Mitigating Patient and Consumer Safety Risks When Using Conversational Assistants for Medical Information: Exploratory Mixed Methods Experiment.

BACKGROUND: Prior studies have demonstrated the safety risks when patients and consumers use conversational assistants such as Apple's Siri and Amazon's Alexa for obtaining medical information. OBJECTIVE: The aim of this study is to evaluate two approaches to reducing the likelihood that patients or consumers will act on the potentially harmful medical information they receive from conversational assistants. METHODS: Participants were given medical problems to pose to conversational assistants that had been previously demonstrated to result in potentially harmful recommendations. Each conversational assistant's response was randomly varied to include either a correct or incorrect paraphrase of the query or a disclaimer message-or not-telling the participants that they should not act on the advice without first talking to a physician. The participants were then asked what actions they would take based on their interaction, along with the likelihood of taking the action. The reported actions were recorded and analyzed, and the participants were interviewed at the end of each interaction. RESULTS: A total of 32 participants completed the study, each interacting with 4 conversational assistants. The participants were on average aged 42.44 (SD 14.08) years, 53% (17/32) were women, and 66% (21/32) were college educated. Those participants who heard a correct paraphrase of their query were significantly more likely to state that they would follow the medical advice provided by the conversational assistant (χ21=3.1; P=.04). Those participants who heard a disclaimer message were significantly more likely to say that they would contact a physician or health professional before acting on the medical advice received (χ21=43.5; P=.001). CONCLUSIONS: Designers of conversational systems should consider incorporating both disclaimers and feedback on query understanding in response to user queries for medical advice. Unconstrained natural language input should not be used in systems designed specifically to provide medical advice.

Patient and Consumer Safety Risks When Using Conversational Assistants for Medical Information: An Observational Study of Siri, Alexa, and Google Assistant.

BACKGROUND: Conversational assistants, such as Siri, Alexa, and Google Assistant, are ubiquitous and are beginning to be used as portals for medical services. However, the potential safety issues of using conversational assistants for medical information by patients and consumers are not understood. OBJECTIVE: To determine the prevalence and nature of the harm that could result from patients or consumers using conversational assistants for medical information. METHODS: Participants were given medical problems to pose to Siri, Alexa, or Google Assistant, and asked to determine an action to take based on information from the system. Assignment of tasks and systems were randomized across participants, and participants queried the conversational assistants in their own words, making as many attempts as needed until they either reported an action to take or gave up. Participant-reported actions for each medical task were rated for patient harm using an Agency for Healthcare Research and Quality harm scale. RESULTS: Fifty-four subjects completed the study with a mean age of 42 years (SD 18). Twenty-nine (54%) were female, 31 (57%) Caucasian, and 26 (50%) were college educated. Only 8 (15%) reported using a conversational assistant regularly, while 22 (41%) had never used one, and 24 (44%) had tried one "a few times." Forty-four (82%) used computers regularly. Subjects were only able to complete 168 (43%) of their 394 tasks. Of these, 49 (29%) reported actions that could have resulted in some degree of patient harm, including 27 (16%) that could have resulted in death. CONCLUSIONS: Reliance on conversational assistants for actionable medical information represents a safety risk for patients and consumers. Patients should be cautioned to not use these technologies for answers to medical questions they intend to act on without further consultation from a health care provider.

A qualitative study of smokers' assessments of four smoking cessation interventions delivered in a hospital emergency department.

BACKGROUND: A recent clinical trial of 1056 adults who smoke tested the efficacy of four components of a treatment intervention initiated in a hospital emergency department (ED) and found two of them to be clinically effective. This paper explores study participants' attitudes towards the four components, whether they identified important interactions, and suggestions for further tailoring. METHODS: Telephone interviews were conducted with participants at the end of the three-month study period. Each participant had received at least one intervention component: nicotine replacement therapy, referral to a smokers' telephone quitline, a brief negotiation interview, or the smartphone-enabled SmokefreeTXT program. Interviews were audio-recorded, transcribed, and analyzed using an iterative approach, grounded in the data, using thematic analysis. RESULTS: Between March 2017 and September 2018, 63 interviews were conducted with participants who received at least one intervention component. The sample was diverse with respect to race, ethnicity, gender, and sociodemographic status. Intervention components were generally well-received by participants. Four themes were identified: Intervention Context, Intervention Content, Communications, and Recommendations. Provision of smoking cessation interventions to ED patients led to reduced self-reported smoking for most. Nicotine replacement therapy diminished cravings, while behavioral interventions provided social support that helped motivate and sustain behavior change. CONCLUSIONS: Intervention components were feasible and acceptable. The data suggest that pharmacological and behavioral interventions be offered simultaneously, that communication skills training be provided to those who deliver the interventions, and that interventions should respect participants' autonomy and preferences concerning intervention timing, frequency, and termination.

Electronic decision support for treatment of hospitalized smokers: A qualitative analysis of physicians' knowledge, attitudes, and practices.

BACKGROUND: We recently demonstrated the ability of a suite of tools embedded in an electronic medical record (EMR) to improve tobacco cessation treatment for adult smokers admitted to the hospital. A randomized controlled trial conducted by our group demonstrated the ability of an EMR-embedded tobacco use disorder treatment tool, the Electronic Support Tool and Orders for the Prevention of Smoking (E-STOPS), to increase the identification and treatment of smokers, but its uptake varied among 126 physicians randomized to the intervention arm. The purpose of this study was to identify facilitators and barriers to using E-STOPS. METHODS: Semi-structured individual interviews from a purposive sample of 12 hospitalist attending physicians and nine internal medicine residents who were randomized to the E-STOPS intervention were analyzed thematically. RESULTS: Three themes shaped E-STOPS use: the inpatient environment, prescriber attitudes and beliefs, and information needs. Overall, participants were pleased with E-STOPS, but had specific suggestions for improvements regarding the timing of the intervention, suppression logic, and additional decision support and training. A few had concerns about the clinical appropriateness of beginning treatment for tobacco dependence during a hospitalization and the proper role of the inpatient team in that treatment. CONCLUSIONS: Tobacco dependence treatment for hospitalized smokers and facilitated by the EMR is generally acceptable to hospitalists and resident physicians. Improvements in provider training and feedback as well as the timing and content of the electronic tools may increase their utilization by inpatient physicians.