Technology and the Doctor-Patient Relationship

Dr. Valerie Press' work primarily focuses on improving patient-centered education for underserved patients with chronic disease and limited health literacy through novel interventions in the community and hospital settings targeted at both patients and clinicians. Dr. Matthew Sorrentino will discuss Dr. Press's latest research projects.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Sorrentino: On today's episode of The Clinical Excellence Podcast, we have Dr. Valerie Press. Dr. Press will talk to us about technology and the doctor-patient relationship.

[00:00:14] Dr. Press: We do find that adults hospitalized with asthma or COPD here at this hospital regularly don't have the right skills to really get that medicine into the lungs from the inhalers. And this is not their fault, this is across the US and globally.

[00:00:30] Dr. Sorrentino: We are back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute. During this podcast, we discuss, dissect and promote clinical excellence. We review research pertinent to clinical excellence, we invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors.

I'm Dr. Matthew Sorrentino, and today I'm joined by Dr. Valerie Press. Dr. Press is an associate professor of medicine in the section of general internal medicine and pediatrics at the University of Chicago Hospitals. Her research focuses on improving patient-centered education for underserved patients with chronic disease and limited health literacy through novel interventions in the community and in the hospital settings.

Dr. Press, welcome to the program.

[00:01:21] Dr. Press: Thank you so much for having me.

[00:01:23] Dr. Sorrentino: Let me start with just the observation that technology has inundated our lives, it's now inundated medicine. There's the ubiquitous use of cell phones, and we're finding now wider use of electronic medical records. There's all these patient portals that patients have to communicate with us.

In your experience, in your practice, how well have patients adopted these technologies as methods of communications between their concerns and their health team?

[00:01:52] Dr. Press: That is a wonderful question and actually is one of the questions I'm trying to answer with my research, so I absolutely love it. Generally speaking, the answer is there is a wide variety.

There are many patients that really use these technologies optimally. They are active on their patient portals. It allows them to have really great and direct communication with their clinicians. They're active on the web, looking up information, they're downloading health apps or watching health videos, and they're really engaged.

Um, there are many individuals though, for a variety of reasons, which we can talk about during this session, um, that may challenge these patients to be able to optimally use them. Things like access to technology services or technology devices. Things like limited electronic health literacy and other kinds of barriers, which wouldn't allow them to use them as optimally.

And there's also choice. Some individuals don't want to take the time to learn or don't want to use technology to interact with the healthcare system for other reasons.

[00:02:47] Dr. Sorrentino: Yeah. I've certainly had some of my patients who say, "Can't you just call me on the phone? I don't want to use that electronic medical record anymore."

I know one of your Bucksbaum Institute pilot grants was designed to develop a family technology survey to understand patients' and patients' family members' preferences for and access to these technology-based services and education. Can you describe some of the questions you were asking to try to get an idea of what your patients are willing to do?

[00:03:21] Dr. Press: Absolutely. And this is a great way to start off in some of the research to answer that first question you ask is, how are patients using this technology? Um, so one of the things we were learning in some of our earlier research before this study was that large range of use. And one of the things that occurred to us is if it had to do with any issues of access to technology and/or ability or willingness to use the technology, perhaps it would be helpful to phone a friend or caregiver or a loved one.

And so, this project was focused on asking both patients and their caregivers about their interest in, willingness to use, caregivers to help them and even their own practices. So our questions focused on everything as simple as, "Do you have a caretaker in your life?" "Does that caretaker help you with technology?" "Would you want them to?" "Um, how could they be helpful?" "How are they helpful?"

So it's just kind of a range of descriptive questions that could really help us understand using caregivers, as you mentioned in my intro that I'm both an adult doctor and a kid doctor, and with kids we bring parents and family members or caregivers in all the time. So the idea was, could we also support our adult hospitalized patients once they go home to use that same resource?

[00:04:28] Dr. Sorrentino: So I know you're just starting some of these surveys, but what were some of the initial responses? Are patients willing to adopt technology or is there still kind of a push going back to the old ways of doing things?

[00:04:42] Dr. Press: Yeah. So we have a wide range. We have many individuals who interestingly note that they have a lot of interest in using technology among those who aren't currently using it. So that's why it's really helpful to understand, well, what are those barriers? There are a smaller number of individuals who aren't interested, but I think the interest is out there, and then it's whether or not they can actually get the help they need, get the access they need, et cetera.

[00:05:05] Dr. Sorrentino: Do you find that most people are willing to use a technology if it's a cell phone, since that seems to be what everybody has? Or is it more computer-based still? The laptop computers and desktop computers where people are willing to go onto their medical records?

[00:05:23] Dr. Press: Yeah. There's actually, um, differences here.

Some of it is age-based. There are some of our older patient populations who do prefer perhaps, due to their vision or just their kind of older use of the bigger laptops or computers than the smaller devices. I won't say we can generalize too much, but there are some indications that there might be some age-based preferences.

Overwhelmingly though cell phones, um, both in my research and others' research do seem to be popular, but it raises an important point about access. We used to think there was a digital divide because people didn't have a laptop, a computer, even a cell phone. Now about three quarters of individuals have at least a cell phone in their pocket, but they don't have equal access to internet.

