clinical skills. So from the best practices that we found in the literature review and from some of the work that we'd also done with patient perspectives and taking into account the opportunity to speak with our patients about how we could do it better here in our own clinic, we actually came up with the skeleton for our curriculum, which was based around these best practices that we call the human level. And this really, I think helps us to encapsulate some of the behaviors and the very teachable skills that we can impart on trainees and to challenge ourselves to do better in the exam room, right? You know, it starts off with age, it's just something that is about honoring the golden minute, right? Walking into the exam room and making that completely technology free, right? You greet the patient, you ask what brings them in, you make that human connection with the patient before you even sort of log on to that computer. And then the U is the triangle of a trust piece which really sets you up for success in the exam room. So you wanna be able to make sure that the screen is set up for sharing with your patient. So you wanna put that computer screen in the top of the apex of the triangle where both you and the patient can see it together so you can sort of work together as you're going through the visit, right? And then the other thing is like maximizing patient interaction and then importantly equating yourself with their chart are really important as well. So do your homework, know what you wanna go into that visit talking about so that you're actually prepared to use the tools and the EHR to make that visit efficient and to synthesize what you wanna do as a provider with what needs and ideas and things that your patient wants to talk about at that visit, right? So Nick's the screen really is about when a patient has a sensitive topic that comes up to completely disengage from the computer. Your hands have to come off the keyboard, you have to turn and face them, you have to really signal with your body language that you are attending and listening and with them in that moment, right? And then inviting the patient to look on, make sure you're engaging eye contact. There's some really interesting studies that take a look at physician eye movements and they've actually seen some gender differences in this, you know, where they find that male physicians who are using the computer in the exam room have more of a tendency to just have their eyes sort of stick more to the screen and there's less saccotting sort of back and forth with the eye contact with the patient than sort of female physicians that they've studied on this. So it's just something interesting to think about, right? And then valuing the computer, so not bad mouthing the EHR, right? Because we all know that the EHR is not going away and how do we figure out a way to think about the positive attributes for our patients so that you don't sort of cloud the overall sort of mood of that encounter. And of course, explaining what you're doing, talking out loud, and then logging off the computer so that the patient's information is secure is incredibly important, right? So these are kind of the core pieces that we put together for the curricula that we had and is still ongoing. So the training that we ended up developing was a, started with the medical student curriculum where we started with second year medical students and it was very intentional to start with second year medical students. They are eager and fresh and learning the core concepts of clinical skills and they have not been tainted necessarily by, by watching others do things in a way that may be less than ideal. We want them to kind of start off on the right foot and learn sort of the best practice in the research behind this. So we deliver a one hour lecture in the clinical skills curriculum and then have the medical students engage in a group, ASCII, right? And this is where they are in the role of the physician and they work with a standardized patient and then they have a group of peers that are observing them as well as a faculty preceptor. And in this way, they're getting feedback about their behaviors, about engaging the EHR from both the standardized patient as well as peer observers. So what we found was that the curriculum was very well received, right? There was a significant increase pre and post ASCII of the student's reported level of training knowledge and skills on this topic and close to 100% of them thought this should be required. So something they felt was needed in their curriculum. What was also super interesting was that the first year we did this we actually rolled out the ASCII to our third year students who at that time had received no training and the training was really just that one hour lecture, right? So these third year students were at the end of their clinical year they had done all their clerkships where they had a year long of experiences working with patients in the exam room trying to use the computer all that in real life, right? So we gave those third year students at the end of their third year the same ASCII, okay? And then we wanted to compare the performance with the second year students who received the lecture. And what we found was that the second year students were actually rated higher than the third year students on these behaviors to include the patient, engage the patient with the EHR, right? And that when you took a look at the capstone question the student's ability to use the EMR to enhance patient provider communication. Again, the second year students were rated as being able to do this at a higher level than the second year students. So in building on this, we were able to put together and package our curriculum and publish on MedEd Portal to try and disseminate some of the work and the curricular training we were doing on this. And then the next question we asked, okay, well, let's move up to the next level learner. We wanted to try and talk about the residents and how we can engage the residents in sort of this training and curricula as well. So we started off with internal medicine and pediatrics residents and inserted it