Physicians With High Productivity And Satisfaction Scores Employ Strong Patient-Centered Communication Skills

People are forever telling me that I am wasting my time talking to providers about the need to improve their patient communication skills.  Naysayers typically cite one of the following reasons for why things will never change:

Reason 1 – Every physician thinks they already have good patient communication skills.

Reason 2 – Physicians don’t have time to talk to patients

Reason 3 – Physicians don’t get paid to talk to patients

Reason 1 is relatively easy to debunk. After all, if all physicians were really such good communicators:

• poor communications skills wouldn’t consistently top the list of patient complaints about physicians
• patient non-adherence wouldn’t be so high since physician and patients would always agree on what is wrong and what needs to be done
• patients would not be walking out of their doctor’s office not understanding what they were told
• patients would not experience so many communication-related medical errors

Reason 3 requires a little straightforward logic:

Since physicians are paid to diagnose and treat patients presenting problems…and the accuracy of their diagnosis and treatment depends upon their physicians’ ability to elicit and listen to the patient’s story…then indeed physicians are already being paid to talk to patients.

Reason 3 (physicians don’t have time) has always been hard to address. That is until now.

Most us tend to think about physician time on a zero sum basis.  Take the office visit for example.  Providers will argue that they either spend more time trying to be patient-centered (associated with great patient experiences) or they can use less time to diagnose and treat patients the way they have always done – but no way can they do both at the same time.

A recent published study conducted by HealthPartners in Minneapolis suggests that physician time is not a zero sum game – that providers can in fact be productive while at the same time creating a satisfying patient experience.

Individual productivity and patient experience scores were calculated and plotted for 22 HealthPartners physicians using a scatter diagram like that shown in Figure 1 (for demonstration purposes only). What the study found was that a relatively equal number of physicians fell into each of 4 quadrants – strong productivity/strong satisfaction, strong productivity/weak satisfaction, weak productivity/strong satisfaction and weak productivity/weak satisfaction.

Figure 1

The researchers then looked to explain the difference between physicians in each of the quadrants. They ended up identifying a set of “behaviors and characteristics” to help explain why some physicians had strong productivity/strong satisfaction scores while others did not.

Physicians in the strong productivity/strong satisfaction quadrant exhibited the following behaviors and characteristics:

• Focused on teaching and explanations
• Conveys warmth from the start
• Well-planned flow of visit with focus on patient’s agenda
• Controlled script with clear parts
• Extremely personable—connects with every patient
• Always looking for buy-in from the patient that s/he fully understands
• Recap the history: “I read your chart …”
• Confident but not arrogant
• Finishes dictation and coding each day
• Clinic staff enters orders and prepares after-visit summary

Physicians in the weak productivity/weak satisfaction quadrant exhibited the following behaviors and characteristics:

• Lack of “being there” emotionally
• Lack of smiling
• Abrupt actions
• Behavior changes when not interested in the “case”
• Patients kept waiting and wondering
• No handshake
• Sense of interrogating to get a diagnosis
• No attempt to match the patient’s energy

What struck me about these lists was that were dominated by the presence (strong productivity/strong satisfaction) or absence (weak productivity/weak satisfaction) of communication-related “behaviors and characteristics.”

Perhaps not so surprisingly, the behaviors and characteristics of physicians in the strong productivity/strong satisfaction are consistent with those traits commonly associated with a patient-centered style of communications. This evidence belies the conventional belief among physicians that they will be less productive (rather than more productive) by adopting a patient-centered style of communications with their patients.

Based upon the evidence, HealthPartners has since gone on to provide its physicians with useful guidelines for how to improve their productivity and patient experience scores.

Take Aways Physicians and practice managers need to seriously reexamine:

1. their assumptions about the value of and barriers to improving their patient communication skills
2. the evidence in support of the adoption patient-centered communications skills and styles

Physicians and managers should consider assessing the quality and effectiveness of their existing patient communication skills. The last time most physicians focused on their patient communication skills was back in medical school.

Implement interventions and guidelines designed to improve the patient-centered communication skills of physicians and their care teams.

That’s what I think…what’s your opinion?

Sources:

Boffeli, T., et al. Patient Experience and Physician Productivity: Debunking the Mythical Divide at HealthPartners Clinics. The Permanente Journal/ Fall 2012/ Volume 16 No. 4.

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.

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?

3 First Principles For Evaluating Patient-Facing HIT Solutions

With the HIMSS13 Conference next week we can expect to hear a lot about how health information technology (HIT) and e-Health is expected to challenge and change the way health care now and in years to come.  To be sure great strides have been made in the adoption of electronic medical records, decision support, and patient web portals… with the promise of more to come.  Health Apps, in spite of their painfully slow uptake by many consumers, press forward with innovative new tools.

