Information in the consulting room (iiCR)

2. Information in the consulting room(iiCR) Research and Development

3. iiCR team Nick Booth Judy Kohannejad Paul Robinson (PRODIGY evaluation team) (Durham and Darlington EHR project team)

4. Health Informatics applied to real practice

5. The Triadic Consultation COMPUTER DOCTOR PATIENT

6. The triadic consultation • Maintain rapport with the patient while using the computer • Explain risk and evidence • EBH for patients

7. The triadic consultation If we don’t get this right the (new) NHS will not work.

8. Background Drives to use the computer in consultation • Changes in clinical practice • Clinical governance Problems with using the computer

9. iiCR: aims • Identify the skills that help the GP to maintain rapport with patient and use the computer during the consultation. • Develop and pilot a teaching package that supports the training of GPs and the development of these skills. (Calgary-Cambridge Guide)

10. iiCR: phases of the project • Phase 1: video-tapes of GP consultations (grounded theory) • Phase 2: simulated patient consultations with immediate facilitated review of tape (IPR, Calgary Cambridge) • Phase 3: iterative development of teaching package (action research)

11. Research Questions • Can these skills be identified? • What are they? • Can they be taught? • Can people divide their attention?

12. 3 types of behaviour: Controlling (the flow of consultation) Responsive/ Opportunistic Ignoring iiCR: what we saw

13. iiCR: what we saw 3 strategies: • Signpost • Blather • Respond (every time)

14. Developing the teaching packageAction Research • Range of professional groups • Community nurses • GP Trainers (5 groups) • Pharmacists • GPRs • Iterative development • Findings of one session fed forwards into the next

15. Messages we are trying to get across • Computer use is increasing, and the use of paper-less record systems and the availability of online decision and information support mean that practitioners are increasingly likely to use the computer during the consultation • Most GPs habitually do record-writing after the patient has left the room: using the computer during the consultation requires a change of behaviour.

16. Messages we are trying to get across • Concentration on the computer screen does carry the risk of losing rapport with the patient. • The key is to avoid trying to attend to the patient and the screen at the same time: in this context multitasking does not work. • There are specific communication skills that can be used to minimise the risk of losing rapport. • These skills are not difficult and they can be learnt and taught.

17. Competencies: Rapport • Adapts behaviour to take into account relative position of doctor, patient and computer • Maintains open posture when using computer • Uses verbal and non-verbal behaviour to indicate when attention is being paid to the computer screen • Controls, or takes advantage of, the structure of the consultation in order to minimise risk of patient talking when doctor’s attention is on the computer • Responds to patient cues when attending to the computer

21. Competencies: Involving the Patient • Explains to patient why computer is being used • If the computer is to be used as an information source, negotiates the use of such information with the patient • Lets the patient read information from the screen when appropriate

22. Competencies: Explanation and planning If using screen-based information (shared screen, PIL etc) • Checks that patient can see the screen clearly • Remains quiet, and gives the patient time to read the text • Checks that patient has understood the text • Gives patient opportunity to ask questions • On a busy screen indicates (points etc) relevant information

23. Methods used • Facilitated group • Role-play, simulations • Video tape and replay (Calgary Cambridge)

24. Issues • Simulated or real consultations • Separate topic or part of consultation skills teaching • Why as well as how • Changing behaviour • Changing role