Thoughts On Patient Engagement, Patient-Centeredness and Communication-Centered Medical Records

Sometimes I come across a post that I absolutely must share… such is the case with this re-print of a post by Rob Lamberts, MD, a primary care physician practicing “somewhere in the southeastern United States.” He blogs regularly at More Musings (of a Distractible Kind), where this post first appeared.

“Patient engagement.”

What is “Patient Engagement?”  It sounds like a season of “The Bachelor” where a doctor dates hot patients.  It wouldn’t surprise me if it was. After all, patient engagement is hot; it’s the new buzz phrase for health wonks.  There was even an entire day at the recent HIMSS conference dedicated to “Patient engagement.”  I think the next season of “The Bachelor” should feature a wonk at HIMSS looking for a wonkettes to love.

Here’s how the Internets define “Patient engagement”:

• The Get Well Network (with a smiley face) calls it: “A national health priority and a core strategy for performance improvement.”
• Leonard Kish refers to it as “The Blockbuster Drug of the Century” (it narrowly beat out Viagra) – HT to Dave Chase.
• Steve Wilkins refers to it as “The Holy Grail of Health Care” (it also narrowly beat out Viagra) – HT to Kevin MD.
• On the HIMSS Patient Engagement Day, the following topics were discussed:
  • How to make Patients Your Partners in Satisfying Meaningful Use Stage 2 Objectives; Case Studies in Patient Engagement, session #64;
  • Review Business Cases for Implementing a Patient-Centered Communication Strategy and Building Patient 2.0, session #84;: and
  • Engaging People in Health Through Consumer-Facing Devices and Tools, session #102.

So then, “patient engagement” is:

• a strategy
• a drug
• a grail (although I already have a grail)
• a “meaningful use” objective
• something that requires a business case
• something that requires “consumer-facing devices and tools” (I already have one of those too).

I hope that clears things up.

So why am I being so snarky about this?  Why make fun of a term used by many people I trust and respect?  I was recently discussing my ideas on a communication-centered medical record with a colleague.  At the end of my pontification, my friend agreed, saying: “you are right; communication is an important part of health care.”  I surprised him by disagreeing.  Communication isn’t important to health care, communication is health care. Care is not a static thing, it is the transaction of ideas. The patient tells me what is going on, I listen, I share my thoughts with the patient (and other providers), and the patient uses the result of this transaction for their own benefit.

But our fine system doesn’t embrace this definition.  We indict ourselves when we talk about “patient engagement” as if it’s a goal, as it reveals the current state of disengagement .  Patients are not the center of care.  Patients are a source of data so doctors can get “meaningful use” checks.  Patients are the proof that our organizations are accountable.  Patients live in our “patient-centered” medical homes.

Replacing patients as the object of our attention (and affection) is our dear friend, the medical record.  We faun over medical records.  Companies earn epic profits from medical records.  We hold huge conferences to celebrate medical records.  We charge patients money to get to see their own medical records.  We even build special booths (portals) where patients are allowed to peer in through a peep hole and see parts of their medical records.

This is why I’ve had such a hard time finding a record system for my new practice.  I want my IT to center on patients, but medical record systems are self-absorbed.  They are an end in themselves.  They are all about making records, not engaging patients.  They are for the storage of ideas, not the transfer of them.  Asking medical records to engage patients is like asking a dictionary to tell a story.

The problem is, documentation has taken over health care.  Just as the practice of a religion can overshadow its purpose: the search for God, documentation chokes out the heart of health care: the communication of ideas .  It did this because we are paid to document, not communicate.  Communication takes time and it is not reimbursed.  Communication prevents unnecessary care, which is a revenue stream.  Communication eliminates waste, and waste is food that feeds the system, the bricks that build the wings to hospitals, the revenue source that pads IT budgets.

