Principle of open communication using screen sharing on electronic medical records

This study aims to determine the principle of open communication using screen sharing on electronic medical records. The research design used in the preparation of this article is a literature review method related to the Principle of Open Communication Using Screen Sharing on Electronic Medical Records using databases such as Google Scholar, PUBMED, Sciencedirect


INTRODUCTION
The development of digital technology in society has encouraged the transformation of digitalization of health services. (Koten et al., 2020, Adiwibowo, 2020 The use of electronic medical records (RME) is a form of health service innovation in the era of the industrial revolution 4.0. (Amin et al., 2021, Adiwibowo, 2020 Institute of Medicine (2016) describe RME as an information technology system that facilitates the storage of patient clinical data and information, data entry and management, decision support, electronic communication regarding effective patient conditions, supporting patient safety, facilitating data administration and reporting, so that RME can provide services to track patient data over time, patient identification for preventive and screening visits, monitor patients, and improving health care. (Koten et al., 2020, Gunawan andChristianto, 2020) The World Health Organization (2016) states that the use of RME has increased globally by 46% in the last five years. (Tiorentap, 2020) America has implemented RME in 2004, Japan has developed RME implementation in 2000, while Denmark has implemented since the mid-1990s. South Korea itself has a much higher level of RME usage compared to European Union countries. The development of RME in Indonesia has begun to be used in several hospitals since the late 2000s. (Octavia, 2022) However, the implementation of RME has many very complex challenges including: high initial costs and treatment, resistance of RME users, patient privacy issues, lack of support from management or outside parties. Therefore, the implementation process needs to be prepared through careful planning so that the continuity of medical record data can be maintained. (Setiatin and Susanto, 2021)Regulation of the Minister of Health of the Republic of Indonesia number 24 of 2022 is the legal basis for the use of RME in Indonesia.
Other studies have reported that there are problems with the application of RME. Doctors devote more time to data entry than to making contact with patients. A study of doctors in the ER showed that doctors spend an average of 43% of their time doing data entry and only 28% of their time on direct patient contact. Doctors neglect physical examinations more, are less keen in conducting analysis of clinical considerations, and focus more on the results of electronic records. (Gunawan and Christianto, 2020)Recent research from the National Academy of Medicine (2019) explains that doctors and nurses spend 50% of their time on contact with computers, but not with patients. This circumstance reduces the doctor's empathy for the patient. (Honavar, 2020) The effect of the application of RME on the communication of doctors and patients has been widely studied. (Zaman and Chauhan, 2021, Ofri, 2019 The main complaint against the use of RME is the change of previously dyadic physician and patient communication to triadic. The application of RME facilities makes doctors have to document anamnesis, physical examination, diagnosis, and treatment plans that will be given to RME facilities in the practice room. (Asan et al., 2015b)Abraham Verghese (2020) calling this condition the phenomenon "iPatient". This has transformed the doctor-patient relationship (dyadic) into the doctor, computer, and patient (triadic) relationship. Eye contact between doctor and patient becomes the most crucial part in the change in such interactions. (Assis-Hassid et al., 2012, Honavar, 2020 Active sharing of information between doctors, computers, and patients is the most ideal communication. This makes the patient understand better and feel involved in the treatment of himself. Two-way communication between doctors and patients is becoming more desirable than more conventional one-way communication. Eye contact is a part of non-verbal communication that is as important as verbal communication in achieving patient satisfaction. Eye contact shows more attention and involvement in interacting with the patient. (Asan et al., 2015b, Montague and Asan, 2014, Asan et al., 2015a Several studies have examined ways to improve the quality of physician and patient communication in the application of RME. (Montague and Asan, 2014, Weiner, 2012 Doctors can be taught how to improve effective communication, namely by sharing medical information (screen sharing) through a computer screen with patients. (Asan et al., 2015b, Asan, 2017, Choudhury et al., 2020, Fletcher et al., 2017, Milne et al., 2016 Other researchers have conducted trials using touch screen propotypes on computer monitors, resulting in patients feeling more actively engaged and the information conveyed is easier to understand. (Milne et al., 2016) Some other advantages obtained by the screen sharing method are that the doctor gets more accurate information, the patient understands the treatment plan given, the patient feels empathy from the doctor, the patient feels actively involved, and the patient does not feel silenced when the doctor fills the RME. An ergonomic examination room is also needed to facilitate the application of RME with the screen sharing method. In other words, technology can also potentially improve physician and patient communication. (Asan et al., 2018, Milne et al., 2016, Asan et al., 2015b, Choudhury et al., 2020, Fletcher et al., 2017, Asan et al., 2015a Further studies need to be conducted to assess the extent of the influence of screen sharing methods on the non-verbal communication of doctors and patients. Until now, there has been no research on the effect of the application of RME with the screen sharing method on the communication of doctors and patients in Indonesia.
Based on some of the results of the research above, it shows that the application of RME has complex challenges, one of which is the change in communication between doctors and patients. Therefore, it is necessary to review and review literature from various sources that support the Principle of Open Communication Using Screen Sharing in RME. The purpose of this review research is to find out the Principle of Open Communication Using Screen Sharing in RME. So that the formulation of the problem in this article is how the Principle of Open Communication Using Screen Sharing in Electronic Medical Records affects patient satisfaction.

