Health Professionals' Education in the Age of Clinical Information Systems, Mobile Computing and Social Networks

Health Professionals' Education in the Age of Clinical Information Systems, Mobile Computing and Social Networks addresses the challenges posed by information and communication technology to health professionals’ education, and the lessons learned from field experiences and research. This book is divided in three parts: "the changing landscape of information and communication technology in health care", in which it discusses how information and communication technology is transforming health care and the implications of these changes for health professions education; "experiences from the field", with real-life examples of health professionals’ education in and for the digital era; and "evaluation of students and programs", addressing the use of technology to assess learners as well as the complexity of evaluating programs to enhance competence in an information technology-rich health care world

Written by leading researchers from different parts of the world, the book is a valuable source for educators and professionals who are active or wish to be part of the health informatics field.

• Brings an in-depth understanding and background on the challenges for education of the health professions brought by information and communication technology
• Provides real-life examples on how technology is used in healthcare and how it can be used in education
• Presents valuable information in a visually appealing format with tables and figures

• Language: English
• Publisher: Academic Press
• Release date: Jul 26, 2017
• ISBN: 9780128093214

Book preview

Health Professionals’ Education in the Age of Clinical Information Systems, Mobile Computing and Social Networks

Edited by

Aviv Shachak

University of Toronto, Toronto, ON, Canada

Elizabeth M. Borycki

University of Victoria, Victoria, BC, Canada

Shmuel P. Reis

The Hebrew University of Jerusalem, Jerusalem, Israel

Table of Contents

Cover image

Title page

Copyright

List of Contributors

Foreword

Preface

Background

Organization of the Book

References

List of Reviewers

Part I: The Changing Landscape of Information and Communication Technology (ICT) in Health Care: Implications for Health Professionals’ Education

Section I: The Changing Nature of the Patient-Clinician Relationships

Chapter 1. Computers, Patients, and Doctors—Theoretical and Practical Perspectives

Abstract

Introduction

History and Models

The Doctor–Patient Relationship as a Social Interaction

The Triadic Relationship

Implications for Medical Education

References

Chapter 2. What’s All This Silence? Computer-Centered Communication in Patient-Doctor-Computer Communication

Abstract

Introduction

Background

Multitasking Interference and Interruption

Computer-Centered Care

Implications

Discussion and Conclusions

Acknowledgments

References

Chapter 3. Overcoming Health Disparities: The Need for Communication and Cultural Competency Training for Healthcare Providers Practicing Virtually in Rural Areas

Abstract

Telemedicine: An Access to Care Intervention Strategy

Perceived Cost Advantages of Telemedicine

Telemedicine in Rural Areas

Application of Telemedicine in Low-Income and Medium-Income Nations

Application of Telemedicine in High-Income Nations

Challenges in the Diffusion of Telemedicine in Rural Populations

The Necessity of Training for Telemedicine Providers in Rural Communities

Cultural Competency in the Virtual Healthcare Setting

Communication Training Specific to Virtual Healthcare Providers

Patient-Centered Care and Patient-Provider Communication

Communication Training for Virtual Providers

Conclusion

References

Further Reading

Section II: Ethical and Professional Conduct in the Digital Age

Chapter 4. The Facets of Digital Health Professionalism: Defining a Framework for Discourse and Change

Abstract

Defining Digital Professionalism

Digital Privacy and Safety in the Health Professional Context

Email, Text, and Instant Messaging

Social Media

Implementing Electronic Communications Recommendations in the Real World

Digital Reputation in the Health Professions Context

Teaching Digital Professionalism in the Health Professional Context

Implementing Educational Interventions for Digital Professionalism in the Health Professions

How is the Digital Addressed in Current Competency-Based Education Frameworks?

Addressing Digital Professionalism Through Focused Faculty Development

Addressing Digital Professionalism Through the Formal Curriculum

Addressing Digital Professionalism Through the Informal Curriculum

Addressing Digital Professionalism Through the Hidden Curriculum

Don't Forget About the Potential for Good

Summary

References

Chapter 5. Privacy and the Hi-Tech Healthcare Professional

Abstract

Personal Information

Personal Health Information

Fair Information Principles

Compliance With Privacy Legislation

Quality Improvement, Program Evaluation, and Research

Special Privacy Considerations

Educational Implications and Challenges for the Healthcare Professional

References

Chapter 6. Ethics, Obligations, and Health Informatics for Clinicians

Abstract

Introduction

Clinical Data and Education: Secondary Data Use

The Expert Patient and HCP Education

Conclusions

References

Further Reading

Section III: Patient Safety and Quality Assurance Thrusts in Digital Healthcare and their Influence on Clinicians and Patients

Chapter 7. Transformative Technology: What Accounts for the Limited Use of Clinical Decision Support Systems in Nursing Practice When Compared to Medicine?

Abstract

Introduction

Definition, Functionality, and Architecture of CDSSs

CDSSs and Clinical Reasoning Support

Evolution of CDSSs in Medicine

CDSSs in Clinical Nursing Practice

Use of CDSS in Clinical Nursing Education

Successful Implementation of a Nursing CDSS

Discussion and Recommendations

References

Section IV: Health Information Literacy and Credibility Assessment

Chapter 8. Developing Digital Literacies in Undergraduate Nursing Studies: From Research to the Classroom

Abstract

Introduction

Digitization of Health by the Internet and Social Media

Health Informatics Literacy

Developing Digital Literacy and Informatics Competency for Health Professionals

Criteria Used by Students to Appraise Online Health Information

Criteria Used by Students to Appraise the Credibility of Social Media Information

Strategies for Improving Health Literacy Competencies

Barriers in Competency Development

Current Informatics Competencies for Nursing Students

Conclusion

References

Part II: Experiences From the Field

Section V: Training Clinicians in Informatics and Practicing in IT-Enabled Settings

Subsection V.A: Curriculum Design and Implementation Strategies

Chapter 9. Lessons Learned and Looking Forward With Pharmacy Education: Informatics and Digital Health

Abstract

Background

Changing World of the Practice of Pharmacy: Focus on Technology

Why Pharmacy Education Must Pivot to Benefit Students and Patients

Transitioning to Include Core Information and Communication Technologies (ICT), Health Information Technologies (HIT), and Informatics Competencies

Digital Health and Emerging Teaching Modalities to Prepare Health Professional Students

The Next Generation of Interprofessional Education

Lessons Learned and Moving Forward in the Days Ahead

References

Appendix 9.1 Glossary of Informatics-Related Terminology Used in This Chapter

Chapter 10. Patient-Centered Technology Use: Best Practices and Curricular Strategies

