Protecting healing relationships in the age of electronic health records: report from an international conference

Abstract We present findings of an international conference of diverse participants exploring the influence of electronic health records (EHRs) on the patient–practitioner relationship. Attendees united around a belief in the primacy of this relationship and the importance of undistracted attention. They explored administrative, regulatory, and financial requirements that have guided United States (US) EHR design and challenged patient-care documentation, usability, user satisfaction, interconnectivity, and data sharing. The United States experience was contrasted with those of other nations, many of which have prioritized patient-care documentation rather than billing requirements and experienced high user satisfaction. Conference participants examined educational methods to teach diverse learners effective patient-centered EHR use, including alternative models of care delivery and documentation, and explored novel ways to involve patients as healthcare partners like health-data uploading, chart co-creation, shared practitioner notes, applications, and telehealth. Future best practices must preserve human relationships, while building an effective patient–practitioner (or team)-EHR triad.


INTRODUCTION AND CONFERENCE DESIGN
The electronic health record (EHR) has profoundly influenced the practice of medicine and patient-practitioner interactions in clinical settings. 1,2 Alongside benefits of consolidated patient records, improved communication, and ability to address population health have come unintended consequences, including challenges to the patient-practitioner relationship [3][4][5][6][7] and, in the United States, a precipitous decline in clinician wellbeing and professional satisfaction. [8][9][10][11] In March 2017, 160 patients, practitioners, educators, technology designers and vendors, government officials, patient advocates, and healthcare stakeholders from the United States and 6 industrialized nations (Canada, United Kingdom, Denmark, Portu-gal, Israel, and Australia) gathered at The Warren Alpert Medical School of Brown University to explore this pressing topic. Practitioners included physicians, nurses, nurse practitioners, and mental health professionals; medical students, and residents also participated. There were plenary sessions, TED-style talks, symposia, research papers, posters, and digital demonstrations. Conference leaders invited experts, distributed email requests for submissions, and advertised this open conference through mailings, LISTSERVs, social media, and word of mouth. Presenters comprised about half the attendees. International participants were invited because non-US practitioners have had longer and generally more positive EHR experiences than many in the United States. This article summarizes conference conclusions. 12

THE VALUE OF THE PATIENT-PRACTITIONER RELATIONSHIP
Patients and practitioners expressed remarkably similar wishes for relationship-based care as technology advances, underscoring the central elements of constructive patient-practitioner interactions. 13,14 Both groups want time and space to rekindle or establish trusting relationships, receive or offer eye contact and full attention, 2,3,13-17 and be heard or engage in careful listening. 1,2 Patients want to be known as individuals who have valuable firsthand knowledge of their health experiences. Practitioners want to be respected for medical expertise and technical skills but recognized as having human limitations, especially when grappling with healthcare system challenges. Both groups believe clinical encounters should be about patient care and not its documentation.

EHR BENEFITS TO PATIENTS AND PRACTITIONERS
Patients praised many EHR features, noting that records do not get lost, are accessible from anywhere, and allow patients to participate in their own care by using portals to schedule appointments, review test results, and communicate with practices. Patients imagine contributing further to their EHRs by uploading health materials, creating personalized biographies, 18 reviewing practitioners' notes, 19 and even co-creating notes. Practitioners value EHRs for their legibility, accessibility, consolidated health information, embedded references, decision support, and potential to enhance patient education and understanding.