RESEARCH METHODS
The research design used in the preparation of this article is a literature review method related to the Principle of Open Communication Using Screen Sharing on Electronic Medical Records using databases such as Google Scholar, PUBMED, Sciencedirect, and Researchgate during the period 2012-2022. In this study, researchers collected literature review materials whose thematic structure was based on thinking concepts that were compiled to answer scientific questions by grouping and discussing library sources according to the topic. The inclusion criteria used by researchers are research that explains the use and evaluation of RME implementation in health care facilities that use Indonesian or English literature, while the exclusion criteria is gray literature.
Search based on the topics discussed by compiling discussion topics in the form of a mind map (figure 1) to facilitate the search for topics in each branch of the mind map, then keyword searches are determined based on the PICO strategy with outcomes: the influence of open communication using screen sharing on RME to physician-patient communication and physician-RME interactions that focus on the concept of patient centred care. Then it starts by entering the keywords "openness EMR OR EHR to the patient AND screen sharing OR screen mirroring", "doctor EMR OR EHR interaction and screen sharing OR screen mirroring", "doctor patient communication AND EMR OR EHR OR screen sharing OR screen mirroring", "patient centered care AND EMR OR EHR OR screen sharing OR screen mirroring". Researchers conducted data analysis using the critical appraisal method with PRISMA 2020 to analyze journals used as theoretical foundations related to differences, similarities, and shortcomings of selected journals (figure 2). Journals are reviewed to select appropriate journals so that they can answer research questions from each branch of the mind map that will be discussed in the concept of thinking above. After answering all the topics from each aspect of the mind map concept, the researcher synthesized and

RESULTS AND DISCUSSION
The openness of RME facilities in question is the disclosure of patient clinical information directly by doctors with RME facilities. RME facilities should be used as a means of communication and a means of educating patients through the method of sharing information directly (screen sharing). This method becomes one of the strategies to solve problems related to communication between doctors and patients and can facilitate patients to be actively involved in consulting with doctors. Patients can view clinical information directly on a computer screen and discuss directly with the doctor. (Milne et al., 2016, Asan et al., 2018 The patient's active involvement in the discussion will assist the doctor in completing the clinical information on the RME until the end of the consultation. Some other advantages obtained by the screen sharing method are that the doctor gets more accurate information, the patient understands the treatment plan given, and the patient does not feel silenced when the doctor fills in the RME. This transparency will make the patient better understand what the doctor is doing so that the patient does not feel that he has lost the empati. (Wali et al., 2020, Asan et al., 2018 Different ways of sharing clinical information with RME tools There are three ways to apply the screen sharing method, namely active information sharing, passive information sharing, and technology withdrawal. (Asan et al., 2015b) 1. Active information sharing.
The doctor will position the computer monitor screen in such a way that the doctor and the patient can see the monitor screen together or the patient is actively invited by the doctor to sit next to each other so that they can see the monitor screen together.

Passive information sharing
The doctor does not position the computer screen or invite the patient to sit together in sharing clinical information, but also does not close the computer screen. The patient can still see the computer screen if the patient really wants to.

