Letters to the Editor  |   June 2018
Patient Engagement in Coauthored Medical Records
Author Notes
  • University of Pittsburgh, Johnstown, Pennsylvania 
Article Information
Evidence-Based Medicine / Practice Management / Professional Issues / Psychiatry
Letters to the Editor   |   June 2018
Patient Engagement in Coauthored Medical Records
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 361-362. doi:
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 361-362. doi:
To the Editor: 
In the February 2017 issue of The Journal of the American Osteopathic Association, the article by Warner et al,1 “Use of Patient-Authored Prehistory to Improve Patient Experiences and Accommodate Federal Law,” introduced a shared decision-making approach to the medical interview by requesting that patients complete a standardized health questionnaire in advance of their face-to-face appointments. Results of this study revealed improved patient satisfaction, efficiency in determining chief complaints, increased accuracy and completeness throughout the diagnostic process, and adherence to federal privacy and safety regulations. 
Despite these encouraging findings, questions remain as to whether this method sufficiently addresses the physician financial demands and growing time restraints brought on by broad adoption rates of electronic health records (EHRs) and the mandates of the Health Information Technology for Economic and Clinical Health Act of 2009.2 Time and money may be saved in length of visit, but scanning, uploading, and reading the information immediately before the patient interview requires preparation time that might be better spent gleaning the information directly from the patient through guided questioning. Although the authors address these issues, further consideration is warranted. 
To begin with, Warner et al1 believe that the prehistory lessens the need for the open-ended greeting, “So what brings you here today?” and allows both the patient and physician to jump right into the crux of the problem. However, this familiar start provides a necessary icebreaker for patients, especially those who are new or who might be afraid to bring up a more sensitive topic (as is commonly demonstrated when a physician's hand is on the door handle ready to leave and a patient states the real reason for the visit). The introduction functions as more than a way to seek information; it is a critical part of relationship development. According to Cegala et al,3 small talk is defined as “utterances comprising social talk/chitchat on nonmedical topics [including] opening and closing rituals.” It facilitates patient rapport by helping to equalize the hierarchical nature of the patient-physician dynamic and to afford a more comfortable, patient-centered, safe environment that nurtures self-disclosure, self-confidence, and self-reflective insight. Small talk serves a purpose. Jumping right into the diagnostic phase after asking a few clarifying questions theoretically sounds efficient, but it lacks a relationship-building atmosphere at the start of the interview. In the relationship escalation model4 created by Knapp, the first stage of “initiation” must occur even in the event of an emergency visit. The length of this introductory phase would necessarily be abbreviated. In less urgent primary care visits, relationship development not only facilitates what Goffman5 calls “impression management” of both the physicians and patients, but it also allows patients to gain comfort with and confidence in their physician while increasing the likelihood of medical advice compliance and overall shared decision-making. 
Beyond the introductions, the prehistory notably serves well in facilitating patients with “communication apprehension,” which refers to “an anxiety syndrome associated with either real or anticipated communication with another person or persons.”5 Typically associated with public speaking,6 this disorder may exist in any communication context using any medium of disclosure7 and can be particularly problematic when people experience language or cultural barriers,8 interact with those perceived as having higher authority, or participate in patient-physician interactions. The prehistory in this case may be an excellent resource in that it allows patients to fill out the form in the comfort of their own home. By gathering information ahead of time, patient apprehension can be minimized during the visit with the physician's awareness of the key health issues that need to be addressed. Time in this case might be saved in trying to ease patients into discussions and providing specific information relating to the problem in a manner commensurate with the patient's language, cultural, educational, or medical literacy challenges. Through subsequent face-to-face appointments, physicians may be better able to adapt to the personal needs of patients, especially when such barriers exist. 
The suggestion by Warner et al1 to have future prehistories built into the patient portal to avoid transcribing errors is of critical importance. If decisions are truly to be shared by both physicians and patients, then (1) the actual words of the patients’ narratives need to be recorded in the EHR by the patient rather than scanned; (2) compliance would likely be improved because electronic reminders (such as emails or text messages) could be sent from the portal, making it more likely for patients to fill out the questions ahead of time and less likely to forget the form at home; (3) patients could be encouraged to adjust their EHRs after their initial visit when additional information is recalled or misinformation is noticed in the records; and (4) patients who participate in this process could witness the effect of their documentation and realize their responsibility in health outcomes. 
The authors1 deserve accolades for their admirable focus on patient narrative, efficiency of the visit, and desire to meet federal laws while adhering to the individual needs of patients. Researchers, educators, and health care professionals alike must recognize the importance of the humanistic “art” of communication in an effort to realize that all medical interactions ultimately involve relationship development and communication skills. Patients benefit from reviewing and pondering prehistory questions and could likewise benefit from entering these directly into the EHR. Patients should act as their own advocates by taking responsibility for the accuracy of their own medical records in an effort to facilitate shared decision-making and, ultimately, to assure safe, effective, participatory care. 
As Lawrence L. Weed, MD, so aptly stated, “a true evidence-based medicine system could develop if evidence would be used to individualize care rather than standardize it.”9 Medical interviews follow a prescribed pattern. Patients need to know that pattern of questioning and be prepared to answer accordingly. However, standardization and efficiency—no matter how accurate—should not replace the one-on-one, give-and-take, conversational dynamic so necessary in the patient-physician relationship. 
Warner MJ, Simunich TJ, Warner MK, Dado J. Use of patient-authored prehistory to improve patient experiences and accommodate federal law. J Am Osteopath Assoc. 2017;117(2):78-84. doi: 10.7556/jaoa.2017.018 [CrossRef] [PubMed]
Health Information Technology for Economic and Clinical Health Act, S 123, 111th Cong (2009). [PubMed] [PubMed]
Cegala DJ, McClure L, Marinelli TM, Post DM. The effects of communication skills training on patients’ participation during medical interviews. Patient Educ Couns. 2000;41(2):209-222. [CrossRef] [PubMed]
Knapp ML. Social Intercourse: From Greeting to Goodbye. Boston, MA: Allyn & Bacon; 1978.
McCroskey JC. The effects of communication apprehension on nonverbal behavior. Commun Q. 1976:24(1):39-44. doi: 10.1080/01463377609369208 [CrossRef]
McCroskey JC, Beatty MT, Plax TG. The content validity of the PRCA-24 as a measure of communication apprehension across communication contexts. Commun Q. 1985;33(3):165-173. doi: 10.1080/01463378509369595 [CrossRef]
Daly JA, ed. Avoiding Communication: Shyness, Reticence, and Communication Apprehension. 3rd ed. Cresskill, NJ: Hampton Press; 2009.
Kim MS, Klingle RS, Sharkey WF, Park HS, Smith DH, Cai D. A test of a cultural model of patients’ motivation for verbal communication in patient-doctor interactions. Commun Monogr. 2000;67(3):262-283. doi: 10.1080/03637750009376510 [CrossRef]
Jacobs L. Interview with Lawrence Weed, MD—the father of the problem-oriented medical record looks ahead. Perm J. 2009;13(3):84-89. [CrossRef] [PubMed]