The 20-45 minute ambulatory care patientprovider encounter has critical value and potential benefits perhaps not fully realized in the 

VA today. Beyond primary care, these crucial 

encounters also occur thousands of times a day 

in VHA Specialty Clinics. For that reason, I 

invite the VA research community to describe 

or develop evidence-based best practices for 

patient-provider encounters. Such research will 

be particularly important as we transform to 

the medical home model. 

My interest in such research is based on four 

factors. First, the daily mission that drives 

us at VA Central California, a Level 2 facility accomplishing 300,000 annual visits, is 

achieving “clinical excellence in a clean and 

safe environment.” I firmly believe a positive 

patient experience, while secondary to an accurate diagnosis and effective treatment, is an 

extremely important aspect of clinical excellence. Our goal for every patient is to improve well being and achieve the best health 

outcomes. The patient-provider encounter is 

critical to this fundamental goal. 

Second, as the single most important determinant of outpatient satisfaction, “the 

physician (or provider) is the focus of the 

patient experience.”1 Of secondary importance are efficiency of support staff and 

length of time in the waiting room.

Third, VHA is committed to Secretary Shinseki’s Transformation 21 core principle of 

“People Centric” care. Overlaying that is the 

current major investment in the primary-care 

“medical home” model, which promises far 

reaching change in the delivery of VA ambulatory care. In this program “home” means 

health care that is friendly, supportive, and 

fully coordinated around each patient’s 

needs. Some have described this model as a 

fundamental transition from provider-centeredness (emphasis on provider expertise 

and patient passivity) to patient-centeredness 

(information sharing, shared decision-making, and emotional support).2

Finally, since 1996, VHA has aggressively 

surveyed, widely reported on, and made 

outpatient satisfaction a core “mission critical” measure among the Executive Career 

Field (ECF) Performance Measures. Today 

the overall “passing” standard on how 

patients rate their care is a score of “9” or 

“10” on a scale of “0” to “10.” Informally 

this is known to directors as the “WOW!” 

rating. Embedded in the SHEP survey are 

several important questions that cover, for 

example, whether or not providers: explained things in a way that was easy to understand; listened carefully to you; showed 

respect for what you had to say; spent 

enough time with you; and talked about the 

pros and cons of treatment options. Outpatient Veterans are also asked to score their 

provider or specialist on the rating scale of 

“0”—representing worst possible to “10”—

representing best possible.

Ideally much can be achieved in the ambulatory care patient-provider encounter: 

positive rapport building; emotional supFORUM

Translating research into quality health care for Veterans

Commentary

The Challenge of Patient-Provider 

Communication in Ambulatory Care

Al Perry M.P.A., M.H.A., FACHE

Director, VA Central California Health Care System

 August 2010

Contents

Director’s Letter 2

Response to Commentary 3

Research Highlight

• Exam Room Computing 

and the Physician-Patient 

Relationship 4

Research Highlight

• The Importance of 

Clinician-Patient 

Communication Behaviors 5

Research Highlight

• Safe and Effective 

Communication to 

Prevent Diagnostic Errors 6 

Research Highlight

• The Case for Communication 

Intervention 7

A publication of the VA Office of Research & Development, 

Health Services Research & Development Service, Center 

for Information Dissemination and Education Resources, in 

conjunction with AcademyHealth. 
port; shared decision-making; building trust 

and confidence in the provider; an open 

dialogue; high likelihood of adherence with 

instructions and therapy; and, of course, arriving at the right diagnosis and treatment. 

For patients, the encounter should provide 

the answer to their most basic concerns; 

“What, if anything, is wrong with me, and 

what are we going to do about it?”

The challenges in ambulatory care are 

considerable: limited space; time pressure; 

potential language barriers; patient anxiety; 

high emotion; required computer use by the 

provider in the exam room; accomplishing an ever-increasing number of clinical 

reminders; patients ranging widely in age 

from an 18-year-old Operation Iraqi Freedom Veteran to a 92-year-old World War 

II Veteran; availability of telehealth (and its 

limitations); and, in some cases, provider 

fatigue and burnout. And then there are the 

numerous patient-provider “connection” 

and approach choices, such as: handshake 

or not, white coat or not, to touch or not, 

standing or sitting, how best to engage a 

patient with the computer, how to prepare 

for visit then execute the optimal visit entry, 

interview and exam, and visit exit. 

My challenge to VA researchers is to determine what evidence-based practices VA 

leaders can draw from ambulatory care 

patient-provider encounter research. What 

have proven to be best practices at leaders 

like The Mayo Clinic, or Geisinger Health? 