Technology withdrawal
Doctors do not position the computer screen or invite the patient to sit together in sharing clinical information even the doctor keeps the computer screen at a distance from the patient so that the patient does not have the opportunity to see the computer screen.
The application of the screen sharing method with active information sharing is the best solution to improve effective communication between doctors and patients. Active information sharing can be done in three ways, namely convincing clinical information, translating clinical information seen on a computer screen (translating), and reassuring clinical information that has been provided (verifying). The position of the monitor screen, patient, and doctor will determine the screen sharing method to be used. (Asan et al., 2015b, Choudhury et al., 2020 The interaction of doctors with the means of RME Doctors play an important role in the use of RME means. Clinical information obtained from patients will simultaneously be stored and managed automatically by the system. The RME application will make it easier for doctors to track and dig up patient information if needed. RME facilities are expected to be able to increase the efficiency and effectiveness of doctors in providing health services (Asan andMontague, 2012, Street Jr et al., 2014) 1. Types of interaction of doctors and means of RME There are three types of doctor interactions and RME facilities, namely technology-centered, mixed, and human centered. These types of interactions are grouped based on the doctor's activity while staring at a computer screen and typing on a keyboard. In the technology-centered group, doctors spend more time staring at computer screens while typing out the results of clinical information obtained from patients. The mixed group refers to the doctor's activities that do not focus too much on the computer screen and keyboard, so that the doctor can still communicate with the patient during the examination. Human-centered groups focus more on direct communication with patients. Doctors don't focus too much on computer screens and keyboards. It is this type of interaction that is considered the best type of interaction that can be carried out in the era of implementing RME. (Asan and Montague, 2012) 2. Inhibiting factors From literature review and literature review, a number of obstacles to the application of RME were obtained. Here are the overall inhibiting factors (table 1).  (Alpert, 2016, Park andHan, 2017) 2 High maintenance costs (Park and Han, 2017) 3 Uncertainty about return on investment 4 Lack of financial resources B Technical 1 Lack of computer skills from doctors and/or staff (Ajami andBagheri-Tadi, 2013, O'Donnell et al., 2018) 2 Lack of technical training and support (Ajami andBagheri-Tadi, 2013, O'Donnell et al., 2018) 3 System complexity (Bowman, 2013) 4 Lack of adjustment (Ajami andBagheri-Tadi, 2013, O'Donnell et al., 2018) 5 Lack of reliability (Ajami andBagheri-Tadi, 2013, O'Donnell et al., 2018) 6 Interconnectivity/Standardization (Rimmerman andColbert, 2014, Reis et al., 2017) 7 Lack of computers/hardware (Ajami and Bagheri-Tadi, 2013) C Time 1 When choosing, purchasing and implementing the system 2 When studying systems (Bowman, 2013) 3 When entering data (Ajami and Bagheri-Tadi, 2013) 4 More time per patient (Bowman, 2013) D Social 1 Uncertainty about vendors (Wu et al., 2022) 2 Lack of support from external parties (Triantafillou, 2017) 3 Disorders in the doctor-patient relationship (Babbott et al., 2014, Jabour, 2020 4 Lack of support from other colleagues (Reich, 2012) 5 Lack of support from the management level (Rothman et al., 2012 (Gottlieb et al., 2015, Dranove et al., 2015 2 Lack of participation (Nguyen et al., 2014) 3. Solution Overcoming barriers to the implementation of RME by doctors as users is a complex process that requires support from several parties such as the government, related insurance companies, vendors, directors, patients and especially the doctors themselves. Policymakers must understand the barriers that occur so that they can immediately determine the appropriate interventions to overcome these barriers. Barriers from users can be overcome by socialization and training to get used to using the means of RME. The RME system used should be an easier, simpler, and user-friendly RME system so that the adaptation process can be achieved immediately. Barriers regarding high costs, especially the cost of purchasing and maintaining devices related to RME, require different solutions, namely incentives from the government, such as low-interest loans or funding programs. Privacy and security concerns require direct government intervention. The government is expected to step in to help maintain the security and privacy of patient data by instructing parties involved in the implementation of RME to follow applicable laws and regulations. (Lau et al., 2012, Dutta and Hwang, 2020, Ajami and Bagheri-Tadi, 2013 Communication between doctors and patients in the application of RME The implementation of RME has changed the communication of doctors and patients that is dyadic to triadic. The existence of computers as a means of RME has transformed the relationship of doctors and patients into the relationship of doctors, computers, and patients. This alteration affects verbal and non-verbal communication between the doctor and the patient. (Jongerius et al., 2022, Yang and Asan, 2016, Asan et al., 2015b, Montague and Asan, 2014 1. Types of RME-related physician and patient communication There are 3 types of communication between doctors and patients related to the application of RME, namely informational-ignoring style, where doctors talk to patients while documenting the patient's clinical information; controlling-managerial style, in which the doctor gives pauses in talking to the patient and documenting the clinical information obtained; interpersonal style, where the doctor will only speak at the beginning of the patient's examination, then document the clinical information obtained.