So what’s a doctor to do?  I’m not sure.  I am still looking for a solution that will meet the central goals of my practice:

• Communication – health care is a hassle,  with communication relegated to the exam room.  I want care to be easily accessible for my patients,using IT in one of its strongest areas: tools for easy communication.
• Collaboration – the patient should be engaged, but in a two-way relationship.  This means they not only should have access to their records, they should contribute to those records.
• Organization – I want a calendar documenting visits, symptoms, problems, medications, past and future events in each patient’s record.  I also want a task-management system I share with patients to make sure care gets done.
• Education – I want to practice high-quality medicine, care that is informed by good information and the best evidence.  Why not do a yearly stress test?  There’s evidence for that.  Why not use antibiotics for sinus infections?  There’s evidence there.  Why use an ACE inhibitor to control the blood pressure?  I need to be able to support my recommendations with data, not just “because the doctor said so.”

The point of all of this is the moving of medicine from an industry where money is milked from disease to a communications network where diseases are prevented.  ”Patient engagement” that is done to the patient for the sake of the doctor or hospital is a sham.  Engagement is about interaction, listening, and learning in relationship to another person.  Engagement is not a strategy, it is care.

If only I could find the tools to make this happen.

HIT-Driven Patient Engagement Is A Bust – Effective Patient Engagement Begins With The Doctor-Patient Relationship

I hate saying I told you so.  But to quote myself…”patient engagement is a physician-patient communications challenge and not an HIT (Health Information Technology) challenge.”

Just take a look at the Mayo Clinic’s patient portal experience which was discussed at a HIMMS 2013 and reported on in HIT industry press.

The Headline

Mayo Clinic Struggles To Meet Stage 2 Meaningful Use Thresholds For Engaging Patients.

Always innovating, the Mayo Clinic some three years ago introduced a web-based portal to share information with their patients.  During that time some 240,000 patients have signed up for online accounts.  That’s pretty impressive.  But there’s a problem.  A BIG PROBLEM.

According to Eric Manley, product manager of global solutions at the Mayo Clinic, they are having a hard time “getting more than 5% “of all the patients who registered with the patient portal to actually use it.   You see in order to meet Stage 2 Meaningful Use requirements, and enjoy the benefits that come with meeting this criteria, people actually have to use the portal to access their own health information.  You just can’t build a portal and in Mayo’s case have fewer than 12,000 unique patients actually use it.    Actually you can…hospitals and physicians do it all the time…they just can’t get incentive payments for their efforts.

 So What Went Wrong?

It’s not like the folks at Mayo haven’t tried.  Mayo’s patient portal offer all the requisite techie gizmos – giving patients access to their medical record, lab results, appointment schedule, and lots of health information.  They also recently introduced their first patient-directed mobile health app call “Patient” which makes it easy for people to access their health information online.   Mayo even has a Center for Innovation to figure this kind of stuff out.

Upon reflection Manley admits that “simply making services available doesn’t cut it,” he said. “Unless you are engaging patients, you won’t meet meaningful use requirements. [Messaging and other mechanisms] need to be a part of your practice.”

But Wait – I Thought Patient Portals, EMRS and Health Apps Were Patient Engagement Strategies?? You Mean We Need To Do More?

Manley is quoted as saying that “patient engagement has been a part of what Mayo has done for a long time, meaningful use, especially Stage 2, is a catalyst to kick it up a notch.”

Let’s face it.  Meaningful Use maybe a good way to get providers to adopt badly needed HIT improvements – but it not a great way to force patients to “engage” with you.   Here’s why.

1)    Forcing patients to do anything is wrong and antithetical to the whole idea of patient-centeredness…even if you think it is in the patient’s best interest. Meeting Meaningful Use seems to take precedence over what the patient wants.  Manley is quoted as saying “just having it [information and portals] out there isn’t enough”…”It’s making the patient use them.”

2)    Patients want to engage with other people regarding their health, particularly their physicians. Health after all is an intensely personal and social affair.  Mobile health apps and email just can’t give patients want they want – to be listened to and understood.  Plus 85% of people want face-to-face access to their physician when they want it.  Patients know that HIT threatens to get in between them and their doctors.

3)    The content on most patient portals is not particularly relevant or engaging after the first 10 seconds….at least from the patient’s perspective.   After all, cognitive involvement is a prerequisite of meaningful engagement and it tough to be interested and spend time thinking about information that is not in context (of a medical encounter), you don’t understand, find boring, completely inaccurate or irrelevant.