into some of their lectures through their noon conferences. But we also wanted to capture a larger audience, right? How do we sort of reach the other residents and fellows who are here at our institution? And there's so many constraints related to the time they have for education. How do we get them all together? They're all in different departments, right? So we were able to partner with our Epic trainers here. So you may all be familiar, right? We, as any new member of an institution, you need to be trained in their electronic health record to be able to use it to provide clinical care. And these trainings are usually quite long. I think the outpatient clinic training is something like four to eight hours, right? So we were able to train the Epic trainers to insert 15 minutes of content on communication skills into this required training. And they were able to roll us out and help us understand whether or not this was helpful for our GME cohort here, right? So in 2015, we were able to train about 160 residents and fellows and interns all across different specialties here at the Medical Center. And about 32 of those participants were in the primary care field. And what we found was that there was also a significant increase in their knowledge of the barriers, best practices and ability to implement these patients under EHR skills. And the vast majority thought that the training was effective, that it should be required, and that it would change their future practice, right? Again, not a perfect study. This is just looking at the impact of a curricular pre and post. The real meat of the matter would be to be able to take a look at some of the patient perceptions and interactions after some of this training is done, and that's something we're hoping to do later down the line, all right? So then we kind of moved on. So we were able to synthesize sizes and sort of publish this. If you want to learn more about it, the article is out there. But the faculty training piece, I think was the last piece we wanted to get at because I think in order to create a culture where EHR use is used in a way that includes the patients and engages them, you really need to focus on faculty training as well, right? So they're able to teach these skills to give feedback in a timely and meaningful way to the trainees. But it's very challenging to do faculty development and sort of CME work around this stuff because it's very labor intensive. So we were able to partner with the Cleveland Clinic to do a study with them as well on faculty training. And we proposed and were able to roll out a study that involved a very short, you know, sort of lunchtime lecture on the best practices and then asked the faculty to do a standardized patient encounter. And we were like, oh my gosh, the faculty are going to hate this, right? Like once the last time a faculty member had to do a standardized patient encounter, might be never, right? But we were really surprised and really pleased to know that at the end of the Oskie training, we had faculty members also do a group Oskie, right? Where they were able to act with a standardized patient and had two or three of their peers observe and give feedback. Faculty loved this. You know, they love seeing their peers in practice and to pick up some tips and tricks and to kind of observe what worked well, what doesn't work well. And this was actually their favorite part of the training which I think was really reassuring. And then we found that again, the faculty reported that their awareness of best practices and barriers really went up. But also, you know, importantly, their ability to teach trainees, they felt much more confident after the faculty development session, right? So beyond that, we began developing more tools around how we can help our trainees learn some of these skills and get feedback. So we developed a direct observation tool that faculty can use with residents or students in the exam room. You know, we have to do this direct observation as part of our medical education oversight of trainees. And so this is a tool that we developed and we're able to validate to use this as a way to give feedback based on that human level mnemonic and best practices, right? So we were able to validate some of this with the video footage that we had of students and students doing oskies and we're able to find that this was a reliable tool to use to measure patients under EHR use. Lastly, we put together a series of CME videos and patient experience videos that are available for free for institutions that wanted to, you know, think about rolling out this type of training for their faculty or students or residents and it's available for free on the doctor's channel and you can sort of see that there's one video where we interview patients about what they, you know, think about their patients using the, their doctors using the EHR and sort of come with some really interesting sort of takeaways from that and then just a overall sort of CME training video that we, people could use for faculty development and resident training. But the last piece I want to talk a little bit about is thinking about awareness, right? And advocacy around patient doctor EHR use and impact on communication and relationship. So this project has been really fun in sort of thinking about how it develops, right? We initially started with medical students, moved on to training for residents, right? And then we're able to do some faculty training here at our institution at Cleveland Clinic but the piece that's left out of this type of thinking and relationship is the patients, right? So we wanted to think about a way to engage our patients and to really empower them to speak up when we are not doing quite as good of a job as we should be doing, right? And to use it and to sort of develop a tool that would be engaging and sort of captivating for our patients. So we were able to work with a really wonderful comic artist who is based out of Northwestern and she helped us sit down and really think about the core things we wanted to communicate via a comic, right? In a way that's fun and colorful and allows patients to kind of be drawn into