Advances in digital technologies are revolutionizing our society in multiple domains, and medicine is no exception. An increasing number of patients are openly or covertly recording their medical encounters, typically on smart phones, so that they can re-listen to the clinical discussion, revisit and clarify often-forgotten medical information, share the encounter with family members or caregivers, and monitor between-appointment progress.1,2,3
The opposite slide of the coin occurs when physicians create digital recordings of patient encounters. In what way might this be beneficial to physicians and patients? Are there any downsides?
To shed further light on this issue, MPR interviewed James Ryan, DO, a family physician in Ludington, Michigan, and co-founder/co-director of The Small Brain Records Project, an “open source, problem oriented, multimedia integrated, collaborative tool for clinicians who wish to explore” the integration of digital technologies into clinical practice.
Is the use of audio recordings during patient encounters a new phenomenon?
Audio recordings are not new. Personally, I’ve been offering to record visits since 2011. But increased use of this technology is definitely the wave of the future.
What are the main benefits of digital recordings of patient encounters?
The biggest and most important benefit is that recording a patient encounter is an opportunity to capture more accurate and complete information, which is what we ultimately can use to advance our knowledge of clinical science. As a field, we are moving at a fairly rapid pace towards greater reporting of measurements such as blood pressure, laboratory values and many others. This is a normal and natural evolution and is how we grow to understand more from a clinical point of view.
I regard clinical audio recordings as another type of data that is a more accurate, objective capture, compared to the writing of notes after the patient encounter is done. Historically, we include the most important aspects of the clinical encounter in our notes, which is appropriate, but we also lose what we don’t deem to be important. We don’t know whether any information told to us may turn out to be of value. Notes are often written in haste and under pressure, which can also contribute to the problem. So there can be a failure of our clinical records to relay as much information as they should, considering that we use them to advance our clinical knowledge. An audio recording is a natural use of a stable technology.
Could you speak more to the potential role of these recordings in research?
We can form a much more complete understanding of the human condition if we can capture subjective data in addition to quantitative data. For example, mental health conditions and subjective issues such as pain can be understood and ultimately helped by an audio recording of how the patient describes his or her experience. With enough recordings we can start to understand how the way we express our feelings may impact what test may lead to an improvement of our health. I hope it will also help us clinicians more effectively communicate to our patients some of the more complex aspects of clinical decision making.
For me as a PCP, patients with certain mental health conditions can be very challenging. If you tell someone that their blood pressure it out of range and such-and-such medication is effective for controlling it, and the individual is healthy when it comes to life management, the situation is relatively simple. I call in a prescription for that medication, it works or it does not, in which case it might be titrated until it works, or the person is switched to a different agent.
But for some people with mental health conditions, prescribing, monitoring, and remaining on top of adherence can be more difficult, and benchmarks of improvement are harder to quantify. Much more rests upon the patient’s subjective experience. The journey towards controlling blood pressure can have many steps and with our current reporting process we fail to recognize small steps towards this valuable goal. So recordings can be an extremely helpful way of capturing the person’s experience and also encouraging the patient to continue the regimen.
How do your patients feel about being recorded?
I leave it up to the individual patient whether or not to be recorded. Most of my patients are comfortable. I would estimate that perhaps 5% or less refuse. For some patients, becoming comfortable can be a large shift, but the history of medicine is filled with advances that challenge the prevailing culture. For example dissections were prohibited, leading to extremely restricted anatomical knowledge. That changed as people gradually overcame the fear, and then an entirely new dataset was available that went on to change the concept of the physiology in the human body.
Certainly, we shouldn’t just rush in like unruly children, but if we don’t move forward, we won’t grow through this change.
What types of recordings do you create, and how are they used?
When I am recording, I have a large screen in each room. I am most interested in problems and task management in chronic complex care. Everything is broken down into problems, and tasks to manage those problems. When patients and caregivers log in, we have messaging that follows those problems or tasks. If the patient is in the system the screen will clearly indicate that the visit is being recorded. There is a pause button that can be pushed in case they don’t want to have something recorded.
What are the nuts and bolts of the recording process?
The real question is how to maximize the utility of recording and minimize the disruption that it could introduce into the doctor-patient relationship, so that is not a one-size-fits-all.
Our system is Web-based and the recording occurs in the browser and is securely uploaded into their chart. Patients are shown how to log in when they wish to access a copy of their recording as it is integrated into their clinical chart.
It is the same interface that we use when we are actually in the room during their appointment on the screen. So when they see me, they can watch me click into a problem called, let’s say, knee pain and read the sentences I write. Whatever orders or recommendations arise are also added into the problem. Patients can access the whole visit, but since the recording is annotated, they can go directly to the discussion of a particular problem or task. Accessing the system is particularly helpful when patients have out-of-town relatives who collaborate with their care – especially in the case of the elderly – who can log in to the system and hear the entire appointment.
Are there any down sides to recording patient encounters?
Audio files are larger and so they cost more to store, but, technologically we are at a fairly good curve in the slope and the cost of storage is diminishing as this becomes more popular.
Are there any privacy concerns in recording patient encounters?
All electronic records must have the technology to ensure privacy and audio recordings are no exceptions. The same methods that protect written documentation within the patient’s electronic record will protect audio as well.
Are there any medicolegal concerns in having patient encounters recorded?
I would be very concerned as to why any physician would not want to be recorded if he or she is practicing appropriately. In fact, I think recording is a very good idea from a medicolegal point of view, so there is no “he said-she said.” Every discussion is documented more thoroughly than it would be in a hastily written note by a busy physician. If you have warned the patient about a potential negative outcome of a procedure, for example, or adverse effects of a medication or risk factors for a disease, it is easy to forget to document those details. But an audio recording would capture all of those discussions.
- Elwyn G, Barr PJ, Piper S. Digital clinical encounters. BMJ. 2018 May 14;361:k2061.
- Elwyn G, Barr PJ, Castaldo M. Can Patients Make Recordings of Medical Encounters?: What Does the Law Say? JAMA. 2017 Aug 8;318(6):513-514.
- Rodriguez M( Morrow J, Seifi A. Ethical implications of patients and families secretly recording conversations with physicians. JAMA. 2015 Apr 28;313(16):1615-6.