EHR CHALLENGES TO THE PATIENT-PRACTITIONER RELATIONSHIP
Many challenges have accompanied the rapid introduction of EHRs into clinical care. Managing the volume of information and juggling the complexities of patient needs and EHR systems, while recording care that justifies reimbursement has overwhelmed US practitioners. 11,16,20,21 Longer workdays, work after work, more time spent documenting care and completing administrative tasks than face-to-face with patients, and fewer patients seen have left both patients and practitioners feeling that people often play second fiddle to computers. [8][9][10][11]13,15,16,[20][21][22][23][24][25][26][27] Both groups described a distressing decrease in human connections and meaningful interactions. 2,[20][21][22][23][24] They worry about patient privacy and confidentiality. [4][5][6]13,28,29 These trends have contributed significantly to the EHR's implication in US practitioner burnout. [8][9][10][11]21,23,26,27,30 Roll-out challenges Conference participants noted that the EHR was introduced into traditional ways of conducting care before rethinking roles, tasks, workflow, workloads, and redundancy. They observed that change is difficult. Implementing untested systems and integrating new tools before having confidence in them is stressful, particularly when patient health is at stake. Furthermore, new systems reveal hidden flaws, for example, poorly controlled patients lost to care. They also present unforeseen challenges like balancing improved access to patient records with maintaining confidentiality [4][5][6]28,29 or leveraging tools such as templates and copy and paste while creating useful and ethical documentation. 4,13,14 Design and vendor challenges The US designers and vendors of small and large EHRs described challenges of designing effective EHRs and interconnected systems. The absence of national standards in areas like preventive measures and laboratory results present additional hurdles. 4,31,32 Regulations imposed by institutions fearing data breaches and subsequent penalties further challenge interoperability and data access, 32,33 as has the open market of the past decade, which led to the emergence of hundreds of companies creating a variety of propriety and open source products. 31,34 The financial burden of designing software to meet changing guidelines such as meaningful use has hampered competition by smaller, innovative companies. Ultimately, however, fewer dominant EHRs may facilitate interoperability.

Government challenges
Government presenters described accountability to tax payers and legislators, and the herculean task of developing programs to move health information technology ahead in US regions with vastly different population densities, demographics, geographies, and technological maturity. They described listening to patients' and practitioners' needs when devising statewide initiatives such as Colorado's telehealth bill and Vermont's improved broadband access initiative, as well as current federal legislative mandates like accountable care, interconnectivity, and data accessibility.

OBSERVATIONS FROM OTHER NATIONS
International attendees recounted stories from their national and personal EHR experiences. While anecdotal, their reports offered valuable opportunities for sharing insights and collaborative reflection. An Australian participant described the pain of rolling out health information technology infrastructure and adopting EHRs in his nation, but noted that patients welcomed EHRs, believing it would be difficult to practice modern medicine without a computer. A Danish presenter elucidated his government's well-regarded EHR used in all facilities of their single-payer health system, allowing clinicians easy access to patient records and clinical data to feed directly into national population and public health research and policy development. 35 A participant from Portugal described that nation's creation of a similar comprehensive infrastructure, but its progression to a more siloed and less streamlined system because of inconsistent internet access and the establishment of parallel infrastructures for e-prescribing, death records, and epidemiology.
In the United Kingdom, EHRs initially designed by family physicians for patient care have been deployed on a national scale and are well liked and trusted. Anecdotally, as US EHRs have been imported for inpatient use, UK hospitals face some of the same challenges to efficiency and overdocumentation as US users of the same products.
In Israel, EHRs also designed around patient care require many fewer clicks for prescribing, writing orders, and documenting than their US counterparts. Billing is separated from the EHR. Israel's 12 major health systems, including the Israeli Defense Forces, have successfully interconnected their EHRs, with data based in each home institution but accessible within seconds from any other system. 36 Thus far there have been no breaches.
A Canadian speaker described innovative efforts to help patients with complex medical problems set visit agendas directly into the EHR. 37 A UK presenter described a pioneering program in Bangladesh connecting patients to primary and specialty care when signing up for banking.
Perhaps the most striking feature noted by international presenters was that their countries' EHRs were designed to record patient care; interestingly, clinical notes are, on average, 4 times shorter than US notes. 27

SUGGESTED SOLUTIONS
While identifying current challenges to the patient-practitioner relationship, conference attendees expressed the need to move toward a constructive triad of patient-practitioner-computer, or patient-healthcare team-computer in coming years. 38,39 Diverse solutions were explored, encouraging all to imagine others.