this idea. So you'll see she helped us actually develop two comics, right? The first comic that you guys see on your left is Computers in the Clinic, Your Role. And this is something that we want to use as a patient education tool. So we summarize our tips for patients through an ABC model, right? A, ask to see the screen. If your provider isn't sharing the screen, it's your right to ask, it's your medical information, right? B, become involved, right? Review your records with your doctor and ask questions, you know, you as a patient can be like, oh, can we just look at our medications and make sure that those are entered correctly or my problem list or, you know, what else has been going on there, right? And then calling for attention. This really gives them the permission to say, hey, you know, Doc, I'm talking about something that's really important to me right now. Can you just focus on me and maybe not do that computer work right now, right? It allows them to empower themselves to ask for the attention that they need in those moments that are critical to them, right? And then you'll see a sort of parallel comic that's on your right here. This was a comic that we developed for the faculty and it's kind of a setup as a scenario of which would you prefer, right? There's a panel, you know, the vertical column on the left and then the column on the right. The one on the left is maybe things that, you know, a way to do things that is not as patient-centered, right? So part of it is really, I'm trying to encourage the physicians to use the EHR to do active chart review with the patient, to review recent labs, look at the A1C trends, help the patient understand patient education resources and do that sort of in the exam room. And so what we did was we were able to take these comics and then study them, right? So for this part of the study, we targeted pediatric faculty and patients as well as internal medicine faculty and patients. And so for the provider perspective, we just put the comic up in the provider workrooms where they have their computers and they were doing their documentation in between visits, right? For the patients, we actually gave the patients the comic right before they saw their doctors. And then that was it. We gave them the comic and said, hey, we have a survey for you to fill out afterwards about if this comic helped you think differently about your encounter and your visit with your doctor, if you did anything differently because of it. And then we asked the subset of those patients if we could call them in about three months to ask if they still remembered the comic and had a lasting impact on them. And what we found was that at the end of the visit, that they had with their doctor after the comic was given to them, the majority of them, 75% reported the comic, encouraged them to be more engaged. And what we thought was really important was that when we took a look at some of the demographic information, we found that Asian American, Hispanic patients, those from a lower educational attainment, and then women were actually more likely to engage in some of the skills that we were advocating on the comic during that clinic visit with their doctor. So they were more likely to ask to see the screen or to call attention to something that they needed to. So I think this could be a very powerful tool for us to think about reaching out to a patient population that maybe has lower health literacy or that is a very short and quick intervention by giving out this comic to really allow them to fully participate in that exam room visit, right? And then for the phone follow-up portion of this, we called the patients three months after they got this comic and said, hey, do you remember this comic? And close to 100% did, about 98%. And most of them were able to recall at least one or two of the ABCs. And we also asked them if they had continued their behavior change, right? Were they continuing to ask to see the screen? Were they using these tools at subsequent doctor's visits they had in the interval? And yes, and the majority of the patients that did also tell us that, that they were continuing to use these skills even after the short intervention of the comic. And then some patient comments, I think were really informative as well. One patient told us the comic was great because I didn't know it was my right to look at the computer, right? I mean, the patients just were not aware that they could ask for that engagement and that level of participation in their care. And then patients often feel like they are rushed and the comic gives them assurance that it's okay to ask questions. And another patient told us, I see some improvements in provider behaviors already, right? And that's really more affording to maybe some of the educational work we're doing with faculty and the comic advocacy we're doing with them as well. So we think that that's sort of a promising avenue to kind of include the patient in that discussion around patient-doctor relationship in EHR. I don't know how many of you have seen this piece in Annals. This is of internal medicine. This is a graphic medicine piece that they have. And this was published a few years back. It's called, they entitled it today's doctor-patient relationship, right? I think any of us who has worked in the hospital or in the clinic with trainees knows that the majority of the time we can find our trainees in that work room in front of a computer screen doing important work, taking care of patients, putting in orders, managing things that need to happen for the patient, right? But this is kind of the reality of what we see a lot on the day-to-day. And I hope today in my conversation and sort of talk about some of the work that I do around EHR use and how we can use that as a tool to engage patients and promote communication and relationship that we can start thinking about how do we turn this tide a little bit, right? And again, remember the studies show that the patients actually are quite neutral and maybe positive to really thinking about how the EHR can help enhance that relationship. So it's a real opportunity, I think for us to, through medical