Satisfaction With Provider Communication In Recent Study Is Lower In Patient Center-Medical Homes (PCMH) Than Non-PCMH

A recent blog headline on the Patient-Centered Primary Care Collaborative (PCPCC) recently caught my attention. It was entitled Patient Satisfaction With Medical Home Quality High. I was intrigued. I asked myself high compared to what? Non-PCMH practices?

The study, which appeared in the November-December 2013 Annals of Family Medicine, asked 4,500 patients (2009 Health Center Patient Survey) of federally-support health centers their perceptions of a number of “patient-centered quality attributes,” including the following measures which the study authors defined as patient-centered communication:

• Clinician staff listened to you?
• Clinician staff takes enough time with you?
• Clinician staff explains what you want to know
• Nurses and MAs answered your questions?
• Nurses and MAs are friendly and helpful to you?
• Other staff is friendly and helpful to you?
• Other staff answered your questions?

Observations About The Study

The first thing that struck me was that compared to patients in the 2012 CHAPS survey (AHRQ) website, patients in the 2009 study actually reported lower levels of 1) patient satisfaction (81% versus 91%) with their clinicians’ patient-centered attributes (including communication) and 2) willingness to recommend their providers (84% versus 89%).

The second thing I was reminded of is that patients themselves are so used to clinicians’ paternalistic, physician-directed communication style that simply allowing them to ask just one question puts the clinician in the top 5% of patient-centered communicators. Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition? Until recently I never have been and I suspect few if any people in the study cited here have either.

[pullquote]Stop and ask yourself when the last time was that you encountered a physician that asked you what you thought about your medical condition? [/pullquote]

The final thing that struck me was that none of the quality measures used in the study captured the “essential and revolutionary meaning of what it means to be patient-centered.” As Street and Epstein point out, patient centered communication is about inviting the patient to get involved in the exam room conversation.

As articulated in hundreds of studies over the years, patient-centered communication skills include:

• Soliciting the patient’s story
• Visit agenda setting
• Understanding the patient’s health perspective
• Understanding the whole patient (biomedical and psychosocial)
• Shared decision-making
• Empathy

We Need To Raise The Bar For Patient-Centered Medical Homes (PCMH)

Studies like the one cited here set the quality bar (and bragging rights) way too low for PCMH. Patient-centered care has to be different than the paternalistic, physician-directed care we all seem so willing to accept. Such studies trivialize what it means for physicians and their care teams to be patient-centered in the way they relate to and communicate with people (aka patients). Patient-centeredness is a philosophy or care…and does not require team care, extended hours or care coordinators. These are great added features, but to equate such services with patient-centeredness misses the boat…something which professional groups like the PCPCC, NCQA, Joint Commission, and URAC should recognize by now.

The Take Away?

Here’s some thoughts:

1) We need to set the bar higher for PCMHs when it comes to how we define and measure patient-centered communication.

2) We need to find better ways to asses patient-centered communications in actual practice. Patient rating of a clinician’s patiient-centeredness are simply not enough. As part of the 2014 Adopt One! Challenge, we will be using audio recording of actual physician-patient exam room conversations to measure and benchmark clinicians’ patient-centered communication skills.

3) We should stop celebrating being average whether it be in PCMH setting or hospitals when it comes to physician-patient communications.
That what I think. What’s your opinion?

Sources:

Lebrun-Harris et al. Effects of Patient-Centered Medical Home Attributes On Patient’s Perception Of Quality In Federaly-Supported Health Centers. Annals of Family Medicine. 2013; 11:6; 508-516.
Street et al. The Value and Values of Patient-Centered Care. Annals of Family Medicine. 2011; 9; 100-103.

The Lack Of Patient-Centered Communication Skills By Physicians in Your Provider Network Will Limit Your PCMH & ACO Performance

 

The Push For Patient Engagement – Who Benefits The Most?

It goes without saying that people – you and I – need to be actively involved (Ok…I’ll say it…engaged) in our own health.  After all it is our health we are talking about.   But I have long suspected that there may be motives behind all this talk about patient engagement that go beyond the simple argument that it’s “the right thing for patients to do.”  Motives which I believe constitute a fundamental “unspoken truth” about why policy makers, payers, vendors and at least a few providers are so passionate about patient engagement.

Truths that have remained unspoken until now that is.

Sam VanNorman, director of business intelligence, from Park Nicollet, shared this unspoken truth about patient engagement at a recent panel discussion on Pioneer ACOs.  In an online Forbes article, Dave Chase quotes VanNorman as saying:

“We have to incorporate the most important member of the care team — the patient. With our finite resources, we must figure out ways to offload what we have thought as tasks that needed to be done by our staff.  In most cases, it’s the patient who can do it more effectively. In the process, the patient is more engaged and it’s more efficient for everyone.”

The heretofore unspoken truth to which I refer is that for some, patient engagement is not about getting patients to do what in their own best  interest….but rather doing what’s in the self interest of policy makers, payers and perhaps providers.

I am not convinced however that most clinicians think this way.