So What Is The Solution?

There’s no question that if done right patient portals can and do work.  One need look no further than Kaiser Permanente, Group Health and the VA for great examples.  The key to their success…and hopefully every provider’s success…is integration.

Health care for us patients occurs within the context of social relations with our physicians.  To be engaging…the information you want to share with us needs to be relevant to us from our perspective, come from our physician and be integrated into our overall care plan.    Only then will we have the trust and confidence that the information is ours…and is something we need to pay attention to.  We focus on our health while we are in the doctor’s office…if you really want to engage us…do it there.

That’s my opinion…what’s yours?

The Truth About Those High Patient Satisfaction Scores For Doctor-Patient Communication

We have all seen them.  You know…those charts showing us how satisfied patients are with the way their doctors communicate.  Did your doctor listen to you?  Did you doctor explain things in a way you could understand?

Funny thing about these charts, whether they be for hospitals or doctor’s offices,  1) they never seem to change from year to year – 80% – 90% of doctors communicate well with patients and 2) patients consistently rate their doctors’ communication skills as high.

The problem with satisfaction data related to doctor-patient communication is that, at face value, it simply doesn’t correlate with other published data on the subject. There is a “disconnect” between what patients say in satisfaction surveys and what happens in actual practice.

Here’s what I mean.

Recent studies of hospitalized patients have shown that:

• 68% to 85.3% of patients could not name the physician in charge of their care.
• 43% to 58% of patients did not know the reason for their hospital admission.
• 67% of patients received a new medication while hospitalized… yet 25% of these patients were unaware that they were given a new medication.
• 90% of patients given a new medication reported never being told of adverse effects of the new medication.
• 38% of patients were not aware of planned tests for the day.

The amazing thing was that majority of these patients (up to 58% in one study) said that their doctors always explained things in ways they could understand!

The same types of “disconnects” show up in satisfaction surveys done in doctor’s offices.   Studies of primary care physicians show that:

• Patients are interrupted by their physicians within the first 18 seconds of their opening statement during office visits

• Physicians and patients agree on the reason for the office visit only 50% to 70% of the time

• Physician underestimate the patient’s desire for health information in 65% of the time

• 50% of patients walk out of their doctor’s office not understanding what their doctor told them to do

• Patient are not asked if they have any questions in up to 50% of office visits

Again, I am sure these same patients praised their physicians’ communication skills on one or another satisfaction survey.

So What Explains The “Disconnect” Between How Physicians Actually Talk To Patients…And Patient Satisfaction?

Today’s high patient satisfaction scores are an artifact of the way we (when we become patients) have been “socialized” when it comes to a trip to the doctor’s office. Here’s what I mean.

1) Beginning with childhood, we have all been socialized to assume the “sick role” when seeing the doctor.  From our initial visits to the pediatrician with our Mom we quickly learned that the doctor is in charge and that our Mom’s role (and ours) is to sit passive by while the doctor does most of the talking.  Notwithstanding all the “talk” about how empowered patients are today, most of us still assume the “sick role” when seeing our doctor.

2) Accustomed as most of us today are to the sick role, and accepting the fact that physicians are very busy, we are not surprised when doctors don’t seem to listen to us or interrupt us. We are not surprised that they don’t have time for all our questions or frown on us bringing in lists of things we have researched on the internet. This for most patients is what we are used to…it is what we are satisfied with given that most of us have don’t another or better point of comparison, i.e., a highly patient-centered physician.

3) Consistent with the sick role, we as patients “tend to be overly patient.” We “grant our doctors the benefit of every doubt.” Most of us begrudgingly put up with poor service, inconvenience, and unnecessary discomforts, until we can’t overlook it anymore. Even then we are reluctant to take our busy, overburdened doctor to task for these shortcomings by giving them a low score on a satisfaction survey.

The Take Away?

Hospital, medical group, IPA and ACO executives need to:

• Be cautious about putting too much credence in patient ratings of physician communication skills. “One can assume that the quality of care is actually worse than surveys of patient satisfaction would seem to show” to quote Avedis Donabedian, MD, an old professor of mine.

