Parent Perspectives in Shared Decision-Making for Children With Medical Complexity.

OBJECTIVE: Shared decision-making (SDM) may improve outcomes for children with medical complexity (CMC). CMC have lower rates of SDM than other children, but little is known about how to improve SDM for CMC. The objective of this study is to describe parent perspectives of SDM for CMC and identify opportunities to improve elements of SDM specific to this vulnerable population. METHODS: Interviews with parents of CMC explored SDM preferences and experiences. Eligible parents were ≥18 years old, English- or Spanish-speaking, with a CMC <12 years old. Interviews were recorded, transcribed, and analyzed by independent coders for shared themes using modified grounded theory. Codes were developed using an iterative process, beginning with open-coding of a subset of transcripts followed by discussion with all team members, and distillation into preliminary codes. Subsequent coding reviews were conducted until no new themes emerged and existing themes were fully explored. RESULTS: We conducted interviews with 32 parents (27 in English, mean parent age 34 years, standard deviation = 7; mean child age 4 years, standard deviation = 4; 50% with household income <$50,000, 47% with low health literacy) in inpatient and outpatient settings. Three categories of themes emerged: participant, knowledge, and context. Key opportunities to improve SDM included: providing a shared decision timeline, purposefully integrating patient preferences and values, and addressing uncertainty in decisions. CONCLUSION: Our results provide insight into parent experiences with SDM for CMC. We identified unique opportunities to improve SDM for CMC that will inform future research and interventions to improve SDM for CMC.

Assessing EHR use during hospital morning rounds: A multi-faceted study.

BACKGROUND: The majority of U.S hospitals have implemented electronic health records (EHRs). While the benefits of EHRs have been widely touted, little is known about their effects on inpatient care, including how well they meet workflow needs and support care. OBJECTIVE: Assess the extent to which EHRs support care team workflow during hospital morning rounds. DESIGN: We applied a mixed-method approach including observations of care teams during morning rounds, semi-structured interviews and an electronic survey of hospital inpatient clinicians. Structured field notes taken during observations were used to identify workflow patterns for analysis. We applied a grounded theory approach to extract emerging themes from interview transcripts and used SPSS Statistics 24 to analyze survey responses. SETTING: Medical units at a major teaching hospital in New England. RESULTS: Data triangulation across the three analyses yielded four main findings: (1) a high degree of variance in the ways care teams use EHRs during morning rounds. (2) Pervasive use of workarounds at critical points of care (3) EHRs are not used for information sharing and frequently impede intra-care team communication. (4) System design and hospital room settings do not adequately support care team workflow. CONCLUSIONS: Gaps between EHR design and the functionality needed in the complex inpatient environment result in lack of standardized workflows, extensive use of workarounds and team communication issues. These issues pose a threat to patient safety and quality of care. Possible solutions need to include improvements in EHR design, care team training and changes to the hospital room setting.

Enhancing patient-doctor-computer communication in primary care: towards measurement construction.

OBJECTIVE: The traditional dyadic dynamics of the medical encounter has been altered into a triadic relationship by introducing the computer into the examination room. This study defines Patient-Doctor-Computer Communication (PDCC) as a new construct and provides an initial validation process of an instrument for assessing PDCC in the computerized exam room: the e-SEGUE. MATERIAL AND METHODS: Based on the existing literature, a new construct, PDCC, is defined as the physician's ability to provide patient-centered care while using the computer during the medical encounter. This study elucidates 27 PDCC-related behaviors from the relevant literature and state of the art models of PDCC. These were embedded in the SEGUE communication assessment framework to form the e-SEGUE, a communication skills assessment tool that integrates computer-related communication skills. Based on Mackenzie et al.'s methodological approach of measurement construction, we conducted a two-phased content validity analysis by a general and expert panels of the PDCC behaviors represented in the e-SEGUE. This study was carried out in an environment where EMR use is universal and fully integrated in the physicians' workflow. RESULTS: The panels consisted of medical students, residents, primary care physicians, healthcare leaders and faculty of medicine members, who rated and provided input regarding the 27 behaviors. Overall, results show high level of agreement with 23 PDCC-related behaviors. CONCLUSION: The PDCC instrument developed in this study, the e-SEGUE, fared well in a rigorous, albeit initial, validation process has a unique potential for training and enhancing patient-doctor communication (PDC) in the computerized examination room pending further development.

Existing instruments for assessing physician communication skills: are they valid in a computerized setting?

OBJECTIVES: This study aims to highlight the differences in physicians' scores on two communication assessment tools: the SEGUE and an EMR-specific communication skills checklist. The first tool ignores the presence of the EMR in the exam room and the second, though not formally validated, rather focuses on it. METHODS: We use the Wilcoxon Signed Ranks Test to compare physicians' scores on each of the tools during 16 simulated medical encounters that were rated by two different raters. RESULTS: Results show a significant difference between physicians' scores on each tool (z=-3.519, p<0.05 for the first rater, and z=-3.521, p<0.05 for the second rater), while scores on the EMR-specific communication skills checklist were significantly and consistently lower. CONCLUSION: These results imply that current communication assessment tools that do not incorporate items that are relevant for communication tasks during EMR use may produce inaccurate results. PRACTICE IMPLICATIONS: We therefore suggest that a new instrument, possibly an extension of existing ones, should be developed and empirically validated.