Call me naïve, but I thought patients were the most important member of the care team because of what they can do for themselves, e.g., share information with the clinician to improve diagnosis and treatment, self-care management and so on.  Patient engagement to those thinking this way is about inviting the patient into their care and the care process to advance their activation, quality of care, clinical outcomes and the patient experience.   This approach begins with the patient.  As such, this approach is patient-centered in that the care delivery process begins by the clinician eliciting the patient’s knowledge and perspectives of their health.

VanNorman seems to believe that patients are the most important member of the care team because of what they can do for the provider and payer,  e.g., provide a more efficient, cheaper (free is pretty cheap) labor pool to which clinicians can outsource work they don’t want to do, don’t have time to do or don’t get paid to do.  Patient engagement for those that think this way begins with policy makers, payers and administrators looking for ways of offloading tasks (of their choosing) to the patient (e.g., lowest pay grade), irrespective of the patient’s willingness, knowledge or ability to comply. This approach could rightly be called bureaucrat-directed care which is antithetical to patient-centered care and the principle of PCMH and ACO models as well as the Triple Aims.

Don’t Conflate Outsourcing With Patient Engagement – They Are Not The Same

I complete understand VanNorman’s logic and agree with the notion of putting patients to work – they are a vastly underutilized resource in so many ways.  What I disagree with is conflating with “outsourcing” with patient-engagement.    I feel that the definition of patient engagement I share with most clinicians carries with it a kind of moral authority to do what’s right for the patient.   VanNorman’s attempts to cloak “physician workload outsourcing” as patient engagement feels manipulative, self-serving and  destined to disengage patients instead.

Furthermore I fundamentally disagree with anyone trying to force patients to do anything without the benefit of first:

• Explaining to patients what you want them to do
• Why you are asking patients to do something
• Asking for their feedback on what you want them to do
• Teaching patients how to do what it is you are asking them to do
• Providing ongoing support to patients regarding what you asked them to do

The Take Away?

Maybe one of the real reasons patient engagement is so hard is that some of us are approaching it from a patient-centered perspective…while others are approaching it from VanNorman’s beauracrat-directed perspective.

This in turn translates into different motives, messages to patients, different measures of patient engagement and so on.

This may also explain why some of my peers in HIMMS and NeHC get so mad at me when I say that patient engagement is a physician-patient communication challenge and not an HIT challenge.

That’s my opinion…what’s yours?

Note:  Later this Summer, Mind the Gap will be announcing the Adopt One! Challenge TM. for physicians and their care teams.  The goal of the challenge is to encourage physicians and their care teams to adopt one new patient-centered communication skill within 2014. 

Sign-up to learn more about this one-of-a-kind “Challenge”:

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Shared Decision Making – Not Ready For Prime Time – Nor Evidently Is Patient-Centered Care

When it comes to delivering truly patient-centered care…how are providers supposed to know when they have “arrived”?   According to Michael Berry, MD, President of the Informed Medical Decisions Foundation, providers will know they have achieved the “pinnacle of patient-centered care” when they routinely engage their patients in shared decision-making (SDM).

In theory, shared decision-making (aka collaborative decision-making) is what is supposed to happen between patients and their doctors when faced with a difficult choice.  Clinicians engaging in shared decision-making would provide patients with information pertaining to the need for the treatment, the available options, as well as the benefits and risks.  But patient-centered clinicians would also do something else. They would attempt to work with patients to arrive at a decision they could both live with.  A kind of “shared mind” that takes into consideration their clinical perspective as well as the patient’s perspective – their preferences, needs, and values (which ideally have been captured over the course of the patient-provider relationship).

The Problem Is That Most Physicians Don’t Really Engage Patients In Either Shared Decision Making  

 A 2003 study surveyed U.S. physicians (N=1,217) preferences and actual practices regarding shared decision-making.  Table 1 presents a summary of findings from this study.

Table 1

Decision Making Style	What Physicians Preferred	What Physicians Actually Do
Shared decision-making	58%	37%
Physician-dominant decision-making	28%	43%
No patient involvement	9%	13%
Patient dominant decision-making	5%	7%

While most physicians in the study may philosophically believe in and prefer shared decision-making…as this data indicates that is not what most physicians in the study reported actually doing.  In fact, 56% of physicians reported that they actually engaged in decision-making that was physician-dominated (with some patient involvement) or totally physician-dominated decision-making behavior (absent any patient involvement).

The Barriers To Shared Decision Making?

The barriers to SDM include the usual suspects:

•  Lack of time during the visit
• Not having access to the right decision support aids tools and training their use
• Physician attitudes about patient’s willingness to engage in shared decision-making
• Provider reliance upon a physician-directed (versus patient-centered) style of communicating with patients

The Take Away – Why Shared Decision Making Matters

•  SDM is the right thing to do – the benefits associated with SDM include better outcomes, lower utilization and cost, lower malpractice risk and enhanced patient trust and satisfaction

•  SDM is a great way to be engaging to patients – it is a way to get patients involved in their care in a meaningful way they can relate to.

• To be eligible to participate in Medicare’s Shared Savings Program, Accountable Care Organizations must implement processes to promote patient engagement, including shared decision-making.

