The information you receive while talking with patients must be transmitted accurately, appropriately, and confidentially (Box 1-1) to physicians and other professional staff members. You must also translate information from physicians and other staff members in a manner that patients can understand. A positive attitude, pleasant presentation, and good communication skills establishrapport, a relationship of trust and understanding, for future interactions with patients. These skills also help maintain the flow of communication back and forth between health care professionals.

Box 1-1 Confidentiality, HIPAA, and You

The importance of patient confidentiality has been an issue in health care since the earliest concept of one person caring for another. The 2000-year-old Hippocratic Oath (or Oath of Hippocrates), a part of the graduation ceremony for physicians, emphasizes the importance of guarding patient information with the following statement:

“All that may come to my knowledge in the exercise of my profession or outside of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.”

The patient’s right to privacy is so important that it is included in every specialty’s code of ethics. However, until recently, a breach of confidentiality was not punishable by law unless it resulted in damage to a person’s reputation, which is called defamation of character. This covers both slander (the spoken word) and libel (putting damaging information into print). Other forms of confidentiality breaches that were less damaging were considered lapses in good judgment and were unethical, but no penalties were imposed.

A Congressional effort to help patients maintain health coverage when jobs changed or ended resulted in the Health Insurance Portability and Accountability Act of 1996, or HIPAA. It was developed to improve the quality of health care, to keep down spiraling costs, and to protect patients from disclosure of medical information without written, informed consent. The problem of guarding confidentiality in systems with multiple points of access was becoming critical with electronic transmission of sensitive patient information. Insurance companies, health maintenance organizations (HMOs), and other interested parties had access to health information that most of us would prefer not to share.

HIPAA applies to any health information created and maintained in any health care agency or body that compiles and maintains patient information. The Department of Health and Human Services (DHHS) issued a regulation called “The Standard for Privacy of Individually Identifiable Health Information” and established the Office of Civil Rights (OCR) to implement and enforce compliance with the HIPAA guidelines.

At the adoption of the HIPAA, any successfully prosecuted breach of confidentiality is punishable by a variety of fines, ranging from $100 for each violation to $250,000 for selling or using information for improper purposes [Sections 1176(a)(1) and 1177(b)(3) of Public Law 104-191]. Imprisonment ranges up to 10 years for the maximum penalty.

Clearly, keeping your patient’s health care information confidential is no longer just an ethical issue; it is now a matter of law.

HOW COMMUNICATION WORKS

Communication at any level forms a bond or connection with another person or persons for an exchange that should benefit at least one of the participants. Ideally, all participants should be equally involved in the message for the best outcome. If one of the participants is not interested in the information, or does not place a value on it, the process of communication may not be complete. For example, think about times you needed to talk to a friend about a problem you hoped she would understand. If she was distracted or did not care to listen, you probably were understandably hurt and frustrated and may not try to confide in her again. Patients feel the same way if they suspect we do not value their concerns.

To be effective, we must determine the information to transmit, choose the best way to send the message, and receive and interpret the responses in the exchange. All forms of communication require the following elements:

• A message to be transmitted in a form understandable to the receiver

• A sender, usually a person, to transmit the message

• A method for transmitting the message—verbal, nonverbal, or written

• A ready and receptive receiver to accept the message

• Clarification or verification that the message was received and understood

The message will not work in a form the receiver cannot understand. If you transmit a message in English to someone who speaks only another language, if you speak above the patient’s comprehension level, or if she cannot or will not hear you, none of the communication elements will work. If the message is not clear or well defined, the exchange is more difficult. For example, how can the patient respond when your message contains very little that he understands, or how will you respond when the physician gives you instructions that make no sense to you? In these cases, the message was not transmitted in an understandable form and communication is incomplete.

The channel or method of transmitting the message may be either spoken or written, it may be body language, or it may be a simple facial expression. We have all transmitted messages to someone across a room using only significant looks and body language. For the message to be transmitted effectively, the receiver must be ready and able to accept it. This is like sending a fax if the receiving machine is not on. If the patient is not ready to accept the message, or cannot receive it because of her physical or emotional state, her “receiver” is not on. In Chapter 2, “Challenges to Communication,” we cover how to determine when the patient is “ready to receive” and how to communicate if he is not ready but you need to talk with him about his health care at the time.

When a message has been transmitted, we should be able to determine whether it was received by clarification or verification responses. Recognizing these responses may be as simple as interpreting the receiver’s body language, facial expression, or a head nod that the message was received. We may simply see it in the patient’s eyes. The verification response may also be as complex as a lengthy and involved written or verbal response.

When the message is in the verbal or spoken form, the sender and receiver alternate roles as they transmit their part of the information needed in the exchange and look for responses in the form of feedback and verification. The process of message exchange is like a tennis match, with the message, like a ball, passing from person to person. Figure 1-1 illustrates the flow of oral communication and its common components.

Steps in the Communication Process

Communication is conducted in steps (Fig. 1-2). The first is the preparatory, introductory, or orientation step. This step introduces the participants to each other and helps form a mutual agreement to exchange information. Roles and responsibilities are established within the first few moments, usually by implied agreement. There is usually no formal agreement that each participant will perform certain functions in the exchange, but by founding the relationship, each participant agrees to fulfill his or her part of the exchange until the situation is resolved or the interaction comes to an end. For example, if a patient makes a health care request that you can help resolve, the guidelines are implied that she will give you all of the information you need to help her. By coming to her aid, you imply that you will do everything reasonable to fill her needs. The two of you have reached an informal agreement, which completes the introductory phase.

The second step is the working, or maintenance, step. The conversation is focused on the task at hand and works to meet the needs of each participant. Each participant observes the responses of the other for communication cues (covered later in this chapter) to determine that all messages are properly received. The health care worker usually directs, or leads, the interaction but should not control it. It is your responsibility to keep the exchange on track—to keep the patient from rambling—but controlling the flow interrupts the free and open exchange needed to determine all of the patient’s needs. Today, he may need to talk about his personal problems rather than participate in an intense and comprehensive health history, and you must respect that need. Helping him talk about his problems may be as therapeutic as any clinical procedure you may perform, but gentle, tactful, probing questions (covered in Chapter 3, “Gathering Information”) may help guide him back on track to direct the conversation toward his immediate health care needs.

The final step is the termination or conclusion. If the exchange was effective and successful, each party is satisfied that messages were transmitted and received as intended. (Guidelines to help overcome a breakdown in communication are covered in Chapter 2, “Challenges to Communication”). At the conclusion of the exchange, goals should be reached, such as determining the patient’s current need for care, or, if you are working in an intermediate position, the relationship is transferred to another worker. The relationship may be as short-term as greeting patients for a one-time visit, or may be an established relationship for long-term, chronic care. In either case, or in any health care situation, the dynamics of communication—how communication works—and the need for exchange remain the same. All of the steps listed above are involved in any exchange, from a brief conversation as you greet your patients to a complicated transfer of complex medical information over an extended period. If the relationship is long-term, well-established, and pleasant for both the patient and you, at its eventual end you may feel a sense of loss, but you should also feel pride in the independence and growth you have helped your patient achieve.