Abstract

Introduction

Best Practices: Promises and Pitfalls

Acquaint Yourself With the Chart

Honor the Golden Minute

Introduce the Technology

Aim for a Conversational Style

Employ the Triangle of Trust

Don’t Fall Victim to the Myth of Multitasking

The Importance of Real-Time Charting

Actively Encourage Patient Engagement With Technology

Accentuate the Positive, Eliminate the Negative

Maximize Use of Verbal and Nonverbal Communication Behaviors

Recognize When to Disengage From Technology

Meaningful Encounter Closure

Challenges to Practical Integration

Curricular Interventions

Medical Student Curricula

Resident Curricula

Practicing Physician Curricula

Evaluation Methods

A Longitudinal Example: The University of Chicago

Challenges to Implementation

Conclusion

References

Chapter 11. Incorporating Patient’s Perspectives in Educational Interventions: A Path to Enhance Family Medicine Communication in the Age of Clinical Information Systems

Abstract

Introduction

Educational Interventions

Assessment Tools for Physician-Patient-Computer Communication

Patients Perspectives and Experience Regarding Computer Use in the Consultation

Future Trends: Design of Educational Interventions, Incorporating Patient’s Perspectives

References

Chapter 12. Strategies Through Clinical Simulation to Support Nursing Students and Their Learning of Barcode Medication Administration (BCMA) and Electronic Medication Administration Record (eMAR) Technologies

Abstract

Introduction

BCMA/eMAR and the Importance to Nursing Education

Literature Review

Developing or Procuring a BCMA/eMAR Platform for Simulated Education

Best Practices Related to Simulated BCMA/eMAR Medication Administration

Evaluation, Quality Assurance, and Research

Future Directions in Clinical Technology Enabled Simulation Education

References

Section VI: Local and Regional Interventions

Chapter 13. From Competencies to Competence: Model, Approach, and Lessons Learned From Implementing a Clinical Informatics Curriculum for Medical Students

Abstract

Introduction

Opportunity

Overview of UME Curriculum

Principles

Implementation

Lessons Learned and Future Directions

Acknowledgments

References

Chapter 14. Nurse Education in the Digital Age—A Perspective From the United Kingdom

Abstract

Introduction

Information Flows in Clinical Settings

Nurses and IT—Ready for the Revolution?

Workforce Engagement

Nursing Informatics and Leadership

eLearning as a Mode of Nursing Education

Advanced Nursing Practice in the United Kingdom—Embedding Informatics Into the PG Curricula (Case Study)

Developing an Online Course

Should a Different Approach Be Used?

eHealth and Digital Nursing—Developing an Honors Option Course for Undergraduate Nurses

Conclusion

References

Chapter 15. Effectiveness of Training Strategies That Support Informatics Competency Development in Healthcare Professionals

Abstract

Introduction

Competency Framework

Modes of Training Delivery

Supporting Technology Within Workflows

Mentorship Roles

Monitoring for Acceptance

Continuing Competency

Conclusion

References

Chapter 16. Integrating Health Informatics Into Australian Higher Education Health Profession Curricula

Abstract

Introduction

Definitions

Past Context

Current Context

Challenges in Health Informatics Education for Clinicians

Strategies to Meet the Challenges

Examples From Australian Higher Education Sector

Implications

Conclusion

References

Section VII: State and National Level Initiatives

Chapter 17. Implementing Informatics Competencies in Undergraduate Medical Education: A National-Level Train the Trainer Initiative

Abstract

Introduction

Faculty Development Workshops

Outcomes and Results

Next Steps and Future Direction

Summary

Acknowledgments

References

Chapter 18. Development and Evaluation of a Statewide HIV-HCV-STD Online Clinical Education Program for Primary Care Providers

Abstract

Introduction

Background and Related Work

Development of CEI Online Education Resources

Usage of CEI Online Education Resources

Evaluation of CEI Online Education Program

Discussion

Conclusion

Acknowledgments

References

Section VIII: Information and Communication Technology as an Educational Tool

Chapter 19. IS4Learning—A Multiplatform Simulation Technology to Teach and Evaluate Auscultation Skills

Abstract

The (Almost) Lost Art of Auscultation

The Essentials of Auscultation

How Do We Teach Auscultation Today?

IS4Health Simulation Technologies

Archetypal Auscultation Learning Use-Cases

Auscultation 2.0

Acknowledgments

References

Chapter 20. The Use of Mobile Technologies in Nursing Education and Practice

Abstract

Introduction

The Use of Technologies in Nursing Education and Practice

The Use of Mobile Technologies in Nursing Education and Practice

Current Challenges and Opportunities of mHealth in Nursing

Future Trends in the Use of Mobile Technologies in Nursing Education and Practice

Conclusion

References

Chapter 21. Leveraging Social Media for Clinician Training and Practice

Abstract

An Overview of Social Media

Social Media Resources for Creating and Editing Websites

Social Networking Sites

Social Media Resources for Content Sharing and Organizing

Social Media in Education

Social Media in Practice

Data Analytics: A New Opportunity for Educators and Practitioners

Conclusion

References

Part III: Evaluating Students and Programs

Chapter 22. Using Activity Data and Analytics to Address Medical Education’s Social Contract

Abstract

Introduction

Background

Ambient Surveillance

Smarter Uses of Data

Bigger Data

Tracking Across Learning Modalities

Tracking Across Time and Context

The Role of Analytics in Meeting the Social Contract

Conclusion

References

Chapter 23. Evaluating Educational Interventions for Health Professions in the Digital Age

Abstract

Introduction

What Evaluation Is and How It Relates to Research?

Evaluation of Educational Interventions: Simple, Complicated, and Complex Interventions

The Five Attributes: Reliability, Validity, Feasibility, Acceptability, and Educational Impact

Levels of Evaluation

Cost-Effectiveness Evaluation

Challenges in Conducting Evaluations

Summary and Future Directions

References

Glossary

Index

Copyright

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List of Contributors

Maria L. Alkureishi,     University of Chicago, Chicago, IL, United States

Kathryn E. Anthony,     University of Southern Mississippi, Hattiesburg, MS, United States

Antonia Arnaert,     McGill University, Montreal, QC, Canada

Hanan Asiri,     Armed Forces Hospitals Southern Region, Khamis Mushait, Saudi Arabia

Timothy D. Aungst,     MCPHS University, Worcester, MA, United States

Tamara J. Bahr,     University of Toronto, Toronto, ON, Canada

Josef Bartels,     Family Medicine Residency of Idaho, Boise, ID, United States

Nicolet H. Bell,     University of Southern Mississippi, Hattiesburg, MS, United States

Rashaad Bhyat,     Canada Health Infoway, Toronto, ON, Canada

Fran Biagioli,     Oregon Health & Science University, Portland, OR, United States

Richard G. Booth,     Western University, London, ON, Canada

Elizabeth M. Borycki,     University of Victoria, Victoria, BC, Canada

Elizabeth A. Breeden,     Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, United States

Kerryn Butler-Henderson,     University of Tasmania, Hobart, TAS, Australia

Ryan Chan,     Western University, London, ON, Canada

Dawn Choo,     University of Melbourne, Melbourne, VIC, Australia

Kevin A. Clauson,     Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, United States