How do we achieve both the desired clinical 

outcome and a positive patient experience? 

Timing answers to these questions with 

the implementation of the “medical home” 

primary-care model throughout VHA will 

be of great value to center directors, and, 

hopefully, will also help VA achieve the best 

health care possible. 

References

1. K. Otani, R. Kurz, L. Harrit, Managing Primary 

Care Using Patient Satisfaction Measures, Red Orbit 

News, August 7, 2009.

2. J. Cvengos, C. Christenson (CRIISP VA HSR&D) 

C. Cunningham (CRIISP VA HSRD), Patient Preference for and Reports of Provide Behavior: Impact 

of Symmetry on Patient Outcomes, Health Psychology

2009; vol 28 No 6: 600-67.

FORUM — Translating research into quality health care for Veterans 2

Director’s Letter

The complexity of health care delivery has increased substantially 

during the past two decades, the result of better understanding 

of disease pathophysiology, the dramatic growth in diagnostic 

evaluations and treatments, increased prevalence of chronic 

disease co-morbidity, lengthening lifespan, and the transformation of health care delivery from inpatient to outpatient 

environments. Complexity of health care delivery has increased further because of 

the unrelenting growth in health care costs and the subsequent need for greater 

efficiency of care (e.g., evaluate more patients in a given time). Reduced patientprovider communication is an unfortunate by-product of medical progress. 

Computerization provides one hopeful approach to increasing the amount of time 

available for communication. Computerization facilitates the aggregation of clinically meaningful data, the transformation of data into information, and the effective presentation of information to providers at the point-of-care. To date, only a 

barely measurable fraction of the computer’s potential impact on health care and 

time availability has been realized. The hospital and clinic patient centered medical 

home, in which a multidisciplinary team coordinates care to support the patient, 

promises not only to improve quality and efficiency of care, but also facilitate communication. Nevertheless, meaningful communication will inevitably continue to 

be squeezed by the limits of time. 

Because emotional issues are so prominent among Veteran and civilian populations, and their impact on physical health and quality of life so high, developing 

improved approaches to effective communication are more essential then ever. 

Developing simple methods to measure communication, developing and testing 

models of communication, developing new approaches to educating providers in 

the art of communication, identifying changeable factors that have a high impact 

on communication and approaches to implementing positive change, and understanding the impact of more effective communication on patient outcomes are all 

imperative research issues. 

Seth Eisen, M.D., M. Sc.

Director, HSR&D

VA Office of Research & Development, Health Services Research & Development Service August 2010
VA Office of Research & Development, Health Services Research & Development Service August 2010

The role of communication between physicians 

and patients is sometimes regarded as merely the 

soft side of medicine. Perhaps more damaging is 

that even when communication skills are valued, 

many view them as innate and unquantifiable, 

thus precluding efforts at improvement. I am 

grateful to this issue’s commentary author Mr. 

Al Perry for raising awareness of the importance 

of physician-patient communication to achieve 

clinical practice success, and for suggesting that 

this communication is amenable to quality improvement efforts. 

Good communication increases patient recall 

of information, adherence to therapy, satisfaction and, ultimately, clinical outcomes such as 

diabetic glucose control and functional status.1

Communication success and failure appear to 

generate more gratitude and complaints than 

any other aspect of the work performed by 

health care professionals and, among non-VA 

primary care providers, poor communication has 

been associated with malpractice claims.2 Most 

importantly, substantial evidence confirms that 

the individual components of good communication can be identified and that physicians can be 

taught to improve those skills.3

These data all suggest there is no conflict between achieving the “desired clinical outcome 

and a positive patient experience.” In fact, they 

are one and the same. To truly achieve the desired clinical outcome one must strive to include 

a positive patient experience. Good communication is not about just being nice. It is about finding ways to interact with patients that enhance 

their interests.

What does good communication look like? 

It starts with patients that feel empowered to 

ask questions and make their needs known. It 

continues with physicians that use reflective 

listening skills to elicit and clarify patients’ 

concerns, and that respond to empathic 

opportunities (i.e., emotional cues) with unambiguous empathic language. It includes 

the ability to negotiate and arrive at a shared 

agenda that reflects both patient and physician priorities. Finally, it requires the giving of 

information in a way that is understood and 

retained by patients and their loved ones.

Changing the Communication 

Culture

Transforming the VA into an institution 

where patients can expect such an encounter 

on every visit is not something that will be 

accomplished through a single CME course 

or innovative clinical practice. Rather, this is 

a culture change that will depend upon multiple, empirically-based efforts directed toward 

patients, physicians, and the system.