There are some zones in our city and across the country that can't reliably connect to the internet, which could limit, even if they have the willingness, their ability to do that.

[00:06:12] Dr. Sorrentino: Are there other barriers that you have found? I especially worry about some of my older patients. I see some of my patients, when they come into the office, they pull out their cell phone to show me something and they get so lost with all the apps and don't even know how to sometimes turn it on.

Are there other barriers that you have found in talking to some patients that we can maybe help with education for them?

[00:06:36] Dr. Press: Absolutely. No, that's a great point. And that's part of what led to that caregiver study, was that exactly. So we have noted vision issues. So I've developed some technology-based interventions using focus groups, and we definitely note that individuals not only older, but that have vision issues, the screens can just sometimes be too small to have the font size that's needed. There is also just that familiarity. So while many individuals are comfortable using a phone to make a phone call, even text, possibly go to the internet, downloading and updating apps can be difficult. So we have definitely seen that education can go a long way.

So you could think about having a patient navigator in a clinical setting, um, having an educator or even having a caregiver help them.

[00:07:15] Dr. Sorrentino: I know you've also been studying how technology may help hospitalized patients with exacerbations of their acute medical conditions. You were working on a project that will focus on pain control of hospitalized patients with sickle cell pain crisis.

How do you see that working? How do you propose that technology may be used in the management of both the sickle cell patients, but in any chronic illness where a patient comes into the hospital?

[00:07:40] Dr. Press: Oh, absolutely. Yeah. So in terms of focusing on patients with pain crises who have sickle cell, this was actually an idea that I learned about when I was at an NIH seminar where someone was presenting on their work from UCLA in the pediatric population, they were testing virtual reality as a way to help pediatric patients who are having pain that had sickle cell distract themselves and be engaged in something. And they noted that pain scores went down when using the virtual reality. I'm part of many different clinical programs here, some of which help address the needs of our patients with sickle cell. And since I have already been studying this area of technology, I thought, why don't we explore this in the adult hospitalized population?

So we look forward to learning if our patients are already using this as a technique, we don't know that whether something like virtuality is something we should also test and other types of technology support.

[00:08:28] Dr. Sorrentino: Whoever thought that we'd be recommending, um, video games to our patients in the hospital to take their mind off of pain? But hey, it may work better than opioids, I suppose. Right?

[00:08:38] Dr. Press: It really could. Um, I think there's often a misnomer that patients in pain couldn't possibly watch TV or be on their phone. And so if we see them doing those activities, we think, "Huh, they must not be in pain," when actually it's probably, whether it's known to the patient or not, a mechanism to help them deal with the pain that they're in.

[00:08:55] Dr. Sorrentino: So many of our patients have chronic illnesses and we assume that they listen to our advice and know how to use their medications and take their medications. I know in an earlier project you showed that the proper use of inhalers and adherence to inhalation therapy in patients with chronic COPD was much lower than I think most of us expect our patients can do with these type of therapies. Can you describe some of your work with, uh, virtual teaching and how this can help patients with chronic illnesses like COPD adhere to and understand their therapies better?

[00:09:33] Dr. Press: Oh, absolutely. So this is a topic near and dear to my heart. For over a decade, I have been studying this topic.

We do find that adults hospitalized with asthma, or COPD here at this hospital regularly don't have the right skills to really get that medicine into the lungs from the inhalers. And this is not their fault, this is across the US and globally. So we've done some initial intervention studies in the hospital setting that really show using the right techniques of education they can learn. Now, with any skill-based learning, it's not usually a one-and-done learning session. So if we teach them in the hospital and we don't provide more teaching, they're going to lose those skills without practice. So we did, with gratefulness to the Bucksbaum Institute, get some funding to look at this virtual program.

So what we were doing, um, because the pandemic was sort of limiting opportunities for interprofessional clinical settings, we were able to harness inpatient visits with our advanced practice nurses when they followed up after being hospitalized for COPD, and then connect them to pharmacists or pharmacy students via Zoom to get the inhaler teaching from our pharmacy team.

So this was a hybrid in-person/virtual education to provide some of that repeated education after they had been taught in the hospital setting.

[00:10:41] Dr. Sorrentino: It's interesting that you said you're using the advanced practice practitioners and the pharmacists. How much should we be teaching our physicians the proper way of teaching these methods to our patients? Is it part of the problem that we as physicians just don't have the time to sit down with the patient and teach them the proper technique? Should we be really getting the rest of the care team involved in these teaching programs?

[00:11:07] Dr. Press: That's a wonderful question and something I've also been looking at. Just over a decade ago, I actually surveyed about 119 resident learners across the city of Chicago, and many of them also needed such teaching.

So we developed a program here, which we still do to this day, where we teach residents at least that they're hard to use and that our patients don't know how to use them. And we do provide some training on the inhaler devices. That said, we are busy in our clinic visits and sometimes it is more optimal to work across our care team. And there are many different devices, so to ensure that all of our physicians are experts in all of the devices might be difficult, but having awareness that there are problems with use and then knowing to bring in a team member at the appropriate time can be very helpful.

