Letters

Figure. Cumulative Number of Patients With Primary Sjögren Syndrome With Autoantibodies Before Clinical Onset

Patients With Primary Sjögren Syndrome Displaying a Positive Test Result, No.

25 Antinuclear antibodies 20

Rheumatoid factor Ro60/SSA

15

Ro52/SSA La48/SSB

10

5

0 >18

≥15

≥12

≥9

≥6

≥3

.99). Such an equal distribution of patients with TIA would actually tend to bias toward the null the estimate of the relationship between onset to treatment time and outcome rather than inflate it. In addition, as shown in eTable 4 of our article, the relationship between onset to treatment time and outcome was comparable among patients presenting with mild to moderate neurological deficits (National Institutes of Health Stroke Scale [NIHSS] score of 0-14) and patients presenting with severe neurological deficits (NIHSS score of 15-42). Because patients with stroke mimics and TIAs on average have substantially less severe neurological deficits at presentation than patients with ischemic stroke,2,3 the magnitude of the relationship between onset to treatment time and outcome would have been lower in the mild to moderate deficit cohort if confounding effects from stroke mimic and TIA were present. These considerations indicate the study’s primary finding is robust (namely that faster initiation of lytic treatment markedly improved outcomes from acute ischemic stroke) and further emphasize the importance of improving public awareness of stroke warning signs and shortening door to needle treatment times in hospitals caring for patients with acute stroke. Jeffrey L. Saver, MD Gregg C. Fonarow, MD Lee H. Schwamm, MD Author Affiliations: Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California (Saver); Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, California (Fonarow); Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts (Schwamm). Corresponding Author: Jeffrey L. Saver, MD, UCLA Comprehensive Stroke Center, 710 Westwood Plaza, Los Angeles, CA 90095 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Saver reported serving as a member of the Get With The Guidelines (GWTG) science subcommittee; being a consultant regarding trial design and conduct to Covidien, CoAxia, Grifols, Brainsgate, Lundbeck, and St Jude Medical; receiving an institutional grant from the National Institute of Neurological Disorders and Stroke; and being an employee of the University of California, which holds a patent on retriever devices for stroke. Dr Fonarow reported serving as a member of the GWTG steering committee; receiving institutional research support from the National Institutes of Health; and being an employee of the University of California, which holds a patent on retriever devices for stroke. Dr Schwamm reported serving as chair of the GWTG steering committee; serving as a consultant to the Massachusetts Department of Public Health, Lundbeck, and the Joint Commission; and receiving study drug from Genentech to his institution for a multicenter study of thrombolysis funded by the National Institute of Neurological Disorders and Stroke.

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Letters

1. National Technical Information Service. NINDS t-PA Stroke Study data set (on CD-ROM). http://www.ntis.gov. Accessibility verified October 3, 2013.

Author Affiliations: Yale University School of Medicine, New Haven, Connecticut.

2. Zinkstok SM, Engelter ST, Gensicke H, et al. Safety of thrombolysis in stroke mimics: results from a multicenter cohort study. Stroke. 2013;44(4):1080-1084.

Corresponding Author: Yunsoo A. Kim, AB, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510 ([email protected]).

3. Winbeck K, Bruckmaier K, Etgen T, von Einsiedel HG, Röttinger M, Sander D. Transient ischemic attack and stroke can be differentiated by analyzing early diffusion-weighted imaging signal intensity changes. Stroke. 2004;35(5):1095-1099.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. White A, Danis M. Enhancing patient-centered communication and collaboration by using the electronic health record in the examination room. JAMA. 2013;309(22):2327-2328.

Patient-Physician Interactions and Electronic Health Records 1

To the Editor In their recent Viewpoint, Drs White and Danis discussed using the electronic health record (EHR) to enhance patient-physician interactions. Whereas others have argued that the EHR can hinder patient-physician communication,2 the authors hold a more optimistic view that expanded uses (such as inviting patients to participate in EHR viewing during the clinical encounter) are untapped tools for patient activation. We share the optimism of White and Danis for health care information technology. During an era of technology innovation and adoption in all aspects of daily life, patients as well as medical professionals are, in general, becoming increasingly familiar with computer use during the clinical encounter. Current EHR systems, however, can be awkward to use, and there is a lack of standardized data structure for true integration of patient data across different EHR platforms.3 These issues are technical and will likely be overcome through innovations in EHR technology, allowing expanded EHR use to further enhance patient care. Additionally, there is a growing repertoire of technologybased tools for patient activation that can complement the EHR. The relatively nascent web-based patient portals allow patients to securely log in and access their personal health information. The portal pulls data from the patient’s EHR and can support items such as screening reminders and patient-physician messaging. One study showed that patient portals in conjunction with an EHR may improve patient engagement.4 Health care–focused social networks also offer a platform for patient activation. Patients can post questions online about their health condition. Physicians registered with the network can then post answers, which can be peer reviewed by other registered physicians. As medical students, we believe proper EHR usage instruction during medical education is important. Patientphysician communication is a part of the standard curriculum at most medical schools. For example, during our preclinical years, we learned a patient-centered model of patient interviewing. These interviews can serve as opportunities for students to practice using the EHR in a way to enhance the interaction. Appropriate use of the EHR to enhance patient activation can thus be taught concurrently with patient communication.2,5 Ultimately, EHR education in medical school will train physicians to become skilled users of this tool. Daniel X. Yang, BS Yunsoo A. Kim, AB

2. Lown BA, Rodriguez D. Commentary: lost in translation? how electronic health records structure communication, relationships, and meaning. Acad Med. 2012;87(4):392-394. 3. Mandl KD, Kohane IS. Escaping the EHR trap—the future of health IT. N Engl J Med. 2012;366(24):2240-2242. 4. Wright A, Poon EG, Wald J, et al. Randomized controlled trial of health maintenance reminders provided directly to patients through an electronic PHR. J Gen Intern Med. 2012;27(1):85-92. 5. Peled JU, Sagher O, Morrow JB, Dobbie AE. Do electronic health records help or hinder medical education? PLoS Med. 2009;6(5):e1000069.

To the Editor The Viewpoint by Drs White and Danis1 illustrated some of the ways in which using the EHR can enhance patient-physician collaboration and patient activation. We would like to point out some additional issues. First, patient-centeredness requires consideration of the patient’s perspective. Not only do the styles of physicians using the EHR vary, but so do the reactions of patients to the computer. For some patients and physicians, sharing the screen may be distracting.2 Physicians need to pay attention to patient cues and how this practice affects the encounter. It can be very easy for the interaction to become driven by the computer rather than supported by it.3 Second, sharing the monitor with the patient is just one of the ways to overcome the potentially negative effect of EHR use on communication. One study identified a range of strategies, best practices, and enabling factors that physicians used,4 which are largely consistent with tips for effective use of EHRs in the examination room from Ventres et al.5 These range from spatial organization of the office to improving technical skills, such as typing and computer navigation, to information management and documentation practices (eg, using standard templates when possible), and management practices for patient encounters (eg, starting with patient concerns and dividing the encounter into patient- and EHR-focused stages). We encourage physicians to familiarize themselves with and adopt these best practices. As frameworks for describing the new EHR-related skills and enhancing their acquisition become available, we hope they will become part of the training of health professionals. Aviv Shachak, PhD Shmuel Reis, MD, MHPE Christopher Pearce, PhD, MFM, MBBS Author Affiliations: Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (Shachak); Bar-Ilan University Faculty of Medicine in the Galilee, Safed, Israel (Reis); Inner East Melbourne Medicare Local, Melbourne, Australia (Pearce).

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Acute ischemic stroke and timing of treatment.

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