Yet in order to realize the full promise of patient-facing like EMRs, PHRs, patient portals and the like, we need to be more mindful of the following “first principles.”

First Principles #1 – Health care delivery and healing occurs in the context of interpersonal relationships.

Today, as in the past, health care is delivered within the context of interpersonal relationships, e.g., the physician-patient relationship.  Sir William Osler, the father of modern medicine, recognized this along with the importance of a clinician’s communication skills when he said “listen to the patient and they will tell you what is wrong.”   Today, as in Osler’s time, encouraging patients to “tell their story” is the hallmark of good communication skills.  Eliciting the patient’s story is also a hallmark of strong healing relationships…since the simple act of “talking” and “feeling heard” have been shown to have clear therapeutic benefits.

The same is true with the intensely interpersonal act of “laying on of hands.”  “Touch” as a method of healing dates back to biblical times and beyond.   Today, physicians like Abraham Verghese, MD continue to speak to about therapeutic value of touch as practiced during patient exams in both the hospital and ambulatory settings.  These same physicians caution us against losing sight of the central role and value of the physician-patient relationship in the false belief that technology will one day be capable of replacing the personal physician.

First Principles #2 – HIT cannot compensate for weak physician-patient relationships or poor physician-patient communication skills.   

We hear today about how primary care physicians are very busy…and getting even busier.  EMR systems, e-visits, decision support tools, patient portals and the like are touted as solutions for saving time, increasing quality, etc.  While all this may be true, a great EMR system or secure e-mail visits cannot turn a physician with sub-optimal patient communication skills into a patient-centered Marcus Welby, MD.  It will probably make things worse.

Absent strong, physician-patient relationships and equally strong patient-centered communication skills, such HIT investments are like building castles upon sand.

Another hallmark of patient-centered communication is a “meeting of the minds” between patients and their physicians regarding issues like the visit agenda, the accuracy and severity of the diagnosis and which treatment options will work best.  Unfortunately since many physicians today continue to employ a physician-directed style of communicating with patients…the patient’s perspective is seldom sought…and a meeting of the minds never has a chance to occur.   Even if EMRs accommodated the patient’s perspective, the clinician first has to ask the patient…and that just isn’t happening.

 First Principles #3 – Beware of unintended consequences

Many HIT professionals will quickly dismiss the above first principles cited above in the name of improving physician productivity.  After all, given today’s shortage of primary care physicians we have no choice but to layer on more HIT like EMRS and self-help patient portals.  But as with anything, one needs to be prepared for the consequences.  And there are always consequences.

In addition to improving productivity, health care professionals cite patient engagement as yet another reason to invest in HIT.  But is that really the case?

We have all seen the research citing how patients would “like” secure e-mail with their doctor, online appointment scheduling, access to their doctor’s notes, etc.   Who in their right mind would not like this?  But liking is not the same as using.  Of perhaps more importance is the finding that the vast majority of patients (85%) want to know that they will still have the ability to see their doctor face-to-face when needed after they have access to the above conveniences .   People aren’t dumb.  We/they know that technology is increasingly getting in between us/them and our/their physician.  Provider organizations that try and channel patients into substituting web portals and PHRs for physician office visits run the risk of pushing patients/members into the waiting arms of their competitors.

A recent study of decision support tools underscores yet another unintended consequence – loss of trust in their physician.  Interestingly, certain patients saw the use of computer decision support tools as a reflection of their physician’s clinical knowledge.   That is, physicians that used decision support tools were perceived as being less knowledgeable than physicians that didn’t employ them.  Since clinical skills are a driver of patient trust, the risk of encouraging physicians to “engage” patients by using decision support tools is that you may well be disengaging them by increasing their distrust.

So What’s The Take Away?

We need to recognize that there are fundamental first principles concerning the delivery of healing and health care.  To that extent that HIT professionals and those that write the checks for HIT understand these principles one has a better chance of meeting their expectations.

Here are three questions that need to be considered when evaluating any patient-facing HIT solution:

1. Does technology support or detract from the physician-patient relationship in a meaningful way?
2. Does the technology presuppose the presence of strong physician-patient relations and physician-patient communication skills?
   Do you even know what kind of patient communication skills your physicians have?
3. What are the potential unintended consequences of adopting the proposed technology?

That’s what I think…what’s your opinion?

Sources

Agarwa, R. et al.   If We Offer it, Will They Accept? Factors Affecting Patient Use Intentions of Personal Health Records and Secure Messaging.    Journal of Medical Internet Research 2013;15(2):e43.