• Recognize that high quality, patient-centered communications (the gold standard for physician-patient communications) is essential to patient engagement, optimal patient outcomes and great patient experiences. If physician communication were as great as patients satisfaction surveys suggest, we wouldn’t be having the problems we are with low levels of patient engagement and non-adherence.

• Benchmark the patient centered communication skills of the primary care physicians on their staff (employed and otherwise) and compare the findings against established best practices.

• Take the additional reimbursement you will get from CMS for your patient high satisfaction scores and invest it back into improving the patient-centered communication skills of their physicians and patients. That is, if you don’t have to pay a penalty to CMS for high re-admission rates – which by the way is another by-product of poor physician-patient communication.

Remember that there is perhaps no better, more cost-effective way to differentiate your physicians (and your brand) these days than to have physicians on staff who really know how to listen and relate to patients.

That’s my opinion…what’s your?

Sources:

Makaryus, A. et al. Patients’ Understanding of Their Treatment Plans and Diagnosis at Discharge. Mayo Clinic Proceedings. 2005;80(8):991-994

Boland, B. et al. Patient-Physician Agreement on Reasons for Ambulatory General Medical Examinations. Mayo Clinic Proceedings, 1998;73(1), 109-117.

O’Leary, K. et al. Hospitalized Patients’ Understanding of Their Plan of Care. Mayo Clinic Proceedings 2010;85(1):47-52.

Olson, D. et al. Communication Discrepancies Between Physicians and Hospitalized Patients. Archives of Internal Medicine. 2010;170(15):1302-1307

Want Your ACO To Succeed? …Then You Better Focus On Improving How Your Doctors & Patients Communicate

The basic premise of the Accountable Care Organizations is simple enough.  By incentivizing providers (physicians and hospitals) to assume financial responsibility for coordinating the health care of a defined patient population, it is possible to increase the quality of care while decreasing the cost of care delivery.

For ACOs to succeed, experts tell us that 3 things are required: 1) health information technology is needed to track and manage patient populations, 2) redesigned care delivery processes are needed to support patient care coordination, and 3) the right set of provider financial incentives must be in place.

But The “Experts” Have Overlooked Perhaps The Most Important Requirement

The improvements in quality and cost effectiveness in large part are predicated upon providers being able to engage patients with the goal of changing their health behavior.  

The problem is that most physicians lack the patient-centered communication skills needed to engage patients in their own health care not to mention persuade patients to change their health behavior. 

An Example – Physician and Patient “Meeting of the Minds” 

I think we can all agree that “telling patients what to do” is not an effective patient engagement or behavior management strategy.  After all, if patients don’t agree with or understand the rationale for a recommendation from their doctor, they are not likely to comply with it.

Rather, a meeting of the minds by physicians and patients is needed…and that requires physicians  understanding the patient’s perspective.  The evidence bears this out.  Higher ratings of trust, satisfaction, and intention to adhere occur when patients see themselves as similar to their physicians in personal beliefs, values, and communication.[1]

The problem is that physicians and patients often disagree on even the most fundamental issues…and herein lies the problem:

• Doctors & patients disagree on the principal reasons for office visits 53% of the time.[2]
• There is “substantial discordance” between the problems patients describe to physicians and the symptoms that physicians document in the EMR.[3]
• For diabetic patients who cited pain or depression as their top health concern their physicians rated these conditions “as likely to affect the patient’s health outcomes” in only 9% and 32% of cases respectively. (Remember, 95% of the treatment for diabetes is patient self care). [4]
• 41% of patients disagree with their physician as to whether their presenting symptoms represented a psychological versus a medical problem. [5]
• Physician perceptions of “how pleased, cheerful, relieved, worried, angry, and disappointed” they thought the patients were during office visits differed significantly from patient rating of how they actually felt. [6]
• Physicians tend to underestimate the patient’s desire for health information in 65% of visits.[6]

So What’s The Take Away?

Many physicians today are ill prepared to assume the role or financial responsibility of care coordination (or care management) given their lack of patient-centered communication skills.  Notice I didn’t mention lack of time since effective use of patient-centered communication skills over time can actually save providers time.

