Connecting the Dots: Evaluating the Use of Graphic Medicine to Empower Patient-Centered Technology Use

BACKGROUND

Tyrone A. Johnson BS1, Jacqueline Nichols BS1, Wei Wei Lee MD MPH2, MK Czerwiec RN MA3, Vineet Arora MD MAPP2, M. Lolita Alkureishi MD FAAP4 1 Pritzker School of Medicine 2Department of General Internal Medicine, University of Chicago 3Center for Medical Humanities & Bioethics, Feinberg School of Medicine,

Northwestern University, 4 Department of Academic Pediatrics, University of Chicago

METHODS

•  Electronic Health Record (EHR) use is ubiquitous in many developed nations worldwide

•  EHR use in the exam room can be detrimental to the patient-doctor relationship

•  Patients may perceive the EHR as an intrusive third party when doctors focus more attention on their devices

•  Providers receive little training on communication skills specific to EHR-related behaviors

•  Prior studies have not assessed if patient-advocacy studies increase patient involvement, engagement, and satisfaction with the EHR

•  Graphic art is shown to be effective in health education

•  Use of graphic comics that advocate for patient-centered technology use may improve how doctors and patients engage with the EMR during office visits

CONCLUSIONS

●  Comics highlighted 3 best-practices for patient-centered EHR use, based on a published systematic review and qualitative patient perception study

●  Parents of patients at the Comer Pediatrics Primary Care Group (PPCG) were approached for inclusion in the study

●  Parents who consented to study were handed the comic with a survey to complete after their visit with provider

●  Willing participants were randomized for selection for a 50-person follow-up phone survey 1-2 months after visit

●  Provider comics were posted in work areas of the Comer Pediatrics Primary Care Group (PPCG)

●  7 PPCG providers took pre-post for perceptions on comic

●  At least 70% (n ≥ 231) of parents rated providers positively in terms of EHR-related communication (Figure 1)

●  Over 50% (n ≥ 158) agreed that provider communication was improved compared to last visit (Figure 2)

●  Over 68% (n = 224) agreed that the comic was effective in encouraging involvement with computer use (Figure 3)

●  Black and Hispanic parents were more likely to ask to see the screen and ask to be involved (p = .023, p = .006)

●  Negative correlation observed between educational status & 4 advocacy behaviors (rs = -0.125 – -0.180], p ≤ 0.04).

●  First study to evaluate the impact of a graphic art intervention on patient and providers’ impressions and behaviors in regards to EHR use in the clinical setting

●  Advocacy comic was effective in encouraging involvement ●  Increase of ratings on follow up indicate an improving

impact of the comic on patient self-advocacy with time ●  Graphic comic may be especially effective in minority and/

or low-to-average education populations

Background References 1Hsu J, Huang J, Fung V, Robertson N, Jimison H, Frankel R. Health Information Technology and Physician-Patient Interactions: Impact of Computers on Communication during Outpatient Primary Care Visits. J Am Med Inform Assoc. 2005;12(4):474–80.

2Ratanawongsa N, Barton JL, Lyles CR, Wu M, Yelin EH, Martinez D, et al. Association Between Clinician Computer Use and Communication with Patients in Safety-Net Clinics. JAMA Intern Med. 2016 Jan 1;176(1):125–8.

3Rose D, Richter LT, Kapustin J. Patient experiences with electronic medical records: Lessons learned. J Am Assoc Nurse Pract. 2014 Dec;26(12):674–80.

4Duke P, Frankel RM, Reis S. How to integrate the electronic health record and patientcentered communication into the medical visit: a skills-based approach. Teach Learn Med. 2013;25(4):358–65.

5Graham-Jones P, Jain SH, Friedman CP, Marcotte L, Blumenthal D. The need to incorporate health information technology into physicians’ education and professional development. Health Aff (Millwood). 2012 Mar;31(3):481–7.

6Alkureishi MA, Lee WW, Lyons M, Press VG, Imam S, Nkansah-Amankra A, et al. Impact of Electronic Medical Record Use on the Patient–Doctor Relationship and Communication: A Systematic Review. J Gen Intern Med. 2016 May;31(5):548–60.

7Lee WW, Alkureishi MA, Ukabiala O, Venable LR, Ngooi SS, Staisiunas DD, et al. Patient Perceptions of Electronic Medical Record Use by Faculty and Resident Physicians: A Mixed Methods Study. J Gen Intern Med. 2016 Nov;31(11):1315–22.

SPECIFIC AIMS 1.  Address negatives of EHR use by using graphic medicine

to educate and empower patients & providers on the best practices of patient-centered computer use

2.  Understand doctors’ and patients’ responses to an advocacy and educational graphic comic

3.  Assess whether exposure to the patient comic changed patient perceptions and behaviors related to EHR use in clinical care

4.  Assess whether the provider comic resulted in improved patient perceptions related to their provider's EHR use in clinical care

5.  Use study results to improve educational materials for maximal parent and provider impact

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

TODAY, our provider...

StronglyAgree(5) Agree(4) Neutral(3) Disagree(2) StronglyDisagree(1)

Made sure we could see the screen

Made sure we could talk face to face

Encouraged Interaction

with computer

Knew when to give full attention to me

Used the computer to educate us

Valued the computer

Compared to LAST TIME w/ same PCP...

StronglyAgree(5) Agree(4) Neutral(3) Disagree(2) StronglyDisagree(1)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

PCP communicated more effectively with us

PCP was less distracted by the computer

We understood more about care b/c of computer use

PCP made better effort to involve us with computer

PCP shared the screen better

More satisfied with our relationship because of how PCP used computer

RESULTS

●  On follow-up, 100% of parents remembered the comic; 42% (n=21) recalled at least one best-practice behavior

●  Significant median increases (p < .001) were seen in self-rated performance of 3 advocacy behaviors (Figure 4)

Because of the COMIC, I...

StronglyAgree(5) Agree(4) Neutral(3) Disagree(2) StronglyDisagree(1)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Asked to see the screen

Asked to be more involved with the computer

Felt more empowered to get involved with computer

Felt more comfortable asking for PCP’s attention

Am more likely to get involved in the future

Think comic is a good way to encourage involvement

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

I F/U I F/U I F/U I F/U I F/U

Asktoseethescreenp<0.001

Bemoreinvolvedp=0.021

CallforaHenIonp<0.001

Empoweredtoget

involvedp<0.001

ComiciseffecIvep=0.056

StronglyAgree(5) Agree(4) Neutral(3) Disagree(2) StronglyDisagree(1)

Comic behaviors & perceptions

*Wilcoxon Signed-Rank

ACKNOWLEDGEMENTS

●  Arnold P. Gold Foundation ●  Bucksbaum Institute for Clinical Excellence ●  Comer Pediatric Primary Care Group Faculty & Staff

RESULTS

●  325 completed surveys (325/417, 78% response) received

Figure 1. Parent ratings of providers’ EHR-related behaviors. The red line at 50% defines the median response value.

Figure 2. Parent ratings of providers’ EHR-related behaviors as compared to last visit. The red line at 50% defines the median response value.

Figure 3. Parent ratings comic’s effect on self-advocacy behaviors. The red line at 50% defines the median response value.

Figure 4. Distribution of ratings on follow-up (F/U) vs. initial survey (I). The red line at 50% defines the median response value.