education, through feedback from patients, through patient engagement in this type of work, to be able to improve patient doctor relationship by using the EHR. So, I would say in conclusion, I think what we found through our research journey was that the EHR can be used as a tool to really actively engage patients to allow you to do really meaningful patient education and to connect with your patients if you are able to use the tools in the right way. And that there are best practices from the literature that we can really learn from, that you can integrate easily into curricular and training, and that the important part is not just giving that one-time training, but really being very proactive in your assessment of how you interact with patients and in getting feedback and giving feedback to your trainees about how we can continue to do this better, right? I mean, just remember back to that drawing that was made by that child and the pediatrician, you guys have a real opportunity to shape how your patients perceive you by how you interact with the computer, with them in the exam room. And then lastly, really thinking about our patients as real partners in this, engaging them in a meaningful way in how we are using the EHR. And for me, that often means that I like to document in the room because if I don't write some of my note while I'm there, seeing the patient, that means I go home and I have 12, 20 notes that I need to finish at the end of the day. And I have a really cute four-year-old that I wanna see for dinner when I get home. And he doesn't want me to be on the computer writing my notes, right? So what is the happy medium? How can we get our trainees to really understand that documenting the room is okay? I mean, I feel like it's just gotta be a reality of our practice these days. How do you do that in a way where your patients feel, hey, my doctor's telling me what they're doing. They showed me some of these really cool x-rays I had recently. They talked to me about the cardiology note. They pulled it up. They showed me the side effects of the new medicine. How can we do it in a way that the patients feel like this is a plus, plus for them? It's value added for them. And then also in really thinking about, how is it that we can turn this documentation into something that actually helps us in our patients, right? For me, when I document in the room, I focus on the HPI and the assessment and plan, right? For the HPI, I ask the patient what their concerns are, and I have them talk a little bit about what they wanna talk about. And I'll add that to the promos, and I just take very short bullet point notes about sort of the main points, and then I summarize it. I'm like, okay, so we talked about this, this, and this. And then at the end, when I'm doing the assessment and plan, I use that as another opportunity. Say, hey, I'm gonna write this down, so I know that we're clear on what it is we talked about today. We talked about your blood pressure. Remember, we're gonna stop the M-loader pin today, and have you come back in a month? So I actually go by and write the assessment plan with the patient, and I'll often, we'll just copy and paste that into patient instructions, so that when they leave in Epic, they are printed the summary of what we talked about at the visit when they leave, so that at the end of the visit, they have something that they can take with them to remember what it is we discussed today. So there are ways, I think that we can make the tool work as a way to engage patients and have them remember that interaction is very positive, and I think those are opportunities we can continue to explore. So none of this work could have been possible without my co-investigators, Lelita Alkoreshi in the Pediatrics Department, and Vinya Rohr who's been working with us as our mentor on this project for many years now. And I love this cartoon from the New Yorker. You can't list your iPhone as your primary care physician. I know many patients are out there, and this maybe is the future of technology, who knows, right? The future of patient-doctor relationships. So again, acknowledging the Merritt's Fellowship and funding from the Buxman Institute, which has given a lot of grants to us over the years to continue to study this project. And at this point, asking you guys, if you have any questions I think I can help, answer about this topic, and if you're interested, I'm happy to share any resources that I talked about today. Feel free to email me, reach out to me on Twitter. And I will end there. Are there any questions that I can help answer about this topic? Yeah, of course, David. This is a section to your question. Yes. Any research on how the changing burden of the electronic health record affects things like people falling behind in the notes and burden of the electronic health record? Yes, yeah. I think that's a really important question. There's more and more research that's done on this idea of the impact of EHR on burnout, right? And Chris Sinski at the AMA has done a lot of work on trying to quantify that and study that in a rigorous way. So she's coined this idea of pajama time, right? That's the time that we as physicians spend after hours at our pajamas finishing up our charting and EHR work outside of the regular clinic hours. So I think it would be really meaningful because we do know that patient-doctor relationship and positive interactions with patients can be very protective against burnout. And so trying to understand whether or not engaging and enhancing the ways that patients and doctors interact with EHR could maybe be a mediator in that. And there's not really been too much that's been published on that aspect of it. Yes. Just to follow up David's question, has anybody studied the relationship between the electronic record and the physical examination? Ah, that's a great question. That seems like something Abraham Varghese might have done. It's sort of up his alley. Abraham Varghese at Stanford is sort of well-known for his physical diagnosis, training, and advocacy, but is also a prolific writer. And I don't know if he's actually, he's done some writing on EHR and impact on