Center to Improve Communication in Health Care
Building Relationships and Eliminating Disparities
Ronald M Epstein, MD, Director
Professor of Family Medicine and Psychiatry
Mission
The mission of the Center is to improve health and healthcare by implementing novel interventions, educating healthcare providers and consumers, and conducting research on healthcare communication, with a special emphasis on underserved and vulnerable populations.
The scope of the Center includes communication among health care professionals, between health professionals and patients, and between health care professionals and diverse communities to optimize health and health care.
By creating a vehicle for collaboration among various departments and Centers at the University, the Center will substantially expand the scope and magnitude of programmatic research that shows that effective communication can (a) improve health outcomes of acute and chronic conditions, (b) reduce the impact of racial, ethnic, disease-specific and socioeconomic factors in care, and (c) improve the effectiveness of prevention and health promotion.
The Center will also be a national and international model for cutting-edge research in communication and health, and a vehicle for translational research and an instrument for the dissemination of strategies to improve healthcare communication.
Rationale – conceptual issues
The Institute of Medicine report, “Crossing the Quality Chasm”, documented the large gap between expected and achieved quality in health care. Many of these gaps result from ineffective communication between providers and patients and their families, providers and providers, health care organizations and providers.
The Institute of Medicine report: “Unequal Treatment: Confronting Racial and Ethnic Disparities in care” documents disturbing gaps in quality between whites and minorities that are not explainable by differences in insurance or socioeconomic status. The report underscores the crucial role that inadequate communication and lack of cultural competence play.
Many patients report that they are not satisfied with the quality of their interactions with healthcare professionals.
Significant gaps in communication between patients and healthcare professionals are evident in the general population. These gaps are more pronounced among (a) marginalized groups such as those with disabilities, low literacy, limited English proficiency or low socioeconomic status, (b) stigmatized groups such as those with HIV infection, obesity, or mental illnesses, and (c) minority populations such as African-Americans and refugees.
Poor communication has a strongly negative impact on outcomes of (a) chronic diseases including diabetes and hypertension, (b) acute illnesses, including pain control, morbidity following surgery, and length of hospital stay, and (c) mental illnesses such as depression and schizophrenia.
It is possible to improve communication in healthcare settings, and such improvements have led to better health outcomes. Furthermore, these changes may contribute to greater equity in health and healthcare for racial, ethnic, socioeconomic, educational and minority populations when compared to the general population.
Better communication has led to improvements in prevention, motivation for behavior change, and adherence to treatment. These factors are central to eliminating disparities and to the mission of several University initiatives, including Project Believe.
There is a need to integrate four parallel trends in research and interventions on communication and health.
- The public health approach has traditionally focused on the use of printed and electronic media to transmit health-related messages to populations. Our current study of ad-driven requests for prescription medication is evaluating the public health effects of mass media.
- The behavioral approach has focused on improving specific physician behaviors believed to improve patient adherence, participation in decision-making and feeling of having been understood. Our current study using standardized patients evaluates the effect of patient-centered care on clinical and cost outcomes
- The patient empowerment approach has focused on training patients to assume a more active role in their care. Our proposed intervention study to improve patient-centered care will use computer-assisted patient coaching interventions to improve health outcomes
- Finally, the health systems approach as exemplified by the chronic disease management model offers promise for changing how providers, nurses and allied health professionals communicate with each other and with patients. All current studies above examine the effect of the health care microsystem on health services delivery.
Effective science in this arena requires a Center that has the capacity both to integrate these approaches and to mount interventions on a sufficient scale to demonstrate success. Although communication research has historically focused on the individual patient-physician level, and on use of mass media, there is clear evidence that the other levels are amenable to rigorous study. The Center will address health-related communication on several levels, including (a) the individual psychological makeup of physician and patient and potential for bias, (b) the 1:1 patient-clinician relationship, (c) the patient’s family and relevant social networks, (d) clinical communication among members the health care team, (e) communication with specific, targeted groups of patients, including the use of electronic media, (f) communication between health care researchers and those in clinical settings, and (g) communication between the larger health care system and individual patients and populations.