Education
Education was cited as a critical component of all solutions. Complex EHR skills require time and effort to master and must be balanced with other medical and systems knowledge clinicians need to learn for their daily work. Institutions must commit time and resources to robust initial and ongoing education of all medical professionals, whether at the outset of training or employment or in midcareer, taking into consideration diverse backgrounds, technological skills, and trends toward inter-professional team care. While software subtleties may allow for more efficiency, users need training and practice in these areas, too, including effective use of embedded EHR feedback tools. 40 Most importantly, education should focus on effective EHR use during encounters to strengthen rather than detract from patientpractitioner communication. 1,2 Tips to create patient-centered EHR best practices are shown in Figure 1. 41,42 Optimal use requires personalization, observed evaluation, ongoing feedback, and organizational support. Curricula are being developed at a variety of institutions 43   selectively employing time-saving tools like voice-to-text, text-forward, and templates. 13,53 Rethinking documentation It is time to reconsider the components of a well-crafted note as past information is accessible in the EHR. Conference attendees spoke about filtering information to meet clinician needs; tailoring the style of notes to fit their clinical purposes such as preventive, chronic care, consult, or community based care; and choosing the form that best conveys information. The imperative to separate billing from extent of documentation was noted throughout the meeting. 53 Until ordering and documenting become more streamlined in US EHRs, it is not realistic-for patients who need full attention or clinicians who are more likely to make mistakes when multi-tasking 3,20,53,54 -to expect clinicians to document fully while attending to patients or for hours at night. [8][9][10][11] Rather, trained scribes or team members co-managing the visit should be documenting. 55,56 This may change when EHR charting becomes simpler and features like dictation, virtual assistants, and natural language processing improve. 57

EHR design
Attendees stressed the need for clinicians and designers to share ongoing front-line experiences and communication. 20 For example, streamlined software will allow nurses to enter data in real time rather than copying handwritten logs, and smaller devices can facilitate bedside nursing care while entering data. 58,59 Rethinking job descriptions and workflow The EHR affords us the opportunity to re-evaluate our work and who does it, improve efficiency, reduce redundancy, and commit to restoring and protecting human interactions between patients and practitioners and among medical professionals. All are integral to excellent patient care and professional satisfaction. Suggested EHR design improvements to support optimal patient care are shown in Table 2.
Lean principles of industrial engineering can help design workplaces to maximize teamwork, 65 streamline patients' movement through care, and utilize EHRs to support and educate. [42][43][44][45][46][47][48][49][50][51] As shown in Table 2, the healthcare team works as a unit according to lean principles with tasks allocated at the level of training; all help document. Many clinical settings still rely on paper for reviewing past care, completing forms, and faxing information. When EHR functions, graphics, and information display become more userfriendly, this work can be done once using the computer. 66 Reimagined care delivery includes teams of medical professionals maximizing their training and skills to support patients and one another. 56,61,62 The patient as team member Patients are indispensable team members who can serve as valuable data providers. 67 This can be achieved by expanding portal functions to enable patients to initiate visit documentation from home or on devices at the point of care. Patients can update demographic,