First, physicians must learn better skills. Many 

doctors have received little formal communication training or none at all. The key to successful 

training is practicing communication skills with 

observation and feedback. Intensive courses 

are the gold standard and, although these may 

seem time consuming and expensive, they can 

be cost-effective given the potential improvements in quality and cost savings from unneeded 

tests, referrals, and treatments. On the horizon 

are computer-based communication skills training programs that use physicians’ own recorded 

conversations for feedback, as well as avatars, 

and thus achieve the same results without the 

requirement for a multi-day course.

However, efforts to improve physician-patient 

communication that concentrate only on 

physician skills will never fully address the 

problem; interventions must focus on patients as well. Patients’ barriers to disclosure 

of concerns do not relate solely to physician 

behavior. A number of proven interventions 

exist that promote patients’ abilities to seek 

information, ask questions, make their needs 

known and, in general, achieve a greater sense 

of control. These include prompt sheets to 

complete prior to visits, the ability to review 

their recorded encounters with their doctor, 

and coaching to help patients formulate questions and overcome barriers to asking. Computerized approaches to such tools are also in 

development and, with added sophistication, 

have the potential to be effective and relatively 

simple to introduce into the clinical setting.

A third cutting-edge tool that can be explored 

is the introduction of direct observation of 

clinical encounters for the purposes of quality 

improvement. The VA is currently very good 

at providing feedback to physicians about 

their patients’ physiological parameters, such 

as blood pressure control or hemoglobin 

A1c. Technology exists to audio-record clinical encounters and code them for the use of 

ideal communication skills. Although more 

complicated than simply extracting an A1c 

from Computerized Patient Record System 

(CPRS), the value of the feedback could be 

significant.

Finally, true culture change toward enhanced 

physician-patient communication will require the 

alignment of incentives to reward good communication. For example, physicians are currently rewarded for completing multiple clinical 

reminders during each patient visit. Although 

worthy individual components, addressing the 

sum of them in a given visit, particularly if it 

involves detailed on-screen instructions, may not 

result in an overall patient-centered experience. 

We should look at how many of these reminders 

can be moved out of the physician-patient encounter itself (e.g., patient self-report using tablet 

PCs), so that the time spent together can focus 

on patients’ concerns.

The recognition by VA leaders—such as Mr. 

Perry—that good communication is central 

to excellent health care is a critical first step 

toward changing the culture. Communication 

research has advanced to the point where 

proven interventions are available that could 

enhance patients’ overall experiences. Both 

physicians and patients will benefit if we can 

find ways to integrate these innovations into 

the health care system.

References

1. Kaplan SH, Greenfield S, Ware JE, Jr. Assessing 

the Effects of Physician-Patient Interactions on the 

Outcomes of Chronic Disease. Medical Care 1989; 

27:S110-27.

2. Levinson W, et al. Physician-Patient Communication. 

The Relationship with Malpractice Claims among 

Primary Care Physicians and Surgeons. Journal of the 

American Medical Association 1997; 277:553-9.

3. Fallowfield L, et al. Efficacy of a Cancer Research UK 

Communication Skills Training Model for Oncologists: a Randomised Controlled Trial. Lancet 2002; 

359:650-6.

Response to Commentary

Good Communication Is Not Magic

James Tulsky, M.D., Center for Health Services Research in Primary Care

Durham VA Medical Center

FORUM — Translating research into quality health care for Veterans 3
The author acknowledges the contributions 

of the following Richard L. Roudebush VA 

HSR&D Center of Excellence on Implementing Evidence-Based Practice researchers to this 

article: Mindy Flanagan, Ph.D., Alissa Russ, 

Ph.D., Marianne S. Matthias, Ph.D., Scott 

Russell, B.S., Angela Harris, B.A., and Jason 

Saleem, Ph.D. 

Mr. Dan Deacon,* the medical director of a large 

VA facility, recently received a letter of complaint 

from Patrick Pawlson, 72, a Veteran who receives 

his care at one of the facility’s outpatient clinics. Mr. 

Pawlson complained that his physician, Dr. Eric 

Salter, “...was more interested in the computer 

screen he was typing on than me and my medical 

problems... To be honest, it made me feel unimportant and uncared for.” Dr. Salter is a general internist who has worked for the VA for three years. 

Soon after he started working at the facility it went 

“paperless” and new computer workstations for the 

Computerized Patient Record System (CPRS) were 

installed in all the clinic’s outpatient exam rooms to 

facilitate the transition. Dr. Salter is familiar with 

the use of computers to document clinical interactions 

in an electronic medical record, but he was new to 

using computers in the exam room with the patient 

present. Mr. Deacon’s job is to give Dr. Salter some 

constructive feedback to help him better integrate his 

use of CPRS while seeing patients. 