Communication components between physicians and patients regarding RME
The application of RME affects verbal and non-verbal communication between doctors and patients. Focus and empathy become part of the components of verbal communication that occur between the doctor and the patient. The interaction of doctors with the means of RME will more or less have a negative effect on verbal communication. This interaction is strongly influenced by the doctor's proficiency and habits in using RME. Some doctors who are still unfamiliar with the use of RME, will devote more of their focus and attention to computer screens. This is what patients complain about in treatment in the era of applying RME. The patient feels that the doctor's attention and focus are reduced, so the patient does not feel empathy during treatment. Changes in the non-verbal component of communication also occur, namely eye contact. Minimal eye contact is the main culprit. Doctors look at computer screens more than they make eye contact with patients. (Choudhury et al., 2020, Esch et al., 2016, Asan et al., 2015b, Montague and Asan, 2014 3. Development of communication between doctors and patients regarding RME Previous research has suggested using mneumonic "LEVEL" in the implementation of good and correct means of RME. Let, let the patient see what the doctor wrote; Eye contact, maintain eye contact with the patient: Value, use computer means as a means of communication; Explain, explain to the patient what the doctor is doing; Log off. An ergonomic practice room is also needed to support the use of the screen sharing method. (Asan et al., 2018) Konsep patient centered care (PCC) The health information system has adopted RME to support the concept of patient centered care (PCC

Patient safety
Hospitals as health care providers are required to provide comprehensive services and refer to patient safety. Patients are entitled to health services with guaranteed safety. Patient safety system is a security system that includes risk identification, risk assessment, and solutions to ensure patient safety in the hospital. One of the hospital's efforts to ensure patient safety is the implementation of RME facilities. RME can be programmed to detect and report matters relating to data documentation, patient medical information and direct or indirect supervision of patient treatment. RME facilities are expected to be able to detect and prevent events that have the potential to threaten patient safety (WHO, 2008). (Firdaus, 2020, Tanner et al., 2015, Tubaishat, 2019, Meeks et al., 2014, Manca, 2015, Greiver, 2015, Aldosari, 2017 2. Quality health services Hospitals are a form of capital-intensive and technologyintensive health services. Hospitals must be able to run health services efficiently so that fast and accurate information is needed. Information is the most important pillar in hospital planning (Kemkes RI, 2011). RME as an information technology system in the form of health service innovation is a patient's medical record record in electronic format written by one or more health workers every time a meeting between a health care provider and a patient. RME can be accessed by computer means aimed at providing or improving efficient and integrated health services (Khasanah, 2020). The use of RME has the potential to provide benefits for basic service facilities and hospitals. One of the perceived benefits is the increased efficiency in the health care process. The use of RME has an impact on reducing operating costs and increasing revenue in hospitals. These recommendations can be considered in the subsequent development of RME. (Saputro, 2020, Andriani et al., 2022, Apriliyani, 2021, Erawantini, 2013 3. Patient satisfaction Patient satisfaction is a complex element that is influenced by multifactorial in healthcare. The application of RME alone cannot directly improve patient satisfaction. On the contrary, it affects the negative issue between doctor and patient communication. (Bloom & Huntington, 2010;Gaffey, 2009). The results of a literature review of the effect of RME on patient satisfaction vary widely. Some patients are satisfied with doctors who use RME as a means of communication. Patients find it easier to get clinical information from doctors. Several other patients reported dissatisfaction with the use of RME. Patients complain that doctors do not focus on the patient when filling out the means of RME. Several other factors that cause dissatisfaction with the means of RME, namely eye contact, direct disclosure of clinical information, and placement of computer monitor screens. , Kazley et al., 2012, Marmor et al., 2018, Wali et al., 2020, Liu et al., 2013.

CONCLUSIONS
Based on the study and literature review above, it was concluded that the Principle of Open Communication Using Screen Sharing in Electronic Medical Records can optimize health services. Optimal health services can be seen from patient satisfaction which is shown by the establishment of positive communication between doctors and patients. Support from various parties, namely the government, management, vendors, users, and patients in the Principle of Open Communication Using Screen Sharing on Electronic Medical Records is able to increase the effectiveness and efficiency of data storage, data privacy and security, allocation of better service times, and end up optimizing patient satisfaction.