Miguel Tavares Coimbra

Instituto de Telecomunicações (IT), Lisboa, Portugal

University of Porto, Porto, Portugal

Amanda Condon,     Winnipeg Regional Health Authority, Winnipeg, MB, Canada

Ovídio Costa,     University of Porto, Porto, Portugal

Noah H. Crampton,     University of Toronto, Toronto, ON, Canada

Ricardo Cruz-Correia

Center for Health Technology and Services Research (CINTESIS), Porto, Portugal

University of Porto, Porto, Portugal

Elizabeth Cummings,     University of Tasmania, Hobart, TAS, Australia

Zoumanan Debe,     Consultant, Ontario, QC, Canada

Sharon Domb,     University of Toronto, Toronto, ON, Canada

Prerna Dua,     Louisiana Tech University, Ruston, LA, United States

Rachel H. Ellaway,     University of Calgary, Calgary, AB, Canada

Gerard Farrell,     Memorial University, St. John's, NL, Canada

Margarida Figueiredo-Braga,     University of Porto, Porto, Portugal

Brent I. Fox,     Auburn University, Harrison School of Pharmacy, Auburn, AL, United States

Richard M. Frankel

Indiana University School of Medicine, Indianapolis, IN, United States

Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, United States

Cleveland Clinic, Cleveland, OH, United States

Candace Gibson,     Western University, London, ON, Canada

Jeffery Gold,     Oregon Health & Science University, Portland, OR, United States

Pedro Gomes

Instituto de Telecomunicações (IT), Lisboa, Portugal

University of Porto, Porto, Portugal

Paul Gorman,     Oregon Health & Science University, Portland, OR, United States

Kathleen Gray,     University of Melbourne, Melbourne, VIC, Australia

Jodi Hall,     Fanshawe College, London, ON, Canada

Seana-Lee Hamilton,     Fraser Health Authority, Surrey, BC, Canada

Robert Hayward,     University of Alberta, Edmonton, AB, Canada

William Hersh,     Oregon Health & Science University, Portland, OR, United States

Kendall Ho,     University of British Columbia, Vancouver, BC, Canada

Mowafa Househ,     King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Steven Kassakian,     Oregon Health & Science University, Portland, OR, United States

Stephanie Kerns,     Oregon Health & Science University, Portland, OR, United States

Paulette Lacroix,     PC Lacroix Consulting, North Vancouver, British Columbia

Julie A. Lasslo,     Eastern Kentucky University, Richmond, KY, United States

Wei Wei Lee,     University of Chicago, Chicago, IL, United States

Sharon Levy,     University of Edinburgh, Edinburgh, United Kingdom

John Liebert,     Private Practice of Psychiatry, Scottsdale, AZ, United States

Brittany Loggie,     Western University, London, ON, Canada

Anthony Maeder,     Flinders University, Bedford Park, SA, Australia

Carey Mather,     University of Tasmania, Hobart, TAS, Australia

Sandra Mattos,     Heart Institute of Pernambuco, Pernambuco, Brazil

Vishnu Mohan,     Oregon Health & Science University, Portland, OR, United States

Zilma Silveira Nogueira Reis,     Federal University of Minas Gerais, Minas Gerais, Brazil

Christopher Pearce,     University of Melbourne, Parkville, VIC, Australia

Daniel Pereira

Instituto de Telecomunicações (IT), Lisboa, Portugal

Center for Health Technology and Services Research (CINTESIS), Porto, Portugal

University of Porto, Porto, Portugal

Norma Ponzoni,     McGill University, Montreal, QC, Canada

Kalyani Premkumar,     University of Saskatchewan, Saskatoon, SK, Canada

Anne Redmond,     Trinity Western University, Langley, BC, Canada

Carrie E. Reif,     University of Southern Mississippi, Hattiesburg, MS, United States

Shmuel Reis,     The Hebrew University of Jerusalem, Jerusalem, Israel

Bev Rhodes,     Alberta Health Services, Medicine Hat, AB, Canada

Marcy Rosenbaum,     University of Iowa Carver College of Medicine, Iowa City, IA, United States

Carla Sá,     University of Porto, Porto, Portugal

Gretchen Scholl,     Oregon Health & Science University, Portland, OR, United States

Tracy Shaben,     Alberta Health Services, Edmonton, AB, Canada

Aviv Shachak,     University of Toronto, Toronto, ON, Canada

Anne Short,     Alberta Health Services, Brooks, AB, Canada

Roger Simard,     Uniprix, Inc., Montreal, QC, Canada

Barbara Sinclair,     Western University, London, ON, Canada

Dilermando Sobral,     University of Porto, Porto, Portugal

Gillian Strudwick,     Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada

Anupam Thakur

University of Toronto, Toronto, ON, Canada

Centre for Addiction and Mental Health, Toronto, ON, Canada

Maggie Theron,     Trinity Western University, Langley, BC, Canada

James Tong,     Western University, London, ON, Canada

David Topps,     University of Calgary, Calgary, AB, Canada

Maureen Topps,     University of Calgary, Calgary, AB, Canada

Dongwen Wang,     Arizona State University, Scottsdale, AZ, United States

Victoria Wangia-Anderson,     University of Cincinnati, Cincinnati, OH, United States

Sue Whetton

Sue Whetton Consulting, Launceston, TAS, Australia

University of Tasmania, Hobart, TAS, Australia

David Wiljer

University Health Network, Toronto, ON, Canada

University of Toronto, Toronto, ON, Canada

Foreword

Hyeoun-Ae Park, International Medical Informatics Association (IMIA)

The book Health Professionals’ Education in the Age of Clinical Information Systems, Mobile Computing and Social Networks edited by Shachak, Borycki, and Reis focuses on how technology is changing health professions education. The text looks at this important issue through three distinct and important lenses. The first lens looks at the new challenges that health information and communication technologies are bringing to health professions education. The second lens provides examples from the field as academic educators prepare future health professionals for practicing in the digital era and the lessons they have learned. The third of these lenses examines how student learning outcomes and educational programs could be evaluated.

Internationally, there are considerable changes and progress taking place with the introduction of new health information and communication technologies. As health information and communication technologies are being developed and adapted for use in health care around the world so there has emerged a need for a technology literate health professional workforce that can effectively use the technology implemented in health care organizations (e.g., hospitals) to care for patients. There has also emerged a need to integrate health information technology competencies into health professions education internationally. Such work is important and critical to the advancement of health care systems.

In my work as the President of the International Medical Informatics Association (IMIA), I have promoted the importance of health information and communication technology use to improve health care quality and to achieve health equity. In keeping with this work, IMIA has promoted the development of biomedical and health informatics as a discipline and the development of health professional informatics competencies.

Today, the work of IMIA members includes not only developing health information and communication technologies for health care, and educating the future academics who teach biomedical and health informatics professionals at the undergraduate and graduate levels, but also educating academics who teach Medicine, Nursing, Pharmacy, and other health professions about the technologies that are part of today’s health care system and developing what it is to be a health professional in an ever changing health care system.

This book is very important to read as it not only celebrates rapid development of health information and communication technologies in health care, but describes how educators of health professions are teaching students about how to effectively use and integrate these technologies into patient care. Lastly, the book closes the loop by describing evaluation approaches involving information technology in health professions education.