Patient-Centeredness and the 

Electronic Medical Record 

In one of its most widely cited and influential reports, the Institute of Medicine (IOM) 

asserted in 2001 that patient-centered care 

was one of six domains of quality in medical care, the others being safety, effectiveness, timeliness, efficiency, and equity. The 

report went on to state that the absence 

of patient-centeredness is associated with 

outcomes such as: lower patient satisfaction, 

poorer adherence to medical recommendations, poorer blood pressure control, higher 

glycosolated hemoglobin A1c, and greater 

propensity to sue for medical malpractice in 

the face of an adverse event. 

A lack of patient-centeredness is clearly the 

focus of Mr. Pawlson’s letter of complaint and 

should raise awareness of the entire health care 

team. At the same time, it is important to note 

that Dr. Salter has had no formal training in 

how to use CPRS with patients in the exam 

room. Recognizing that a gap in knowledge 

and skills may account for the complaint, 

Mr. Deacon decides first to give Dr. Salter a 

copy of the IOM report. He also suggests that 

Dr. Salter consider using a “communication 

coach” to help guide him in how to better integrate the computer into his daily practice, citing 

a study that showed communication coaches 

were effective in improving patient satisfaction 

in a health care organization similar to VA.1 

Computer Placement

One of the most interesting and challenging 

aspects of implementing CPRS into clinical 

workflow is the physical placement of the 

computer screen.2 There are currently no 

national guidelines for optimal placement 

and there is a great deal of variation in the 

geography of exam rooms. Our research 

team is currently working on an HSR&D 

Investigator Initiated Research (IIR) (08-

300) to study the overall effects of CPRS 

use, including placement, on physicianpatient interactions. Unfortunately, the 

computer screen in Dr. Salter’s office is in 

a corner of the exam room forcing him to 

turn his back on his patients when using 

CPRS. Mr. Deacon suggests that Dr. Salter 

explain what he is doing in CPRS and 

apologize for having to turn away to use 

CPRS. Dr. Salter states that he will look 

into rearranging the exam room to optimize 

CPRS use. 

Non-verbal Behavior

One powerful way to communicate caring 

and concern is through non-verbal behavior. Body orientation, eye contact, gestures, 

and touch are all elements of non-verbal behavior that can affect the course, direction, 

and satisfaction with care.3 Reframing Mr. 

Pawlson’s complaint in terms of non-verbal 

behavior, Mr. Deacon explains to Dr. Salter 

that too much time using CPRS will be seen 

by patients as a preference for the technology over the person. He recommends that 

Dr. Salter make it a habit of making eye 

contact every 30 seconds or so to reassure 

the patient that he is listening and personally 

attending to all concerns. 

Typing Skills

Many older physicians grew up in an era where 

typing was not a required subject and where 

dictation substituted for having to type. While 

younger physicians may be proficient typists, it 

is not usually with an audience present. Many 

physicians report poor typing skills and embarrassment at having to type in front of patients. 

Mr. Deacon asks Dr. Salter if this a problem 

for him, learns that it is, and offers to pay for 

a self-paced typing tutorial that will improve 

speed and accuracy. 

Partnership

Much technology in the exam room is physiciancentered. The blood pressure cuff, otoscope, 

and stethoscope all give the physician information that may or may not be shared with the 

patient. One of the precepts of patient-centeredness is that care is based on partnerships, 

and partnerships, in turn, are related to sharing 

information. The same holds for CPRS. As an 

educational tool, CPRS can be a rich source 

of information and guidance. Mr. Deacon reminds Dr. Salter that the word “doctor” comes 

from the old French “docteur,” meaning 

teacher, and describes how CPRS can be used 

to partner with, and educate patients.

FORUM — Translating research into quality health care for Veterans 4

VA Office of Research & Development, Health Services Research & Development Service August 2010

Research Highlight

Exam Room Computing and the 

Physician-Patient Relationship

Richard M. Frankel, Ph.D., The Richard L. Roudebush VA HSR&D Center of 

Excellence on Implementing Evidence-Based Practice, Indianapolis, Indiana 

continued on page 8
VA Office of Research & Development, Health Services Research & Development Service August 2010

FORUM — Translating research into quality health care for Veterans 5

Clinician-patient communication is the 

primary process by which medical decisionmaking occurs, and the communicative 

features of the consultation (e.g., information exchange, shared decision-making) can 

influence outcomes. Poor communication 

is associated with worse patient satisfaction, 

less trust, more complaints and malpractice 

claims, and worse health outcomes. 