[00:11:48] Dr. Sorrentino: It seems to me that the more you go over something, just the repetition, you're going to get better understanding, better knowledge, better adherence.

So do you see these programs occurring like once a quarter, once a month, or that we constantly recontact patients with some of these programs so that we make sure they keep their learning skills at a very high level?

[00:12:09] Dr. Press: That's a great question. So really you're talking about dosing, both frequency and number of doses.

And we're actually fortunate enough to be funded by a federal agency to develop an expanded virtual training program that wouldn't just be situated in our clinic that I just described, but this virtual opportunity would also allow for training in patients' homes. And in that study we'll be able to look at how long should we go between doses, how many doses are needed to really develop that skill and really have long-lasting results.

[00:12:38] Dr. Sorrentino: So you said you've developed this virtual program. Is this like a video that is done that they can, patients can access through their phone? Is it a phone call? How exactly does it work?

[00:12:49] Dr. Press: There are two virtual programs. I've been primarily talking about more of a televisit type format where it's two live individuals, a patient and an educator, participating over a video conferencing type session.

I also have developed a virtual program that is more like an interactive module, so there's a video component and also some questions that a patient can do on their own time. And what's nice about this module is, it uses adaptive learning technology. So if they watch the video and they answer the questions and everything's right, they're probably pretty good with their skills.

Most patients though, have some learning opportunities, so if any of those questions are incorrect, it just points them back to the video. They can watch it a few more times and then develop those skills. Dosing for that is also unknown, and that's part of what we'll be learning about in this new grant.

[00:13:32] Dr. Sorrentino: So they potentially can do it over and over again until they get it right.

[00:13:35] Dr. Press: Correct, as much as they need. Exactly.

[00:13:36] Dr. Sorrentino: Fantastic. Good. Well, you know, the world has changed these last two years. Covid has introduced many of us to telemedicine. Many of us didn't do much telemedicine before the Covid pandemic, and now of course, we're seeing many of our patients on screens instead of in-person.

What do you see are some of the strengths and also some of the weaknesses of using this type of technology to care for our patients with chronic diseases? Is it hindering? Do we really need to see these patients every couple of months in the hospital or is that touch with a televisit able to enhance care?

[00:14:13] Dr. Press: Yeah, that's a great question. I mean, I think it's a mixed picture. I think that there are a lot of strengths, a lot of our patients with chronic diseases, if you want to take patients with chronic obstructive pulmonary disease, for instance, they're often on oxygen or it's difficult for them to move around with breathing issues, so having a televisit could be ideal.

That said, many of these patient are in the older bracket, age bracket and may have some of the limitations that we've mentioned earlier about using that technology. There are also wonderful opportunities to provide some of the educational materials that we just discussed that we don't always have time for in a clinic visit.

So there are definitely opportunities. I think one important thing to keep an eye on in any technology-based intervention is that we don't widen any health disparities, so that if we are developing technology-based interventions, that we vet it thoroughly across different subpopulations of our patients to ensure that they have equitable access to these opportunities.

[00:15:08] Dr. Sorrentino: I think it probably depends a lot on what we're following up with on patients as well. And some of the televisits I've done have worked really well. Patients where I'm just following up on their blood pressure and I know that they're taking accurate blood pressures at home. Some patients that I see with heart failure trying to assess if they're in heart failure over a televisit has been hard.

I remember one patient trying to lift up her leg into the camera to show me how much swelling she had, and I was afraid she was going to fall off her chair. So, I think certain things may work better, I would expect on these televisits, then in others we just have to have the patient come back to the office.

[00:15:42] Dr. Press: That's a great example. And you could also think about how we have the option to do phone or video visits with these televisits. And similarly, if you're trying to teach how to use an inhaler, that's more difficult over the phone, whereas video would be okay in that instance as would in person...

[00:15:55] Dr. Sorrentino: Because you can show them.

[00:15:56] Dr. Press: Because you can actually show them, here's how you do it, and you can also see them. How are they doing it? So you can kind of go back and forth.

[00:16:01] Dr. Sorrentino: Yeah. Well, this is great. I think all this work is really exciting. Obviously we've got to figure out a way of getting out of the office and following up on our patients and patients with chronic disease, these different areas that we can touch them, hopefully will teach them the right way to take their medications, make sure that not only they're adherent, but they're doing well with these medications, and we can see how they're doing.

What's your next step? What's the next major project you want to work on?

[00:16:31] Dr. Press: Well, I think one of these major projects is really working with our patients to develop this televisit program that can happen across settings. We can provide visits in the hospital setting if they're hospitalized, in the clinic setting, but also importantly, as you noted, at home, that added convenience.

But developing that program with our patients such that we overcome the barriers that we've already discussed so that these opportunities are equitable. So I'm very excited about that next step.

[00:16:57] Dr. Sorrentino: Well, thank you, Dr. Press, for going over your work. It's really an exciting area, and I want to thank all of you for joining us on this episode of The Clinical Excellence Podcast.

We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez. Thank you everybody.