As an international organization, IMIA promotes the advancement of health informatics around the globe. This book provides perspectives from several regions of the world including North America, Europe, Australia, and the Middle East. These contributions are brought by academics who provide us with knowledge about how to improve and educate health professionals about health information technologies in health care and turn our readings and thought toward the lessons learned so that we can improve technology and education over time.

We have all seen the impact of health information and communication technologies. Today, we are learning more about how we can educate health professionals about using these technologies to improve patient care!

Preface

Background

Information and communication technology (ICT) relentlessly transforms all aspects of modern life globally and health care is no exception. Electronic Health Records, mobile applications, internet use for health queries, big data collection and analysis, personalized medicine, and bioinformatics are all turning ubiquitous. This is certainly the case for high income countries where even in countries such as the United States and Canada that previously lagged behind about 80% of primary care physicians now use electronic medical records [1,2]. In medium- and low-income countries, too, there has been a steady growth in the use of ICT for health care, and some noteworthy initiatives, especially in the use of mobile technology [3–5].

A lot has been written in the health informatics literature about the implementation of clinical information systems. Through this research we learned a great deal about the importance of socio-technical issues and particularly the role of engaging stakeholders, support from administration, training, and special people such as champions and super users [6,7]. We also learned about the unintended consequences of health information technology that are not always positive including impact on clinicians’ workflow and workload, overdependence on the technology, health information technology safety issues, and privacy breaches [8–10]. As clinical information systems are widely adopted, it is now time to switch our attention from implementation issues toward effective use of these systems, realizing their potential to improve care, and minimizing their negative unintended consequences.

Beyond clinical information systems, ICT transforms traditional power relationships within the health care system. Patients now have access to vast amounts of health information literally at their fingertips and are increasingly interested in viewing and contributing to their own medical records. Patient engagement, where patients are informed, involved, empowered, partnered with, and form communities to exchange knowledge and support each other, is now viewed as an essential component of high-quality health care; especially for people living with chronic diseases. Technology can be a great enabler of this, but it also brings with it multiple challenges including design of the technology to match patient needs and characteristics, reliability and credibility of health information online, health information literacy of patients and health care practitioners alike, and the tension between the level of service expected of health ICT and the need to protect people’s privacy [11–13]. For example, there have been cases where patients pressured providers and policy makers to authorize unproven treatments based on information distributed on social media; of people self-(mis)diagnosing their conditions; and of privacy and security breaches [10,14,15]. And there have also been the opposite examples of expert patients partnering with their health care providers to achieve better outcomes and patients becoming more active in their own care [16].

While ICT applications in health care make headways, complementary ripples ensuring their effective, efficient, and moral use are called for. Central to these is the need to educate healthcare professionals about their brave, new technology-soaked field of practicing. From high to low income countries, ICT opens new options for affecting the health of individuals and communities, and forms new roles based on novel competencies that these options mandate. In addition, these ripples make ample use of ICT in order to educate, monitor, and evaluate this drive. The purpose of this book is to provide a comprehensive resource for health professions education in, and for, the digital era. It summarizes contemporary knowledge of the challenges and lessons learned from educators around the globe and several disciplines (Medicine, Pharmacy, Nursing, and Health Informatics) who are researching these issues and have developed educational interventions to deal with them.

Organization of the Book

This book is organized around three intersecting themes: challenges for health professions education that are brought forth by the use of ICT in health care; experience from the field of educators who have been addressing these challenges and the lessons they have learned; and, finally, evaluation of students and educational programs intended to enhance health professionals’ competence for the digital era.

In Part 1, our contributors have identified several challenges related to the use of health information technology. The first is the impact of using ICT on the patient–clinician relationships. In Chapter 1, Computers, Patients, and Doctors—Theoretical and Practical Perspectives, Christopher Pearce provides an overview of the impact of electronic medical records on the patient–clinician relationship. Josef Bartels in Chapter 2 specifically addresses the topic of conversational silence in the computer-assisted patient–clinician encounter. They highlight the new triadic patient–clinician–computer relationship that replaces the traditional dyadic patient–clinician interaction and the positive and negative impacts that this may have on the consultation. Chapter 3, Overcoming Health Disparities: The Need for Communication and Cultural Competency Training for Healthcare Providers Practicing Virtually in Rural Areas, by Lasslo, Anthony, Reif, and Bell, takes us beyond the traditional face-to-face interactions and discusses the challenges of virtual encounters via telemedicine. While common challenges with telemedicine such as health practitioners’ compensation and licensing issues have been discussed quite extensively [17], these authors highlight a different challenge: the need for communication and cultural competency training for those who practice virtually via telemedicine in remote rural areas. While the chapter mostly focuses on rural areas in the United States, it also has multiple implications for low-resource countries were telemedicine has become a viable option to providing health services.

The second set of challenges has to do with the professional and ethical use of ICT in health care, and particularly with regards to communication forms such as email, text messaging, and social media. In Chapter 4, The Facets of Digital Health Professionalism: Defining a Framework for Discourse and Change, Bahr, Crampton, and Domb provide a framework for defining and discussing digital professionalism. Among other issues, their chapter explores the definitions of digital professionalism, privacy, and reputation issues, as well as teaching and modeling professional digital behavior. Following this broad discussion of digital professionalism, Lacroix and Hamilton specifically address privacy challenges in Chapter 5, Privacy and the Hi-Tech Healthcare Professional. Their chapter highlights the need to find balance between the often conflicting demands of utilizing health ICT effectively, and compliance with privacy legislation. Chapter 6, Ethics, Obligations, and Health Informatics for Clinicians, by Wiljer and Thakur completes the discussion of ethical and professional aspects by focusing on the learning environment of future health care professionals with the unique challenges and learning opportunities it provides, including the digital responsibilities of the learners in that context.

Finally, the last set of challenges deals with effective use of ICT in health care. Arnaert, Ponzoni, Liebert, and Debe in Chapter 7, Transformative Technology: What Accounts for the Limited Use of Clinical Decision Support Systems in Nursing Practice when Compared to Medicine? ask What accounts for the limited use of clinical decision support systems in Nursing practice when compared to Medicine? and call the profession to address the barriers to use of these systems in Nursing, including via education. In Chapter 8, Developing Digital Literacies in Undergraduate Nursing Studies: From Research to the Classroom, Theron, Borycki, and Redmond discuss the growing need for students in health professions in general, and nursing in particular, to be able to search for, retrieve, and critically appraise the quality of online health information. They highlight the need for health information literacy education so that future professionals can make better use of various forms of online health information.

Part 2 of the book features curricular approaches and designs, and educational interventions to address the challenges of the digital era as well as use of ICT to deliver health professions education. In this part, educators and researchers describe their initiatives, experiences, and the lessons they have learned from them. In Chapter 9, Lessons Learned and Looking Forward With Pharmacy Education: Informatics and Digital Health, Clauson, Aungst, Simard, Fox, and Breeden describe the opportunities that ICT opens for transforming the practice of pharmacy. They provide direction for pharmacy education to adapt to the changing practice and examples of how pharmacy informatics topics can be introduced to students.