Tailor information presentation
• Present timeline with filterable displays of symptoms, labs, treatments, and responses • Embed visualization of data using pictures, graphs, tables, or formats most helpful to user 53,58 Match data entry modality with task • Include typing, voice-to-text, and dictating • Use artificial intelligence to extract text via natural language processing, select information from a list by mouse-click or touch screen, or record a photo, video, or sketch 53,57 Tailor note design to encounter type • Straightforward acute-problem visits (eg, urinary tract infection, pharyngitis), template pre-populated by patient • Complex visits note design (eg, diagnostic dilemma, multiple chronic problems): combine unique patient narrative, standard text blocks for routine actions (eg, calculating cardiovascular or surgical risk with display for patient teaching), facilitate history and data synthesis, enhance clinical decision-making (including graphic display), and a brief summation of key findings Use virtual assistants • To search, retrieve, and apply information like retrieving a previous test, creating referrals (that also forward prescriptions and print out preprocedure instructions), calculating risk profile automatically using chart data, or presenting decision-support tools 57,58 Use EHR to educate • Use patient's results and images to explain symptoms • Share internet materials, smart phone applications, Bluetooth technology, photography and videography for communication, shared decision-making tools, and data analysis • Cocreate office notes Protect patient confidentiality • Create confidential tab organized as medical history that can be addended over time, accessible only to patient and practitioners (cannot be forwarded) 53 Embrace patient contribution 67 (eg, screening, visit agenda 37 , updated personal data and biographies 18 ) • Enable patients to become data providers • Offer robust patient portals for secure messaging, requesting prescription refills, appointment scheduling, accessing test results and clinical notes, and reviewing medications, problem lists, and care plans for completeness and accuracy • Allow bidirectional data sharing remotely and at point of care (eg, screening, visit agenda, updated personal data and biographies) Facilitate meaningful documentation • Meld different styles of recording-prose, checklists, templates-that encourage modification to unique situation 53 Improve interoperability and data sharing • Advance standardization of data presentation 31 • Discourage data blocking 32,33 • Consider a single national EHR Workflow improvement Previsit preparation Staff oversees: • Completion of labs and tests • Requesting patients enter biographical information and complete appropriate screening (eg, mental health, health disparities), and start visit agenda • Identify care gaps (immunizations, age-based screening tests, follow-up for previous problems) • Team huddles Task reallocation ("Lean" concept) a • Recognize physician, nurse, and staff time and attention as precious and costly resources • Reallocate tasks to match professional training, decrease physician administrative burden, and diminish distraction Additional staff • Enter, review, and manage EHR data, complete order entry, and communicate with patients between visits; can include scribes 55,60 or clinical team coordinators 61,62 • Some models describe 2-3 coprofessionals (eg, medical assistants, nurses, pharmacists) per physician 61,62 Reduce administrative burden 11,30 • Dedicate time during normal hours to address administrative tasks (continued) insurance, and biographical information, 18 or review EHR data and set visit agendas. 37,53 The OpenNotes project has pioneered promoting patient access to their clinical notes, including behavioral health notes 68,69 ; remaining challenges include maintaining adolescent and parent confidentiality 6,29 , and practitioner perceptions that sharing notes impacts full discussions of clinical thinking, differential diagnoses, and psychosocial issues. 68,70 Interestingly, patients and practitioners have expressed overall satisfaction with shared notes, finding them respectful and communicative, and patients are better able to adhere to recommendations when they review the thinking behind them. 19,69 Patients also identify and correct errors in their records. 19,69 Patients have begun sharing photos and videos with clinicians on their smart phones; these can be uploaded into their records-first steps toward having patients co-create documentation. One can imagine a future in which a personal health record belongs to the patient, who shares data with practitioners and institutions, generating care centered around shared decisions, clear communication, and consideration of the patient's life outside the medical system.

New technologies
Many ideas were shared among participants across disciplines regarding new technologies. For example, SMS texting is a powerful tool to remind patients about appointments, support behavior modification, 71 and communicate information. So too, applications ("Apps") can help patients manage health issues like dietary change, asthma, 72 diabetes, 73 menstrual cycles, and anxiety. Some are employed by patients on their own, while others transmit data to practitioners for review. Patients and practitioners need guidance in sorting through the many available products to be confident that apps advance patient health and support clinical care with manageable data loads. Telehealth also holds great promise to connect patients, practitioners, and family members when geographical, medical, and psychological barriers prevent in-person visits. 74

SUMMARY
Participants at this groundbreaking conference valued hearing the aspirations, challenges, and perspectives of a diverse group of attendees. They remained committed to protecting the patient-practitioner relationship as the foundation of excellent care and patient and practitioner satisfaction in this age of advancing health information technology. International colleagues demonstrated the value of EHRs with documentation centered around clinical care, seamless interoperability, and prompt data access for patient care and population health. The US attendees were challenged to find ways to decrease clicks, screen shifts, and excessive documentation and improve interconnectivity and data sharing. Conference attendees highlighted the importance of ongoing communication and advocacy by all to ensure a future medical system that preserves the healing power of human relationships, while harnessing the tremendous potential of health information technology to improve medical care and health.
Two commercial products are mentioned in the references.