As readers of Mind the Gap know, I am a proponent of the adoption of patient-centered communication by providers, beginning with primary care.   Shared decision-making has rightly been identified as a leading indicator when it comes to assessing the “patient-centeredness’ of a physician practice.   So before you go around telling everyone how patient-centered your provider teams are first do a reality check.  Because if you aren’t regularly engaging your patients in shared decision making you are not there yet.

That’s my opinion…what’s your?

Sources:

Heisler, M. et al. Physicians’ participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study. Chronic Illness. 2009 Sep;5(3):165-76

Street, R. et al  The importance of communication in collaborative decision making: facilitating shared mind and the management of uncertainty. Journal of Evaluation in Clinical Practice 17 (2011) 579–584.

Frosch, D., et al. An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles. Health Affairs. 32, no.2 (2013):311-320.

How To Speak So Your Doctor Will Listen

This guest  post was written by Vicki Whiting, Ph.D., MBA is a Professor of Management at Westminster College, and an Award-Winning Author of the health care advocacy book, “In Pain We Trust.”

Doctors interrupt patients 18 seconds into an office visit, on average. Given this fact, patients who seek to maximize their healthcare must learn how to speak so that doctors will listen. There are three communication skills that, when applied to a doctor’s visit, can increase odds that your physician will hear, and help solve the problem.

1st – Prepare what you will say. 

2nd – Know what you would like to achieve.

3rd – Formulate collaborative questions.

1) Prepare:The first step in effective communication is to prepare your message. Successful preparation for a doctor visit requires identification your primary health concern, symptoms relevant to this concern, and the length / frequency / intensity of each symptom. Stick to the facts, keep focused on what you believe to be relevant data, and keep your explanation short.

A friend called this morning. Her daughter has suffered from abdominal pain for four months and has begun to vomit after each meal. As my friend prepared for an appointment with a new specialist, she called to ask my advice.I got an earful of physical details, ailments, concerns about her daughter’s future, and conjectures about an injury five months ago that might be related to her daughter’s problems.

After two minutes I stopped my friend. I reminded her that her doctor would likely stop listening after 18 seconds. What did she want her doctor to know that could be heard in 18 seconds? After a bit of coaching she focused on the increase in her daughter’s focal pain, the fact that a diagnosis of SMA (Superior Mesenteric Artery Syndrome) was made, but was not being treated, and that her daughter has thrown up after each meal since a feeding tube was removed after a recent hospital stay.

Once the Mom’s message was stripped of dramatic details, non-related facts, and instead focused on relevant, actual elements of her daughter’s symptoms and medical history, chances that the doctor would listen to issues key to her daughter’s health greatly increased.

2) Communicate with purpose: Complex health concerns are solved in increments. If you have an earache, diagnosis and treatment is straightforward. However,appointments related to complex and chronic health issuesmake the desired outcome ambiguous for both the patient and the physician. If you don’t know what you want to achieve from the doctor visit, it’s unlikely that you will be content with outcome of the visit.

Since SMA is not cured in one doctor visit, my friend needed to think about a realistic outcome for the doctor’s appointment. “I want to understand the standard protocol for fixing SMA, and what plan the doctor recommends to fix my daughter’s SMA.” With this focus, my friend can leverage the doctor’s expertise, and start down a path of wellness for her daughter.

3) Prepare questions. To maximize the 14 – 16 minutes a primary doctor spends during an appointment (less for specialists) prepare questions you would like to have answered. If questions occur to you during the appointment, add these to your list. Some doctors are frustrated that patients spend time researching symptoms, medicines, and treatments on-line prior to an appointment. Given the amount of unreliable data available on-line, this is understandable. The key to being a good patient questioner is to base your questions on valid, reliable data, and your own symptoms and responses to treatment. The National Institute of Health is a great place to understand your medical condition, and what questions you might ask.

It is also critical that you have listened to your doctor throughout the appointment. Use questions to fill in gaps that might not have been addressed during the exam. Let’s go back to my friend and her daughter. The Mom wanted to ask the doctor if surgery would fix her daughter. I cautioned against asking this question. While mentioned as a cure for SMA on some websites, this is not a standard approach to resolving SMA. Also, based on information shared during the appointment, this question might not be relevant.

Finally, avoid questions that begin with “Why?” Why questions invite defensiveness. Why is my daughter sick? Why didn’t they fix her at the hospital? Instead, ask collaborative questions. What do you recommend?What would you do if you were in my shoes? Do I understand that you want me to…? These questions draw on the doctor’s expertise, invite thoughtful response, and focus on problem resolution.

To maximize time spent with your doctor, focus on the portion of the physician – patient interaction that you have control over – how you speak to your physician.  If you prepare for the appointment, focus on what you would like to achieve from the office visit, and formulate meaningful, collaborative questions, you’ll help yourself and your doctor create positive health care outcomes.

Dr. Whiting consults for health care organizations and providers across the United States on leadership, communication, and management issues. Contact: @docwhiting vickiwhiting.com, or vwhiting@westminstercollege.edu