Flipping the EHR: A Trust Builder

Over the next several weeks, I will devote this letter to writing about the winners of the ABIM Foundation’s recent Trust Practice Challenge. The Challenge asked for practices that built trust across a wide gamut of relationships in health care, including between patients and physicians, patients and health care organizations, and clinicians and health systems.  We received 68 submissions, and expert judges selected eight winners.  These practices serve as concrete examples that allow organizations and clinical practices to be more intentional about how to build trusting and respectful relationships with patients, colleagues and organizations. My letters will summarize what I learned from each fabulous practice. 

Like you, when I see physicians, I am annoyed when they pay more attention to the electronic medical record (EHR) than to me. Many physicians are equally annoyed, and view EHRs as a burden and a prime source of burnout. University of Chicago Medicine is experimenting with seeing the EHR in a different light, one that can promote communication and understanding rather than impede it.  One simply way to do that is by flipping the EHR: turning the screen for the patient to see what the clinician is typing in the EHR about the visit.

That is only the beginning of the story. The health system has used graphic medicine – a comic– to educate patients about core advocacy behaviors during office visits. The comic is entitled “Computers in the Clinic:  YOUR ROLE!” and uses an ABC format. The first advocacy behavior starts with A – Ask to see the screen; ‘B’ stands for Become Involved (review your records with your doctor) and ‘C’ is for Call for Attention (when you have something sensitive to discuss). A curriculum on patient-centered EHR use for medical students, residents and faculty was also developed.

According to Lolita Alkureishi, MD, at its core this practice relies on trust. “A patient needs to trust that their relationship with a provider is one that allows them to ask questions without fear of upsetting their provider or appearing as a challenging or ‘difficult’ patient,” she said. “Providers learn how to leverage the EHR as a tool to enhance communication and patient education.” Flipping the EHR and turning the screen causes a shift in the perception of an EHR as a technology in the proverbial dog house—the villain, and cause of burnout—to a valuable patient engagement and education tool.

It is interesting to note that African-American and Hispanic parents of patients were more likely than White parents to remind the clinician to let them see the screen after reviewing the comic and to ask to be involved in their computer use, according to patient surveys.  Also, lower education levels were associated with higher rates of self-advocacy.

I was impressed by the many ways this practice enhanced trust.

How does this practice build trust?

• Empowerment: Patients with tools to advocate for themselves will feel more empowered and more trusting of their providers.
• Engagement: This practice gives parents and patients permission to ask more questions and get the information they want. The patient becomes more engaged in her care and not just a passive listener. I think this was largely because they had more trust.
• Nothing about me without me: The practice creates a certain amount of transparency that creates trust.
• Focus on the patient: The message that is driven home is that my physician cares about me. Caring and compassion are the key to building trust.
• Diminished power differential: With both the physician and patient/parent looking at the EHR screen and sharing information, the power differential is reduced and patients feel in greater partnership with their physicians. Trust grows.

This practice truly transforms this technology into a real asset – a trust builder and maybe an antidote to clinician burnout.  Now that is a real flip.

To get more detail on all of the Trust Practice Challenge winners, go to https://abimfoundation.org/what-we-do/initiatives/trust-practice-challenge

Daniel B. Wolfson
EVP & COO, ABIM Foundation