The next two chapters take us back to one of the challenges introduced in the first chapters of the book: integrating the electronic medical record into the patient–clinician interaction. In face of a growing frustration and dissatisfaction with this aspect of EMR use, especially in the United States [18], Alkureishi, Lee, and Frankel (Chapter 10: Patient-Centered Technology Use: Best Practices and Curricular Strategies) outline the best practices identified through research and describe curricular approaches to teach these skills. Figueiredo-Braga, Sorbal, and Rosenbaum complement this picture in Chapter 11, Incorporating Patient’s Perspectives in Educational Interventions: A Path to Enhance Family Medicine Communication in the age of Clinical Information Systems, by bringing in the patient’s perspective and discussing their experience with specific educational interventions to enhance patient–clinician–computer communication in Portugal.

To complete this subsection on curricular approaches and designs, Chapter 12, Strategies Through Clinical Simulation to Support Nursing Students and Their Learning of Barcode Medication Administration (BCMA) and Electronic Medication Administration Record (eMAR) Technologies, by Booth et al. focuses on the specific topic of barcode medication administration and electronic medication administration record use in nursing practice. They propose a simulation-based approach to teaching these processes in Nursing education, and highlight key considerations and best practices in developing such educational interventions.

Chapters 13–16 take us through local and regional education and training programs in the United States, the United Kingdom, and Canada. First, Hersh et al. (Chapter 13: From Competencies to Competence: Model, Approach, and Lessons Learned from Implementing a Clinical Informatics Curriculum for Medical Students) take us through the conceptualization and implementation of the exemplary program in clinical informatics at Oregon Health and Science University (OHSU) medical school. Their insights on the obstacles and success factors would provide multiple valuable insights for similar initiatives. Next, Levy in Chapter 14, Nurse Education in the Digital Age—A Perspective From the United Kingdom, provides an overview of the Nursing Informatics landscape in the United Kingdom, followed by a case study on embedding informatics competencies into postgraduate Nursing education at the University of Edinburgh in Scotland. In Chapter 15, Effectiveness of Training Strategies That Support Informatics Competency Development in Healthcare Professionals, Rhodes, Shaben, and Short reflect on their experience at Alberta Health Services (Canada) with the training provided in the implementation of health information technology to build healthcare professional competency in using ICT to provide safe and quality patient care. Finally, Cummings, Whetton, and Mather (Chapter 16: Integrating Health Informatics Into Australian Higher Education Health Profession Curricula) demonstrate the strategies employed by one Australian university for introducing nursing informatics contents into programs at the undergraduate, postgraduate, and continuing professional development levels as well as how they developed mobile learning opportunities for clinical preceptors.

Scaling up these local and regional experiences is a challenging task. Two chapters in this book provide insight into how this can be done. In Chapter 17, Implementing Informatics Competencies in Undergraduate Medical Education: A National-Level Train the Trainer Initiative, Bhyat et al. describe how two Canadian organizations with a national focus—one representing medical schools and another that is responsible for the national eHealth strategy—partnered to develop and deliver health informatics contents to medical educators, taking a train the trainer approach. Wang (Chapter 18: Development and Evaluation of a Statewide HIV-HCV-STD Online Clinical Education Program for Primary Care Providers) provides another example of a large-scale initiative: a statewide continuing medical education program on Human Immunodeficiency Virus (HIV), Hepatitis C (HCV), and other sexually transmitted diseases (STDs) in New York State. The program created a large repository of multimedia educational items and disseminated them using multiple channels. It demonstrates innovative use of health informatics tools such as classification systems and clinical guideline representation model in an educational context.

As highlighted in Chapter 18, Development and Evaluation of a Statewide HIV-HCV-STD Online Clinical Education Program for Primary Care Providers, described above, ICT not only introduces new challenges, but it also provides opportunities and can be used as a vehicle for delivering educational interventions. While this may, in and of itself, be the topic of a whole different book, we included a number of chapters in this book that provide insight into how ICT may be used in health professions education. First, Pereira (Chapter 19: IS4Learning—A Multiplatform Simulation Technology to Teach and Evaluate Auscultation Skills) describes a novel simulation technology for teaching heart auscultation skills. While some argue that auscultation is largely replaced by ultrasonic imaging and Doppler techniques these days, Pereira submits that it remains a simple cost-effective method and thus, teaching the almost lost art of auscultation is still valuable. This may be especially important for low resource settings.

In Chapter 20, The Use of Mobile Technologies in Nursing Education and Practice, Asiri and Househ provide an overview of the use of mobile technology in nursing educations and discuss opportunities, challenges, and future directions. Wangia-Anderson and Dua (Chapter 21: Leveraging Social Media for Clinician Training and Practice) complete this section by discussing the use of social media in health professions education highlighting opportunities and calling on educators to take advantage of them.

Part 3, the last part of the book, presents the topic of evaluating the above-mentioned efforts. While evaluation has been included within many of the interventions discussed in previous chapters, we have identified a gap in systematically embedding it within program designs. This gap is addressed at two levels. First, in Chapter 22, Using Activity Data and Analytics to Address Medical Education’s Social Contract, Topps, Ellaway, and Topps propose an intriguing and potentially controversial approach to evaluating individual students’ performance using ambient surveillance tools. They argue that smarter use of data could overcome the biases and inconsistencies of preceptors when it comes to students’ performance assessment. Second, Shachak and Reis (Chapter 23: Evaluating Educational Interventions for Health Professions in the Digital Age) discuss the evaluation of educational modules and programs. They highlight the need for evaluation at multiple levels and the specific challenges involved in evaluating interventions aimed at preparing clinicians for the challenges of the digital era including choice of study design, small number of participants, and lack of specific measure instruments. Case studies within the chapter, including a contribution from Gray, Choo, Butler-Anderson, Whetton, and Maeder, illustrate these challenges and approaches to handle them.

We believe that this smorgasbord in three sections gives a comprehensive overview of the current state of the field, and will supply insights and innovative examples to the readers. We hope that the continued professional conversation will be fostered by this volume and look forward to hear from our readership.

References

1. The Commonwealth Fund. Commonwealth Fund International Survey of Primary Care Physicians in 10 Nations; 2015. Available from: <http://www.commonwealthfund.org/interactives-and-data/surveys/international-health-policy-surveys/2015/2015-international-survey> [cited 04.03.17].

2. National Physician Survey. National Physician Survey; 2014. Available from: <http://www.nationalphysiciansurvey.ca/> [cited 28.01.15].

3. Lewis T, Synowiec C, Lagomarsino G, Schweitzer J. E-health in low- and middle-income countries: findings from the Center for Health Market Innovations. Bull World Health Organ. 2012;90(5):332–340.

4. Bastawrous A, Armstrong MJ. Mobile health use in low- and high-income countries: an overview of the peer-reviewed literature. J R Soc Med. 2013;106(4):130–142.

5. Hall CS, Fottrell E, Wilkinson S, Byass P. Assessing the impact of mHealth interventions in low- and middle-income countries---what has been shown to work? Glob Health Action. 2014;7:25606.

6. Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people. Int J Med Inform. 2003;69(2–3):235–250.

7. Shachak A, Montgomery C, Dow R, et al. End-user support for primary care electronic medical records: a qualitative case study of users’ needs, expectations, and realities. Health Syst. 2013;2(3):198–212.

8. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH. Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc. 2006;13(5):547–556.

9. Kushniruk AW, Triola MM, Borycki EM, Stein B, Kannry JL. Technology induced error and usability: the relationship between usability problems and prescription errors when using a handheld application. Int J Med Inform. 2005;74(7–8):519–526.

10. Mlinek EJ, Pierce J. Confidentiality and privacy breaches in a university hospital emergency department. Acad Emerg Med. 1997;4(12):1142–1146.

11. Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient engagement: a state of the science review. J Med Internet Res. 2015;17(6):e148.

12. O’Grady L. Future directions for depicting credibility in health care web sites. Int J Med Inform. 2006;75(1):58–65.

13. Järvinen OP. Privacy management of patient-centered e-health. In: Wilson EV, ed. Patient-centered e-health. New York: Hershey; 2009.

14. Chafe R, Born KB, Slutsky AS, Laupacis A. The rise of people power. Nature. 2011;472(7344):410–411.

15. White RW, Horvitz E. Cyberchondria: studies of the escalation of medical concerns in Web search. ACM Trans Inf Syst. 2009;27(4):1–37.

16. deBronkart D. How the e-patient community helped save my life: an essay by Dave deBronkart. BMJ. 2013;346:f1990.

17. Weinstein RS, Lopez AM, Joseph BA, et al. Telemedicine, telehealth, and mobile health applications that work: opportunities and barriers. Am J Med. 2014;127(3):183–187.

18. Rosenbaum L. Transitional chaos or enduring harm? The EHR and the disruption of medicine. N Engl J Med. 2015;373(17):1585–1588.

List of Reviewers

Maria (Lolita) Alkureishi,     University of Chicago, USA

Tamara J. Bahr,     University of Toronto, Canada

Elizabeth Cummings,     University of Tasmania, Australia

Sharon Domb,     Sunnybrook Health Sciences Centre and the University of Toronto, Canada

Raya Gal,     York University, Canada

Candace Gibson,     Western University, Canada

Drew McArthur,     The Office of the Information and Privacy Commissioner of British Columbia, Canada

Janessa Griffith,     University of Toronto, Canada

Mowafa Househ,     King Saud bin Abdulaziz University for Health Sciences, Kingdom of Saudi Arabia

Avi Hyman,     University of Toronto, Canada

Christopher M. Pearce,     Australasian College of Health Informatics, Monash University and University of Melbourne, Australia

Peter Pennefather,     University of Toronto, Canada

Gurprit K. Randhawa,     Vancouver Island Health Authority and University of Victoria, Canada

Esther Sangster-Gormley,     University of Victoria, Canada

Laurel M. Schwartz,     Eastern Kentucky University, USA

Gillian Strudwick,     Centre for Addiction and Mental Health, Canada

Danica Tuden,     University of Victoria, Canada

Dongwen Wang,     Arizona State University, USA

David Wiljer,     University Health Network and University of Toronto, Canada

Part I

The Changing Landscape of Information and Communication Technology (ICT) in Health Care: Implications for Health Professionals’ Education

Outline

Section I The Changing Nature of the Patient-Clinician Relationships

Section II Ethical and Professional Conduct in the Digital Age

Section III Patient Safety and Quality Assurance Thrusts in Digital Healthcare and their Influence on Clinicians and Patients

Section IV Health Information Literacy and Credibility Assessment

Section I

The Changing Nature of the Patient-Clinician Relationships

Outline

Chapter 1 Computers, Patients, and Doctors—Theoretical and Practical Perspectives

Chapter 2 What’s All This Silence? Computer-Centered Communication in Patient-Doctor-Computer Communication

Chapter 3 Overcoming Health Disparities: The Need for Communication and Cultural Competency Training for Healthcare Providers Practicing Virtually in Rural Areas

Chapter 1

Computers, Patients, and Doctors—Theoretical and Practical Perspectives

Christopher Pearce,    University of Melbourne, Parkville, VIC, Australia

Abstract

The core activity of medicine remains the interaction between humans although this is increasingly being challenged, or at least changed, by the revolution brought by the digitization of society. While other aspects of societal transactions (such as banking and law) can now be conducted almost entirely in an online environment, the practice of medicine still requires personal contact, both because it is done to the person and increasingly with the person. In parallel with this, development in health has come academic research to understand these changes at a deeper level. Such research has included both empirical analysis and theory development, described in this chapter.

Keywords

Patient–physician relationships; electronic medical records; social interactions; language; computers

Introduction

The core activity of medicine remains the interaction between humans, although this is increasingly being challenged, or at least changed, by the revolution brought by the digitization of society. Whilst other aspects of societal transactions (such as banking and law) can now be conducted almost entirely in an online environment, the practice of medicine still requires personal contact, both because it is done to the person and increasingly with the person. In parallel with this development in health has come academic research to understand these changes at a deeper level. Such research has included both empirical analysis and theory development.

Theory development is essential to academic understanding yet in this particular area, theory development has lagged behind empirical analysis [1]. The object of this chapter is to outline the conceptual development of this interaction, both as a dyadic (patient and doctor), and now a triadic environment (including the computer), and to relate these concepts to the implications for educating health professionals into the future. It shall include history, models, and theory, to better understand where the social practice of medicine has come from, and were therefore it might go into the future.

The rapid computerization of the world in general has changed many of the fundamentals of society. Computers—as characterized as the box that sits on a desktop, are now taking a conceptual back seat as the internet (itself nothing more than networked computers) and devices such as phones and tablets come to mediate our relationship with the digital world. Increasingly, it is about information, not technology. Human society has experienced such changes in modernization before—the age of enlightenment, the industrial revolution, and each has been associated with upheaval as society adjusts to new ways of doing things and new ways of thinking. In each case, the practice of healthcare has made adjustments to integrate these new ways of thinking, but in each case, it has maintained the human interaction at its core.

In many ways, the largest most recent challenge to this human interaction has been the introduction of the scientific method in the latter part of the 19th century. The concept of the body as a machine has permeated much of medical science in the last century. The understanding of the body as a machine and the promise of truly effective cures, led to a belief that medicine no longer needed to worry about the nonmechanical parts of the human, that a pill would fix all things. Because of this, over the last century science has in many ways attempted to remove the doctor–patient relationship from our political and social structures [2]. As a result, modern medicine is an extraordinary work of reason: an elaborate system of specialized knowledge, technical procedures, and rules of behavior. However, by no means is medicine purely a rational process; our conceptions of disease and responses to it unquestionably show the imprint of our culture.