patient-doctor relationship and what he calls the eye patient. So the eye patient is a term that he coined to refer to the patient that we are taking care of as an icon in the computer screen as opposed to the patient who is sitting in front of us. I don't think he's actually made a direct link between EHR use and physical diagnosis, but that's certainly something that's very interesting, I think, to investigate further. Thanks very much for your talk, it was great. One of the things that I see happening, so I'm in surgery, so one of the workarounds for not spending time on the EHR is to have scribe. Yes. So is this seen as positive or negative? Is there been any assessment about how this impacts patient satisfaction? Yeah, absolutely, so you asked a great question, which was a question we asked ourselves a few years ago as well. And so a lot of the scribe literature that's out there is actually targeting sub-specialties like surgery, emergency room, and then different practices that are not necessarily primary care related. We know from those studies, a lot of those take a look at the economics of it. Is it cost effective? Are we getting our return on investment in having a scribe by allowing the surgeon or the ER doctor to see more patients per clinic session, per ER session, whatever it might be. And the answer is yes, usually it is cost effective when you're thinking about certain specialty fields. But we were actually able to pilot a study in our primary care clinic here of a scribe for five faculty physicians who were working with the scribe over a three month period. And we took a look at both patient and provider satisfaction. It was a study we published last year and it was published in the journal, journal, internal medicine. And what we found was that the patients were totally okay with having a scribe in the room. And that might be because we are an academic institution, right? So they're used to having learners in the room, sometimes residents, lots of bodies in there that are helping with the care team. And so the idea of team-based care is one that I think the scribe model will really sort of continue to add to. But it's just a band-aid, right? Like not every practice is gonna be able to have a scribe to really help them with some of this documentation work. But you know, this is also where the future of technology and the future of the patient-doctor relationship may sort of converge, right? There's a lot of funding going into artificial intelligence, so AI, in being able to maybe like have a Siri-like device listening to your patient encounter and to have that somehow auto-generate into the right field into a note to help you document some of the things that need to be in that note. And I don't think it's science fiction. That research is happening now. But at the same time, you know, it really begs us to ask the question of the EHR, like who are we serving with it and what is it that we need to sort of take back as physicians who are using this on a day-to-day basis to make sure that the patients are front and center and all that. So the scribe question is really important. But again, I still do think that it's probably not a resource available to the majority of physicians who are practicing. And that it is a workaround to a system that's too conky right now. Yes? Do you have a don't want to call their attention to other things with other patient information or other things that they need to find their way onto the screen when they're part of that? That's a great question. That's really important. We don't want to, you know, sort of jeopardize any other patients their health information being secure. But I think that if you get into a habit of practice where you're able to, I mean, I wouldn't say the whole time you're in the visit, you should be like showing them everything that you're doing. But I think there are key times in the visit when you want to do that. And for me, those key times are the HPI where I can actually document and talk to them about that. And then at the end, an assessment and plan where I can summarize and make sure they understood what it is I want them to take away from that visit. And then I'll do it also sort of hodgepodge in between when I'm looking at their, you know, their chart and their labs and whatnot. But I'm also very intentional when I'm in the room and I first log in, I use my tap badge, you know, so I use my tap badge to log into the system so I'm not sort of trying to key in my password and all that. I let that sort of, you know, sort of run while I'm trying to, you know, get acclimated and get to figure out what's been happening to the patients since I last saw them. And then once I'm in the chart, I actually open up their chart first and I just make sure there's no more of those other fields open. But you do have to be intentional about it because, you know, we work in a health system where, you know, many of my patients are employees here. And, you know, you don't want to put the risk for anybody, not just people who work here, but for any of your patients by sharing that inappropriately. But I think it can be done in a safe way. Yes. We have the same documents. Really, Facebook or the soft market or looking at Wikipedia or something that we should have. Yes, Wikipedia, yes. Good question. Yeah, so there's this idea of distracted doctoring. So there's been, you know, there's been perspective pieces written about it and case studies written about it, but there's not really, you know, sort of a definitive research study that takes a look at it more systematically. It was written up in the New York Times, you know, about five or six years back about distracted doctoring. And, you know, they compare it to, you know, distracted driving, right? When you are driving and you're using your, your cell phone and your texting, you're gonna get into an accident, right? This is like a core tenant of like driver's ed, right? And so I feel like seeing patients should be no different, right? Trying the best you can to, again, you know, try and stay as focused and as intentional in the use of the computer as an education tool, as a way to, you know, sort