Specific communication behaviors of clinicians and patients can be targeted to improve 

communication. These include patients’ active communicative behaviors such as asking 

questions, being assertive, and communicating 

concerns. They also include clinicians’ patientcentered behaviors such as being supportive, 

giving information, and building a relationship. 

Role of Empathy

Empathy is a powerful method to provide 

support, yet it is infrequently used by clinicians. When clinicians’ focus is largely 

biomedical, cognitive tasks of determining 

diagnoses and treatment recommendations 

occupy their attention. As a result, clinicians 

find that it is challenging to respond to patients’ emotional needs.

The VA HSRD Center for Management of 

Complex Chronic Care evaluated clinicians’ 

empathic responses given to Veterans undergoing work-up or treatment decision-making 

for lung cancer. As part of this work, we characterized the types of “clues” or “empathic 

opportunities” that patients might raise in a 

medical encounter.1 We classified the empathic 

opportunities in patients’ statements as relating 

to the bad news/impact of lung cancer, difficulty with diagnosis or treatment, and health 

system barriers, among others. Our hope is 

that such a typology will be useful for clinicians 

in raising awareness of patients’ emotional 

needs and as an educational framework to help 

clinicians learn to respond empathically.

We also noted that empathy was infrequent 

and given late in the medical encounter, representing an all too common pattern where 

clinicians provided too little empathy and 

provided it too late in the encounter. Earlier 

provision of empathy and provision of these 

empathic responses periodically throughout 

the encounter (“interval empathy”) are likely 

to allow clinicians to build understanding and 

validate patients’ concerns, and progressively 

build trust and rapport with patients. 

Fortunately, clinicians can be taught to express empathy, a behavior that can be brief 

and does not prolong encounters. Our classification of empathic opportunities may be 

useful in educational modules for teaching 

clinicians to express empathy. 

Why should we consider interventions to improve patients’ communication? It would seem 

much more efficient to just focus efforts to 

improve communication on clinicians (because 

there are fewer physicians and each physician has 

numerous patients). One challenge is that clinicians have developed routines of communication 

that can be difficult to change. Though interventions to change clinician behavior often are 

lengthy, interventions to improve patients’ communication do not need to be as intensive and 

can often be administered in the waiting room 

immediately prior to the visit.

In preparation for the development of an intervention for Veterans, we conducted several 

focus group interviews to evaluate patients’ 

perspectives on using active communicative behaviors with their physicians. Veterans perceived 

that they had little influence on the course of 

their own medical encounter. Veterans felt that 

clinicians’ styles that were paternalistic, pushy, 

lecturing, and jargon filled discouraged their 

participation in the encounter. Also, patients 

admitted that they withheld information and 

avoided asking questions because of guilt, embarrassment, or fear of the clinician devaluing 

the importance of their questions or concerns.2

These results are useful for educational efforts 

to increase awareness of the problems that 

patients perceive when communicating with 

physicians. 

Looking Forward

Efforts to improve clinician-patient communication should recognize that communication is a two-way street. Patients who 

ask questions are more likely to influence 

their clinician to provide answers, and clinicians who are supportive are more likely to 

encourage patients to be active participants 

in the interaction (e.g., ask questions). These 

two-way dynamics between patient and 

clinician mean that improvement in communication of patient, clinician, or both, can 

improve overall communication. 

It is important to make efforts to improve 

communication in medical encounters 

because patients who have difficulty communicating with their clinician are less involved in the visit, receive less information 

from their clinician, and are less satisfied 

with care. Effective communication by both 

patients and clinicians can produce better patient self-management, adherence to 

treatment recommendations, and patient 

follow-up, thereby lessening the impact of 

disease on functional status.

Interventions to improve communication 

are often not even attempted in clinical 

practice. Efforts to refine and develop interventions that can be implemented are an 

important goal of future research.

References 

1. Morse DS, Edwardsen EA, Gordon HS. Missed 

Opportunities for Interval Empathy in Lung Cancer 

Communication. Archives of Internal Medicine 2008; 

168(17):1853-58.

2. Gordon HS, Sharp LK. Diabetes Patients’ Perceptions of Barriers to Communicating with Physicians. 

Journal of General Internal Medicine 2010. Abstract.