Whilst any interaction between humans can be characterized as a social interaction, what is unique about this relationship? The relationship even has a specific name, the consultation, a name based on one of its key features being that it is (usually) initiated by the patient, who consults the doctor as to how their problem can be addressed [3]. The common thread throughout the doctor–patient relationship is the presence of, or more correctly a concern about the presence of, disease. And it is this concern, this oft unspoken presence, which underpins the whole relationship. The concern about disease has different meanings for the participants of the relationship. Diseases can have different natures according to the perspective of the participants [4]. The patient can see it as a threat or a burden to their life, or a source of fear, while the doctor may approach it more as a riddle, to be organized and classified in order to be understood; an intellectual puzzle. So disease may not necessarily imply a physical problem, but has been more correctly described as disease, or the presence of a disturbance in the perception of the patient [5]. We will see later how computers are now involved in this process of translation. Indeed, it is the computer’s role in information flow that is central to its involvement.

History and Models

The relationship between physicians and their patient has long been recognized as being of central importance to the practice of medicine [6]. In 1991, the Toronto Consensus Statement on Doctor-Patient Communication [7] was created in response to the recognition that roughly 50% of patient complaints and concerns are often not identified in the consultation [8], and that trainees [9] and practicing physicians [10] often have significant deficiencies in effective communication skills toward their patients. Seven principles have been described that underpin good doctor–patient communication [11]; that it should:

• serve the patient’s need to tell the story of his or her illness, and the doctor’s need to hear it;

• reflect the special expertise and insight that the patient has into his or her physical state and well-being;

• reflect and respect the relationship between a patient’s mental state and his or her physical experience of illness;

• maximize the usefulness of physicians’ expertise;

• acknowledge and attend to its emotional content;

• openly reflect the principle of reciprocity of the standing of those involved—doctors and patients; and

• help participants overcome stereotyped roles and expectations so that both participants gain a sense of power and freedom to change.

Michael Balint, an English psychiatrist in the 1950s, was one of the first to examine the patient–doctor relationship in detail. He worked with large numbers of inner London general practitioners to identify some of the details of the relationship in a groundbreaking study. He presented the results of this work in his book The Doctor. His Patient and the Illness [12]. In his introduction, he says:

The first topic chosen for discussion at one of these seminars happened to be the drugs usually prescribed by practitioners. The discussion quickly revealed…that by far the most frequently used drug in general practice was the doctor himself, i.e. that it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient – in fact the whole atmosphere in which the drug was given and taken. (12: 1)

Balint’s description above was the first time that anyone had specifically identified the doctor as an important, independent part of the relationship. Nevertheless, his view took a very doctor-centric approach, and in many ways followed the doctor-dominant paradigm of the time in which doctors did things to patients; whether they used themselves, or drugs, or other procedures. Whilst Balint was emphasizing the role of the doctor, others were attempting to emphasis the relational aspects of the interaction, by describing it as an abstraction embodying the activities of two interacting people [13], thereby suggesting that the consultation was in some way different to just a simple interaction, that it was in some way unique.

Stott and Davis [14] highlighted the potential positive effect that could be generated by each primary care consultation. They outlined how each interaction had the potential to manage both the presenting and potential problems, provided the opportunity for health promotion activities and the modification of help-seeking behavior. This was modified [15] to identify how in each consultation there exists a patient and a doctor agenda, which must then merge into a negotiated plan or outcome from the consultation.

George Engels, an American psychiatrist, described the failings of the biomedical model, and suggested a broader approach that included both psychological and social issues. Not surprisingly, this method was called the biopsychosocial model [16]. The outcome of this concept was to shift the focus from diseases doing something to a person, to illnesses as something being experienced by a person. Development of this model of patient-centered method continued, with many interpretations of this term. Moira Stewart and colleagues [17] have provided the most comprehensive definition of Patient Centered Clinical Method (PCCM), with six key components:

1. Exploring both the disease and the illness experience.

2. Understanding the whole person.

3. Finding common ground.

4. Incorporating prevention and health promotion.

5. Enhancing the doctor–patient relationship.

6. Being realistic.

Whilst PCCM is a practical approach, others have been continuing the theory development, describing different models of the relationship [13]. Emanuel and Emanuel [18] followed the notion of ideal types [19], and constructed a typology for the doctor–patient relationship. An ideal type is formed from characteristics and elements of the given phenomena, but it is not meant to correspond to all of the characteristics of any one particular case. It is designed to stress certain elements common to most cases of the given phenomenon. From this work, we can generate four ideal types of the relationship:

• Paternalistic: also called the parental or priestly model. In this model, the doctor acts as the patient’s guardian, articulating and implementing what they feel is in the patient’s best interest.

• Informative: also called the scientific, engineering or consumer model. The obligation here is for the doctor to provide all the available facts, and then the patient, with their own value set, determines the outcome.

• Interpretive: here the aim is for the doctor to elucidate the patients’ value system, and thereby help select the best intervention.

• Deliberative: In this final model, the doctor acts as teacher or friend.

These models can then be expanded: including the further elements of patient values, doctor’s obligations, patient autonomy, and physician role (given in Table 1.1). The subsequent matrix represents a comprehensive framework to understand the patient–doctor relationship.

Table 1.1

Aspects of the Doctor–Patient Relationship

The Doctor–Patient Relationship as a Social Interaction

In approaching a physician for help, a patient brings not only a physical problem but also a social context. [20]

Beyond the creation of models of the consultation, social theorists have analyzed the interaction from a social perspective. A patient’s experience of their physical problems is inseparable from the wider social context in which these problems occur [21] and it is impossible to separate the patients from the context in which they exist. Their context includes relationships at work, in the family, and in the wider community. This environment has best been described by Jurgen Habermas as the lifeworld. Lifeworld is a term first used in a phenomenological description of human society [22]. Lifeworld is the stock of skills, competencies and knowledge that ordinary members of society use in order to negotiate their way through everyday life, to interact with other people and ultimately to create and maintain social relationships [23]. Lifeworld contrasts with the system, which is a rules-governed element, usually representing either the economy or the state [24]. It is in the consultation that the system interacts with the patient’s lifeworld.

Dramaturgy

Alongside Habermas, the theories of Dramaturgy by Goffman offer a useful lens to examine the consultation relationship. Goffman held that the entire structure of society is made of rituals, and thus the self is in fact a socially enacted ritual. When an individual plays a part, he or she implicitly request their observers to take seriously the impression that is presented to them. It allows that the performer can be taken in fully by their own act, or may not be taken in at all [25], and it is the effect of the act on the audience that has significance.

Within the medical consultation therefore, we can see that the actions can stem from several motivations according to this schema. Effectual action for instance, is based on emotional states, seen when doctors become angry with patients for not following their treatment recommendations. Traditional action is seen in many of the ritualized encounters, perhaps for worker’s compensation certificates. Actions can be based on values, where the patient believes the doctor is seeking important information from the computer. Finally, we can find means-end rationality in the PCCM approach of finding common ground. Multiple actions require the participants (now including the computer) to adopt multiple roles, often at different times throughout the consultation.