Unless and until medical groups, hospitals, health plans, CMS, and ACOs address this critical shortcoming through providing physicians with the  training, tools and resources needed to develop and refine patient-centered communication skills, ACOs will not deliver on their promise of more effective and efficient medical care.

That’s my opinion. What’s yours?

Sources:

[1] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of Family Medicine. 6:198-205.

[2] Greer, J. and H. R. (2006). Predictors of Physician-Patient Agreement on Symptom Etiology in Primary Care. Psychosomatic Medicine, 282, 277-282.

[3] Stein, T. et al. (1999) Inaccuracies in physicians’ perceptions of their patients. Medical Care.  Nov;37(11):1164-8.

[4] Keulers, B. J., Scheltinga, M. R. M., Houterman, S., Van Der Wilt, G. J., & Spauwen, P. H. M. (2008). Surgeons underestimate their patients’ desire for preoperative information. World Journal of Surgery, 32(6), 964-70.

[4] Street, R. et al. (2008) Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity. Annals of  Family Medicine, 6:198-205.

[5] Freidin, R., et al. (1980). Patient Physician Concordance in Problem Identification. Annals of Internal Medicine, (93), 490-493.

[6]Stein, T. et al., Inaccuracies in Physicians’ Perceptions of Their Patients.  Medical Care. 1999 Nov;37(11):1164-8.

[7] Pakhomov, S. et al. (2008). Agreement between Patient-reported Symptoms and their Documentation in the Medical Record. American Journal Of Managed Care, 14(8), 530-539.

Wonder What Your Doctors And Patients Talk About…Or Don’t Talk About…Behind Closed Exam Room Doors?

Soon you can stop wondering…

For the most us, our first patient experience was a trip to the Pediatrician’s office with our mother. As we age things don’t change much…the doctor’s office remains the center of most people’s “health care experience” except that now we are taking our parents to see the doctor.

The physician-patient relationship is and will continue to be the key stone holding together the rest of U.S. health care system. Why? Because the primary care physician’s office is where the vast majority of health care decisions are made and where most health care is delivered. We are still 13 times more likely to visit our doctor’s office than we are to require an overnight stay in the hospital.

What happens behind the closed doors of the exam room between doctor and patient drives everything else in health care – patient health status, patient adherence, referrals, ER visits, hospital admissions and re-admissions, patient satisfaction and so on. Other than our own personal experience and some vague top line satisfaction survey data, we health care professionals (non-physicians) really know very little about how doctors in our organizations talk with and relate to patients one another once the exam room door closes.

We Know Even Less About The Impact Of Different Styles of Physician-Patient On Our Organizations

For example, what impact does a paternalistic, physician-directed communication style have on patient activation and engagement in hospital-owned physician practices? Or how successful will a physician with poor patient- centered communication skills be when it comes to managing the health of a patient population in an ACO?  Can physicians with poor communication skills hope to retain members attributed to the ACO?  How much money will your organization forfeit next year in incentives and penalties due to poor physician-patient communications resulting in preventable re-admissions and sub-optimal patient experiences?

Exciting New Research Will Soon Provide You Invaluable New Insights Into How Physicians And Patients In Your Market Communication With One Another…And The Implications For Your Organization

It is not often that one gets the chance to become involved in landmark research.  I guess this in my luck day.  Working together with a corporate partner Verilogue in the upcoming months I will be analyzing the patient communication skills of 2,500 HIPPA-compliant physician-patient interviews collected from across the U.S.  The goal of the research will be to deconstruct what primary care doctors and their patients say (and don’t say) to one another and how they say.  We will then benchmark the patient communication skills of physicians in the study against agreed upon industry best practices – aka patient-centered communications.  Ideally the results can be used by hospitals, physician groups, ACOs and health plans to improve the patient-centered communication skills of primary care physicians across the country.

Stay Tuned

As more details of this excite new research become available you will find them here at Mind the Gap first. I look forward to helping advance the field of physician-patient communications. More importantly, I look forward to doing what I can to disseminate and make actionable the finding on behalf of those who will benefits the most – patients.

What things would you like to learn from this research?  Please let me know.