Research Highlight

The Importance of Clinician-Patient 

Communication Behaviors

Howard S. Gordon, M.D., Jesse Brown VAMC and the VA HSR&D Center for 

Management of Complex Chronic Care, Chicago, Illinois 
Diagnostic errors (i.e., diagnoses that are delayed, wrong, or missed) are increasingly recognized as a patient safety concern in ambulatory 

care. Although multiple factors influence the 

diagnostic process, communication is a central 

theme. From the initial patient-provider encounter to confirmation of a diagnosis through 

diagnostic testing, procedures, or subspecialty 

referrals, good communication is essential to 

timely and accurate diagnosis. Accordingly, 

communication breakdowns are emerging as a 

leading preventable cause of diagnostic errors 

and are the focus of our current work. In this 

brief, we discuss some of the early lessons and 

challenges in this work. 

Most ambulatory malpractice claims data suggests that diagnostic errors are the largest 

category among U.S. malpractice claims.1 Outpatient diagnostic errors may not necessarily 

involve only rare diseases or unusual disease 

presentations,2 but also relatively common conditions such as cancer, ischemic heart disease, 

and infection. Many such errors involve communication breakdowns, which are at times 

complex and difficult to define. It is not surprising that those breakdowns occur—ambulatory 

care involves several settings of care and is longitudinal in nature, making it increasingly chaotic 

for information processing. 

Communication and the 

Diagnostic Process: A Hard 

Nut to Crack

Communication challenges are virtually a 

given in ambulatory care settings, where barriers include time and workload pressures on 

busy clinicians, the sheer volume of both verbal and electronic communication among providers, and several patient factors that affect 

information transfer.1 Identifying the point(s) 

at which critical communication breakdowns 

occur is a first step in understanding the 

origins of error. It is important to recognize 

that, in health care settings, communication 

is often intended not only to transmit information but also to elicit some response from 

the recipient. For instance, when providers receive notification of abnormal test results, they 

might order follow-up diagnostic tests, notify 

patients, or refer to subspecialists. Thus, the 

desired outcomes of communication can be 

viewed in steps: message transmission (sending accurate, complete, and unambiguous information); message reception (perceiving the 

information accurately and taking appropriate 

next steps); and message acknowledgment 

(providing feedback that the message has been 

received and/or acted upon).3 Pinpointing the 

weakest links in those steps can help prioritize 

interventions. 

Our work has shown that errors in the diagnostic process span five interactive dimensions, 

each of which is closely related to one or more 

aspects of communication.

• Patient-provider encounter: Problems with 

history, physical exam, or ordering diagnostic 

tests for further work-up.

• Diagnostic tests: Problems with ordered 

tests either not performed or performed/

interpreted incorrectly.

• Follow-up and tracking: Problems with 

follow-up of abnormal diagnostic test results 

or scheduling of follow-up visits.

• Referrals: Lack of appropriate actions on 

requested consultation or communication 

breakdown between consultant and referring 

provider.

• Patient factors: Delay in seeking care or 

non-adherence to appointments.

Challenges Despite Technology

Integrated electronic health records (EHRs) 

readily address certain problems that are endemic to paper-based record systems, such as 

illegible handwriting, misplaced documents, and 

distance barriers between providers. However, 

the EHR must resolve communication problems that might contribute to errors in any of 

the five interactive dimensions above, which is 

a challenge of itself. Meanwhile, we must also 

remain vigilant for communication breakdowns 

that are uncovered or introduced by new technologies. While clinical decision support (CDS) 

interventions in the EHR can enhance communication by prompting important questions 

or actions during the diagnostic work-up, we 

need to ensure that these interventions fit into 

providers’ clinical workflow in order to achieve 

maximal benefit.2

Similarly, the EHR eliminates the need for a 

physical “paper trail” for referral communication 

and replaces it with referral requests and results 

that are always accessible electronically. However, remaining communication vulnerabilities 

to prevent patients from being lost to follow-up 

in the referral process must also be addressed.1, 3

What Next?

Multidisciplinary interventions that take into 

account both technology as well as patient and 

provider behavior in complex care settings are 

needed to ensure good communication practices 

that lead to diagnostic error reduction.2 Our ongoing work, for instance, applies a multifaceted 

approach to improving EHR-based communication and emphasizes integration of key lessons 

learned into systems, policies, and procedures.

Finally, advances in provider-patient communication are also needed. Personal health 

records and secure messaging to improve patient-provider communication are a few such 

innovations that merit further study. Bringing patients into the communication loop is 

a potentially powerful but underdeveloped 

strategy to help ensure the quality and safety 

of care in the outpatient setting. 

References 

1. Singh H, Weingart S. Diagnostic Errors in Ambulatory Care: Dimensions and Preventive Strategies, 

Advances in Health Sciences Education Theory and Practice

2009; V14S1:57-61.