Goffman describes how the interactions between physician and patient can be elucidated in detail, and describes units of social interaction called frames, which are the schemata of interpretation which individuals use to organize their everyday perceptions [26]:

When an individual…recognizes a particular event, he tends…to imply in this response (and in effect employ) one or more frameworks or schemata of interpretation of a kind that can be called primary. Frame analysis is based on his view that it is how humans interact with each other that is important, that an individual can be defined by his interactions with others. [27]

Therefore, a frame is a description of a socially derived reality, and is usually discussed in terms of the physical world, social ecology, and institutional setting; all of which have relevance in the highly ritualized interactions involved in the consultation.

Power

Important in the consultation is the role of power and authority. If we maintain that the computer is changing the power structure in the consultation [28,29], then how power is manifest is important to understand. Power manifests itself by proxy in the consultation, and this discussion is an analysis of those manifestations. From Marx, through to recent discussions of information technology and culture [30], power has been ascribed to institutions and can be sought by them. Power, at the most rudimentary and personal level, originates in dependence, which has also been used to describe the patient’s place in the consultation [31]. The medical profession has had an especially persuasive claim to authority. The dominance of the medical profession in its interactions with patients goes considerably beyond simply the rational foundations provided by science. Its authority spills over its clinical boundaries into an arena of moral and political action for which medical judgment is only partially relevant and often incompletely equipped [20]. The profession derives its power from two sources, personal authority by dint of character and intimate knowledge of patients, and institutional authority conferred by the standards of the profession. The first role of the doctor has been described as a political one—the struggle against disease must begin with a war against bad government [2]. Thus, power can have many manifestations.

Power in social theory begins with the work of Marx. In brief, Marx introduced the concepts of control by use of language, and the power inherent in social structures such as class. Weber discussed power in the context of the probability an actor in a social relationship will be able to exert his will. Balint [12] terms this the apostolic function of the doctor, where the doctor exhibits an almost religious zeal to convert the patient to the doctors way of thinking. Foucault refocused the discussion away from the Marxist view of power related to economic concepts, to a study of power relations. For instance, Foucault believed that, in the modern world, the methods of power have assumed responsibility for life processes, [32] and he discussed how the power in medicine derives as much from social and cultural issues as it does from science [2]. Giddens examines the influence of structure on social interactions, and vice versa, in what is termed structuration theory. Structuration theory holds that social structures are both constituted by human agency, and yet at the same time are the very medium through which structures are created. Thus structure is the medium and outcome of the conduct it recursively organizes, and the actors in the structure are knowledgeable and competent agents who reflexively monitor their action, and adjust their action accordingly [33].

One way of thinking about power in the doctor–patient relationship is to consider the extent to which the relationship revolves around four elements or types of power [34]. Structural power arises from the speaker’s affiliation with the social institution of medicine; Charismatic power is based on personal characteristics; the influence of Social power is based on social prestige; whilst Aesculapian power is the ability to heal based on medical knowledge. Doctors need specialized knowledge and the power to be their patients’ advocates. Patients are unlikely to choose a doctor whom they perceive or know to be powerless. Therefore, doctors need the ability (1) to share information with patients, respond to patients’ cues, and obtain a full understanding of patients’ wants (accountability); (2) to help patients tell their stories, formulate and express preferences, and make informed decisions on treatments (autonomy); (3) to act in a trustworthy manner in healthcare matters on behalf of, and for, patients (fidelity); and (4) to interact with patients with sensitivity and compassion, bearing in mind the increased emotional vulnerability that illness and fear of death can produce (humanity).

We begin to see how the human actors in the consultation will be able to ascribe power to the computer for a variety of reasons, and through a variety of frames. It is not just about the knowledge it contains, the position it occupies on the desk, or its very role as a participant in the consultation. To do so the computer acquires cultural and social standing. The summation of this section is this: in the past, the doctor embodied power in the consultation for several reasons. The doctor had knowledge and training, a revered position in society, and this power manifest itself in the consultation, in creating the paternalistic model of the interaction. They represented a Habermasian system, which interacted with the patient’s lifeworld. However, this balance is changing, with other factors coming into play [35]. Patient centeredness has shifted power closer to the patient, with a greater recognition of the importance of both the patient’s perspective and the information that the patient brings [36]. Into this dyad, we have introduced the computer, which can and does manifest power as well. If knowledge is power, then the computer also represents a significant source of power by dint of its knowledge, limited only by the human’s ability to find and interpret that knowledge. Doctors have become much more managers of information rather than repositories of same, as we will see later in this chapter.

Communication

Good communication is clearly essential to an effective doctor–patient relationship. This section will discuss communication from two perspectives that apply both to the doctor–patient relationship and the increasing role of the computer-language and nonverbal behavior. The doctor–patient relationship is a subset of the many and varied interactions between humans that can occur. It particularly falls into the category of one on one communication, differentiating it from one to many (group communication) and the align=center communication that occurs within one’s own mind [37].

People communicate for many reasons [38]:

• As a means of reducing uncertainty

• To achieve social influence

• As part of our membership of certain groups (work groups, etc.)

• To achieve a certain identity or self-concept

• To identify with one another

• As an expression of culture

• To improve our relationships

• As entertainment

• To know each other better

Many of these can be applied in differing circumstances and with different emphases in the consultation.

Language

The importance of the spoken word should not be forgotten when considering power in the consultation. Conversation as a form of communication forms part of a greater process of the narrative or discourse. So to contribute to the relationship, the computer must also contribute to these processes. The computer does not use human language, and cannot communicate in the same way. Nor should it interfere with the expression of the narrative; it must not turn the interaction into a technical one. The computer needs to find ways to communicate effectively and not interfere. It can do so in a variety of ways. The humans can act as transcribers and interpreters (the computer says you have had your test). We can use means such as paper (written information), or audible warnings to notify one of the results of a test.

Language can be an expression of knowledge and power. This is influenced by the social and cultural background (and rules) that the participants bring to any conversation [39], and by our understanding of discourse is influenced by our perception of the agent of delivery [40]. Thus on legal matters we give more weight to the statements of a lawyer than a plumber. Discourse is different to communicative action: the latter occurs when there is meaningful interaction between persons, and the former when there is imbalance in communication, when one party challenges the assumptions of the other [23,24].

Language is characterized by rules that may change according to the background and cultural perspectives of the participants [41]. It is also a key expression of the concept of narrative. Narrative is underpinned by the use of language. Narrative theory gives us the concept of the fabula [42], which is the basic story material that we try to interpret, and to which we give structure. In the modern medical context, that fabula can be organized into an oral form, then a written form, and now may undergo a further processing, as the doctor places information about the patient into the computer [43]. The information changes in form at each level of processing. The conversational process aims for doctors and patients to come to a common understanding [44], and it is by listening to their stories that doctors can come to a deeper understanding of their patient’s lifeworld [45]. The narrative provides much more information than the bare bones of the disease.

The dichotomy created here is in the different lifeworlds—where humans think in terms of this fabula—which in turn is reduced to data by the doctor placing information in the record [46]. A complex human process is therefore transformed into a series of data points that the computer can understand—and must therefore be similarly transformed. This constant transformation and interpretation is at the heart of the new relationship.

Nonverbal Behavior

There has been considerable research on the significance of nonverbal cues in medical practice.