of, you know, provide that level of communication engagement that's meaningful for your patient, I think has to be sort of front and center. There have been some case reports published. The one that comes to mind is one where they talked about a physician, I think it was a trainee, who had gotten a page about, about discontinuing a patient's warfarin medication because they are blood thinner, that's a blood thinner that you have to monitor, you know, a blood test for to make sure it's in the right therapeutic range. If that range is too high, your patient's gonna be at high risk of bleeding. And so this resident had gotten a page about stopping the INR because the, stopping the warfarin medicine because the INR, which is a lab test, was too high. What they found was that the resident started putting in that order, but got distracted and started texting on her cell phone and never got back around to canceling that order and that patient ended up having intracranial bleed. That was a very poor outcome. And so that was actually written up as a case study of like, we need to apply the same tenets that, you know, about patient safety and about distraction and screens in a meaningful way when we're talking to our trainees and in sort of completing tasks. And multitasking in general, we know from the research, it's just not necessarily a safe method. We all think we can do it well, but actually none of us do it very well. So that's a great question. Thank you. Yes. So I already knew that doctors needed you. Yes. They used to learn that patients don't necessarily... They don't, yeah. They need them so much, which was, it's a quite personal experience. Mm-hmm. When I met my doctor, she's buried in her computer. She's buried in her computer, but in the service that you can hear of me, kind of like, you know, my father was never around, but he was supporting the household. Yes. And I'm thinking the interesting... So your work is interesting because it could help patients have a better view of EMRs. Mm-hmm. But maybe even more, I think doctors have a better view of EMRs and giving them less. I hope so. And I think that goes back to, you know, the question around, you know, whether or not like that, if you think about the EHR as an engagement opportunity and a way to connect with the patients, maybe that's a better perspective on it than seeing it as, you know, that huge burden. That, you know, I think it is important that the physician perspective is very negative on the EHR. We know that from the lay literature, from stuff that's published in the newspapers and, you know, opinion pieces and personal experience. But the patients actually are neutral or generally see the potential in it. So I do think that the faculty perspective and the physician perspective, it's one that we can think about shifting a little bit because I think that will overall hopefully improve, you know, the level of care on engagement with our patients. Yeah, Dan. Thank you. That's super interesting. Yeah. Thanks for that question. So Lalita and I have... Dr. Alcourchin and I both try to kind of think about integrating this at a higher level. So we presented at the Epic user group meetings, which is sort of this like bizarre that they have in, you know, Wisconsin where that's like Epic headquarters. And, you know, they have like this conference that has like, it's incredibly attendant and it's really meant to really think about issues like this. So we've had a chance to present there are two or three times now on this topic. It's really hard. Their priority list of things they wanna do is really quite high. But, you know, we are working with the Gold Foundation to really think about ways that we can advocate for this type of integration and focus on communication with patients when the EHR is used. And maybe, you know, who wants another alert in their system, but maybe this is one that is actually like helpful, you know, like maybe once we get a picture of the patients, you know, in the Epic chart, then the picture will pop up occasionally. You'll remember to like go over and look at them or something like who knows. But I think there are ways to nudge physicians to just remember a little more about that eye contact and that body positioning and that kind of stuff. And we're trying to figure out ways at a systems level to kind of integrate this in a meaningful way. And here at the Medical Center, we've been working to kind of roll out the comic at other clinics so that patients can also sort of start getting engaged. You know, we have a speak up program that exists already for patients to be able to bring up any concerns they have on their mind with their doctors and we wanted to make this part of that speak up program. So hopefully you'll see a little more of this as far as on the patient advocacy empowerment piece here in the next few months. Yes. I think a lot of those lines would be relatively simple. I would refer them to the button for like viewing during the patient encounter where your other patient's name is the patient that's going to be here. Yeah, no, that's true. Yeah, so that gets at that HIPAA question of protecting privacy. I do think, so yeah, I mean, I honestly think that there's a lot of role in thinking about not just Epic as that, like, you know, for the clinical enhancement is extremely important, right? We want to make sure first and foremost, our EHR is able to really help us clinically and medically care for our patients. But this is another huge aspect of that, right? Like sort of the ability to use it in a way that is meaningful with patients in the room because that's what the majority of us do. We have to use the EHR in the room with the patient. So I do think there needs to be a parallel, you know, tracking consideration with the EHRs to really think about that. I think more physician input is incredibly important in work like that, especially if it can potentially have an impact on how physicians perceive the EHR and in turn, you know, hopefully continue to nudge how patients are sort of responding to the EHR as a positive tool. Oh, yes. Thank you so much. Oh, you're welcome. Thank you. Thank you, Mark. Thank you.