2. Singh H, Thomas EJ, Mani S, et al. Timely Follow-up 

of Abnormal Diagnostic Imaging Test Results in an 

Outpatient Setting: Are Electronic Medical Records 

Achieving their Potential? Archives of Internal Medicine

2009; 169:1578-86.

3. Singh H, Naik A, Rao R, Petersen L. Reducing Diagnostic Errors Through Effective Communication: 

Harnessing the Power of Information Technology, 

Journal of General Internal Medicine 2008; 23:489-94.

FORUM — Translating research into quality health care for Veterans 6

VA Office of Research & Development, Health Services Research & Development Service August 2010

Research Highlight

Safe and Effective Communication to 

Prevent Diagnostic Errors

Hardeep Singh, M.D., M.P.H., VA HSR&D Houston Center for Quality of Care 

and Utilization Studies, Houston, Texas 
VA Office of Research & Development, Health Services Research & Development Service August 2010

The manner by which patients and their health 

care providers communicate with each other 

significantly affects patient perceptions of 

health care quality and outcomes. Previous 

work by Hall et al. in 1988 assessing the impact 

of patient-provider communication in health 

care settings showed that patient satisfaction 

improved when physicians: (1) treated patients 

as partners; (2) used more words with positive 

connotations; (3) used fewer words with negative connotations; (4) engaged in more social 

conversation with their patients; and (5) exchanged a greater amount of information. Furthermore, a study by Safran et al. in 1998 found 

that higher patient ratings of communication 

are associated with higher rates of adherence to 

physician recommendation of preventive health 

activities and higher patient ratings of health 

status. Kaplan et al. in 1989 showed that blood 

glucose control and blood pressures improved 

when there was more patient control and less 

physician control of the communication, more 

information provided by the physician, and 

less negative tone of the communication. In 

a recent meta-analysis of more than 100 studies, physician communication was significantly 

positively correlated with patient adherence 

in which there was a 19 percent higher risk of 

nonadherence among patients whose physicians communicated poorly than among patients whose physicians communicated well.1

Despite these beneficial effects, studies assessing patient-provider communication in 

clinical settings have determined them to be 

inadequate. A study published in 1984 by 

Waitzkin et al. showed that physicians spend 

less than 1 minute out of a 20-minute visit 

discussing treatment and planning. While 

patients typically want more information 

about their illness, recall of the information 

physicians communicate is frequently lacking. McBride et al. in 1994 found that patients considered communication to be one 

of the top three competencies a physician 

should possess, but frequently rated their 

own physicians’ communication skills to be 

suboptimal.

As patients who are informed and involved 

in decision-making are more likely to adhere 

to medical recommendations, having patients 

fully informed about alternatives and potential 

risks of treatment is a worthwhile clinical goal.2

However, in real practice this does not appear 

to be occurring. The Braddock et al. study in 

1999 audio-recorded 1,057 clinical encounters 

between patients and their health care providers in which there were 3,552 clinical decisions 

involved. Information exchange was limited 

with only a minority of instances having a discussion of alternatives (11.3 percent), pros and 

cons (7.8 percent), assessment of patient understanding (1.5 percent), and eliciting of patient 

preferences (21 percent). Similarly, analysis of 

audio-recorded primary care visits by Ling et 

al. published in 2008 in which colorectal cancer 

screening discussions were targeted for analysis, 

there was a lack of discussion of alternatives (26 

percent), pros and cons (17 percent), assessment 

of patient understanding (6 percent), and eliciting of patient preferences (17 percent) in those 

instances when a screening test was ordered.

Interventions Enhance 

Communications

As such, numerous studies have focused on 

interventions designed to enhance patientprovider communication. A systematic review 

of the literature in 2004 examined interventions 

directed at patients to improve patient-provider 

communications from 25 studies. The review 

found that interventions involving patients in 

communication training using techniques such 

as improved question-asking led to higher levels 

of patient perceived control over health, preferences for an active role in health care, recall of 

information, and adherence to recommendations.3

 Physician-directed interventions were 

also found to be beneficial. A meta-analysis 

by Zolnierek et al. in 2009 of 21 studies found 

that training physicians in communication skills 

resulted in substantial and significant improvements in patient adherence, with odds of patient adherence 1.62 times higher than when a 

physician received no training.1

 

While patient-provider communication has 

traditionally occurred in person, technology has 

advanced and now allows patients and providers to communicate electronically outside of 

the clinic setting. Providers and patients can 

now communicate electronically to address 

issues such as following-up on test results, 

asking questions, exchanging information 

before a visit, scheduling appointments, sending reminders, and renewing prescriptions. 

