Digital clinical encountersBMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2061 (Published 14 May 2018) Cite this as: BMJ 2018;361:k2061
- 1Dartmouth Institute for Health Policy and Clinical Practice, Lebanon NH 03756, USA
- 2Ryan Family Practice, Ludington, MI, USA
- Correspondence to: G Elwyn
Many patients already record clinical encounters, usually on smart phones.1 Data on the prevalence of this behaviour are being collected and already indicate that it occurs in most clinical settings.2 UK patients are not breaking the law when they record their visits; in other countries, the law might be more complex.3 Whatever legal frame might exist, we predict that more and more patients will make a digital recording of clinical conversations and that health systems will follow. In the advent of powerful artificial intelligence (AI) the broad implementation of audiorecording in healthcare could greatly benefit both patients and clinicians, but risks also exist, and clear principles to guide the collection and use of recordings must be established from the outset.
Patients make recordings so that they can relisten to the clinic discussion and share it with a family member or care giver. They can revisit and clarify medical information that is often forgotten, check that they have clearly communicated important information to their clinician, and monitor agreed treatment goals before their next visit.4 Few patients are motivated by an intent to prove neglect or wrongdoing.1 Lawyers, reviewing the practice of giving patients copies of recordings, thought that it did not add to the risk of malpractice complaints.5
Organisations are puzzled about how to handle patients’ requests to record encounters, with few policies to guide them. Yet a handful of clinics in the US are taking a proactive approach.2 A cancer clinic in Texas offers patient digital recorders to capture their visit information,6 and a neurological institute offers patients video recordings of their visits that are accessible on a secure website.7 One doctor in Michigan has been offering to record clinical encounters since 2011.8
When talk can be transcribed into an accurate digital record that in turn could be automatically coded, the potential of abandoning the keyboard could bring back some sanity to a clinical process that has become weighed down by data entry. The move to fully digitise the clinical encounter becomes the next logical step on the journey towards a more accurate record of clinical interactions.910 Documentation is a barrier to effective communication with patients11 and an important contributor to clinician burnout, accounting for 50% of clinician time, much of which occurs after hours. Inaccurate documentation is also associated with adverse clinical outcomes.11
Technology giants such as Google and Amazon are racing to create language processing systems that can use clinical conversations to populate electronic records.1012 The resulting digital record would provide accurate verifiable evidence of what was said and not said in clinical encounters. Recording the clinic visit could have far reaching implications for the health system and all its stakeholders. The possibilities extend beyond better documentation to novel strategies of patient and family engagement, shared decision making, education (including feedback on clinician performance), and research.
Furthermore, clinical interactions could be evaluated on dimensions that were previously considered impossible. For example, a fee-for-service model might be replaced by a payment-for-value model if payments could be based on proof of informed shared decision making. The ability to analyse the decisions that occur as diagnoses lead to actions, in terms of adherence to clinical guidance and sensitivity to context and patient preferences, could provide valuable data about practice variation.
Given the rapid pace of developments in this area, we urgently need clear guiding principles, regulation, and legal reform. The vision of a digital future for clinical encounters is disruptive, with serious implications for consent procedures, privacy, and cybersecurity. It will require a new model of health data ownership where people govern their records, as in banking systems.
Even with secure systems, the risks are ominous, as shown by recent examples of commercial companies inappropriately collecting, sharing, and exploiting vast amounts of personal data for commercial and political gain.13 Health data are commercially valuable to companies such as Google’s Deep Mind, which caused controversy by acquiring data from 1.6 million NHS patients in a partnership with a London hospital without patients’ personal consent.14 Sensitive clinical data must be protected from vulnerability to hacking, inappropriate distribution, and microtargeting: ownership, storage, and sharing systems will need to be much better defined, described, and regulated.
The digitised clinical encounter, enriched with voice data, and interrogated by AI systems will arrive soon. It is time to develop policies on how to collect, store, manage, and share these resources and to maximise the value of the data to patients and to many other stakeholders. Commercial entities, acting alone, are not the best custodians of data that have the potential for such enormous social good.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following interests: GE has edited and published books that provide royalties on sales by the publishers: the books include Shared Decision Making (Oxford University Press) and Groups (Radcliffe Press). He has provided consultancy on patient support tools for organisations, the most recent being Emmi Solutions, National Quality Forum, and Washington State Health Department. He is the director of &think LLC, which owns the registered trademark for Option Grids patient decision aids. He currently provides consultancy to Access Community Health Network, and EBSCO Health Option Grids TM patient decision aids. He owns copyright in measures of shared decision making and care integration: collaboRATE, integRATE, and Observer OPTION-5 and Observer OPTION-12. These measures are freely available for use. PB is leading a project funded by the Gordon and Betty Moore Foundation and National Library of Medicine to develop a platform that will enable patients to record clinic visits.
Provenance and peer review: Commissioned; not externally peer reviewed.