Rationale -- pragmatic issues
The Department of Family Medicine is a national leader in research on healthcare communication and health disparities, with over $10 million in funding over the past 10 years. The Department’s reputation of being one of the top 15 Family Medicine Departments in the USA rests on our work on communication, health, and disparities.
During the past 3 years, there has been a significant expansion of funding for research on communication, disparities and health from the same federal (especially AHRQ, NIA, NCI) and foundation (especially Robert Wood Johnson) sources who have funded our current and past research. Recently, Elias Zerhouni, Director of the NIH, on the issue of health disparities, said that "to call it a priority is wrong. It should be a core mission… It is something that permeates the entire concerns of NIH."
As co-chair of the largest international conference on communication and health (Barcelona, 2002), Dr. Epstein has achieved international prominence in the field. Dr Epstein has received grants for the first qualitative and mixed-methods studies on clinical communication from AHRQ and the Robert Wood Johnson Foundation, and one of the largest AHRQ R01 grants in the field.
Since publication of his seminal review in JAMA, Dr. Fiscella has achieved international prominence for his work on eliminating disparities in health care.
Historically, research on communication and health on a national/international level has been the province of individual investigators and small collaborations. Many faculty members at the URSMD have expertise in the study of communication, disparities and health services, but to date their interactions and collaborations have been relatively informal. By creating a Center, we will pool intellectual resources, enhance the quality and quantity of research, and improve our visibility in the community.
Specific activities in service of the mission
Research areas include:
- basic research on the science of communication in health care settings to develop further theories of communication practice and guide interventions.
- applied research on interventions to improve communication and relationships between patients, physicians and other personnel in the health professions.
- translational research on the application of new basic research findings to healthcare practice, particularly genetic testing, treatment of chronic illnesses, and mental health.
- research on disparities in care for marginalized, underserved and minority populations.
- research on individual and health systems changes to improve access, awareness, and communication.
Educating clinicians and patients to improve communication.
Community outreach to empower patients from marginalized and underserved populations.
Training the next generation of health communication researchers.
Funding pilot projects.
Target Populations
Vulnerable populations that have been the focus of research by members of the proposed Center include:
- members of racial and ethnic minority groups, including refugees
- people infected with HIV
- people who are under- or un-insured
- people who are deaf or hard-of-hearing
- people who are lesbian, gay, bisexual or transgender\
- people who have experienced domestic violence and abuse
- people with undetected and/or chronic mental illness
- pregnant women
Faculty expertise, collaborators and affiliations
The core faculty of the proposed Center have expertise in areas such as (but not limited to):
- care of an aging population, especially with regard to access to information and involvement in decision-making
- care of those with mental disorders and psychosocial distress, including patients with multiple unexplained symptoms
- healthcare for people with disabilities as well as those who are deaf and communicate in American Sign Language (ASL)
- improving patient safety and reducing medical errors by improving communication within the health care team
- informed decision-making, adherence to treatments, and behavior change
- involvement of family members and social networks in care, including complex ethical and genetic issues
- physicians’ responses to patients’ stated requests and expectations
- prevention and treatment of cancer, HIV and chronic diseases
- racial, ethnic and socioeconomic disparities in care
- remote healthcare interpreting using telehealth technology
Interest has been expressed by members of the following schools/departments at the University of Rochester: Anesthesiology, Cancer Center, Center for Future Health, Clinical and Social Psychology, Community and Preventive Medicine, Family Medicine, Genetics, Medical Humanities, Medicine, Neurology, Nursing, Pediatrics, Project Believe, Psychiatry (including the Deaf Wellness Center, the Family and Marriage Clinic, and the Laboratory of Depression and Medical Comorbidity), and Telemedicine Committee
Current collaborations with other institutions
- Community partners
- Public Schools #12 and #17
- Westside Health Services
- Academic partners
- Bowman Gray School of Medicine, Wake Forest University
- Case Western Reserve University, Center for Family Medicine Research
- Harvard University, Department of Social Psychology
- University of California, Davis, Center for Primary Care Research
- University of California, San Francisco
- University of Western Ontario, Center for Studies in Family Medicine
- Universities of Cordoba, Madrid and Barcelona, Spain
- Corporate/philanthropic partners
- Kaiser-Permanente Research Foundation, Oakland, CA
- The Kenneth Schwartz Center, Boston, MA