In a study conducted by Hassol et al. (2004) 

as an online survey of 4,282 members of the 

Geisinger Health System in which patients are 

able to communicate electronically with their 

providers and view selected portions of their 

electronic health record, patients preferred 

e-mail communication for some interactions 

(e.g., requesting prescription renewals, obtaining general medical information), whereas they 

preferred in-person communication for others 

(e.g., getting treatment instructions). A 2002 

Harris Interactive poll found that 90 percent of 

those with Internet access would like to communicate with their physicians online, with 55 

percent stating that the ability to communicate 

with their doctors electronically would influence their choice of health plans and 56 percent 

responding that this capability would influence 

their choice of physicians.

In conclusion, while patient-provider communication is considered an essential component of quality health care, it seems to be 

inadequately performed in the clinical setting. 

Development and implementation of communication interventions directed at patients 

and/or providers, as well as greater utilization 

of technology-driven approaches such as email, may be beneficial in improving patientprovider communication.

References

1. Zolnierek KB, DiMatteo MR. Physician Communication and Patient Adherence to Treatment: A 

Meta-Analysis. Medical Care 2009; 47(8):826-34.

2. Beck RS, Daughtridge R, Sloane PD. Physicianpatient Communication in the Primary Care Office: 

A Systematic Review. Journal of the American Board of 

Family Practice 2002; 15(1):25-38.

3. Harrington J, Noble LM, Newman SP. Improving 

Patients’ Communication with Doctors: a Systematic Review of Intervention Studies. Patient Education 

and Counseling 2004; 52(1):7-16.

FORUM — Translating research into quality health care for Veterans 7

Research Highlight

The Case for Communication 

Intervention

Bruce S. Ling, M.D., M.P.H., Core Investigator, VA HSR&D Center for 

Health Equity Research and Promotion, VA Pittsburgh Healthcare System, 

Pittsburgh, Pennsylvania
Conclusion

Mr. Deacon and Dr. Salter’s meeting lasts 

20 minutes, about the length of a routine 

clinic visit. Dr. Salter is amazed to learn 

about the literature in this area and is appreciative of not being judged on the basis 

of a skill that he was never taught. He is also 

grateful for the concrete evidence-based 

feedback and suggestions and is eager to try 

them out. Mr. Deacon, for his part, feels 

reinforced in his job and is pleased that Dr. 

Salter is receptive to the feedback. Both are 

grateful to Mr. Pawlson for his letter and 

intend to tell him so at his next visit. 

*All names and events in this commentary 

are fictitious. 

References

1. Stein T, Frankel RM, Krupat E. Enhancing Clinician Communication Skills in a Large Healthcare 

Organization: A Longitudinal Case Study. Patient 

Education and Counseling 2005; 58(1)4-12.

2. Frankel, R. M., A. Altschuler, et al. The Effect of 

Computers on Clinician-Patient Communication in 

Outpatient Visits: An Example of Digital Amplification. Journal of General Internal Medicine 2004; 19 

(Supplement 1): 216.

3. Hall, J. A. (1995). Affective and Nonverbal Aspects 

of the Medical Visit. The Medical Interview. M. J. Lipkin, S. M. Putnam and A. Lazare, (Editors). New 

York, Springer-Verlag: 495-503.

David Atkins, M.D., M.P.H.,

QUERI Director,

Washington DC

Peter L. Almenoff, M.D., 

FCCP, Assistant Deputy 

Under Secretary for Health for 

Quality and Safety, VA Central 

Cynthia Caroselli, Ph.D., R.N.,

AssociateDirector for Patient 

Services & Chief Nurse 

Executive, VA New York 

Harbor Health Care System, 

New York, NY

Martin P. Charns, D.B.A., 

Director, VA HSR&D Center 

of Excellence, Boston, MA

Seth A. Eisen, M.D., M.Sc., 

Director, HSR&D

VA Central

Washington DC

Joseph Francis, M.D., M.P.H., 

Chief Quality and 

Rodney A. Hayward, M.D., 

Co-Director, VA HSR&D 

Center of Excellence, 

Ann Arbor, MI

Alan S. Perry, M.P.A., M.H.A., 

FACHE, Director, VA 

Central California Health Care 

System, Fresno, CA

Frances Weaver, Ph.D.,

Director, VA HSR&D Center 

of Excellence, Hines, IL

FORUM

Geraldine McGlynn, Editor-in-Chief

Margaret Trinity, Editor

Editorial Board

Exam Room Computing continued from page 4

FORUM