Patient Activation Is Only Half The Solution – Physicians Need To Be Activated As Well

Not long ago Nick Dawson, a friend and fellow blogger, paid me the compliment of saying I had inspired a post of his.   Well Nick now you have inspired me…and this post is the result.

Regarding the February Health Affairs edition on Patient Engagement the and follow-on Washington D.C. briefing, Nick writes:

Personally, I was disheartened by some word choices. Implying patients need to be activated suggests patients are passive and something has to be done to them in order for them to care about their health and interactions with healthcare providers. That misses the mark.

What about physician activation? … We should be helping health systems and providers find ways to reduce the stress and fear for patients who are already engaged.

Nick is right. 

The “Belle of the Health Affairs Ball” based on the social media coverage was Judith Hibbard’s interesting work linking health care costs to a person’s level of health activation.   While Dr. Hibbard takes pains to differentiate “activation” from “engagement,” most people are quick to conflate the two.  (Patient-centered communication bears a close resemblance to patient activation as well.)  Nick’s point is that focusing just on what the patient brings to the party in terms of their “knowledge, skills and confidence” is only half the problem.

What about physician activation?  Where in the Health Affairs special, or anywhere else for that matter, are discussions about the need to make sure that physicians (and other clinicians) have the knowledge, skills and confidence to effectively manage all the “already engaged” patients among us?

It Can’t Just Be About Fixing Patient Behavior

For too long, the focus among health care thought leaders has been all about fixing the patient.   If only patient were more engaged, more knowledgeable, more compliant, more trusting, more prepared, ask more questions, etc. 

There is a significant body of research which suggests that provider behaviors (like their communication style) are just as responsible as patients for many of the short coming in health care today.

Just as PAM research has shown that more activated patients generate lower costs…studies have shown that the physicians with strong patient-centered communication skills have lower costs as well.   I guess you could say that physicians with a physician-directed, bio-medical communication style have an equivalent of a 1-2 level of activation whereas physicians with a patient-centered communication style have an equivalent activation level of 3 to 4.

Which Comes First – Activated Physicians Or Activated Patients?

I would argue that the real challenge facing providers today is to how to avoid disengaging or deactivating otherwise engaged and activated patients.

That’s because most people are already engaged in their own care, albeit not necessarily in the same way that providers want or expect.   So too, patients may well believe that they have the skills and knowledge they feel they need to deal with their own health…even if it is different from those skills, etc. measured by tools like PAM.

See : Patients Are Often More Engaged In Their Health Than Providers Think

In fact there is evidence to support this.  Patients with a regular source of care displayed significantly lower levels of patient activation that those without a regular source of care.  According to the researchers, “one possible explanation is that respondents with a regular physician are more likely to take a passive, deferential role in their care, believing their health care needs are being met by their provider(s).” *

The degree to which there is a “meeting of the minds” on engagement and activation between patient and physician, particularly during the office visit, will determine if patients are as engaged and activated when they leave the doctor’s office as they were when they entered.  It all boils down to how well the physician and patient are able to communicate.

Here’s what I mean.  How engaged or activated is a person going to be if what they have to say is interrupted, ignored or otherwise dismissed by busy, stressed  clinicians?  Is a patient going to share information or new skills they found on the internet with their physician if they are dismissed as a Googler?

The Take Away?

Nothing against PAM or Dr. Hibbard’s work which stand on its own merits.  Rather, it’s about health care being a two-way affair…with patients and clinicians both have a stake in health outcomes.  The sooner health care providers, academic researchers, and health publications like Health Affairs realize this…the sooner things can improve.

That’s what I think. What’s your opinion?

Sources:

Levinson, W., Lesser, C. S., & Epstein, R. M. (2010). Developing physician communication skills for patient-centered care. Health Affairs, 29(7).

Olson, D. P., & Windish, D. M. (2010). Communication discrepancies between physicians and hospitalized patients. Archives of Internal Medicine, 170(15), 1302-7. doi:10.1001/archinternmed.2010.239

Roumie, C. L., Greevy, R., Wallston, K. a, Elasy, T. a, Kaltenbach, L., Kotter, K., Dittus, R. S., et al. (2010). Patient centered primary care is associated with patient hypertension medication adherence. Journal of Behavioral Medicine.

Bertakis, K. D., & Azari, R. (2011). Patient-centered care is associated with decreased health care utilization. Journal of the American Board of Family Medicine : JABFM, 24(3), 229-39.

* Alexander, J. a, Hearld, L. R., Mittler, J. N., & Harvey, J. (2011). Patient-Physician Role Relationships and Patient Activation among Individuals with Chronic Illness. Health Services Research, 1-23.