Tag Archives: patient engagement

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 toimagesols.

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.

Pt Centered Communications and Outcomes2

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.

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.

CSC_0359A 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

The 10 Commandments of Patient Engagement

As a patient, care giver, researcher and a human being, here ‘s my “take” on what physicians and hospitals, and all the entities that work with them like health plans, ACOs , etc. need to do to effectively increase patient engagement in 2013 and beyond.

Tweet to Hospitals

  1. Act like you are glad to see them (patients) and have time for them… no matter how busy you really are
  2. Say something relevant to suggest that you actually remember who they are – don’t get this one wrong
  3. Ask how they have been since their last appointment and what brings them in to see you today
  4. Probe for the patient’s ideas as to the cause of their complaints and what they would like you to do for them
  5. Listen to what the patient has to say without interruption – ask clarifying questions
  6. Tell the patient what you recommend doing in the way of tests, treatments and new medications…and explain why you are making those recommendations – ask if that’s ok with the patient…if it’s not ok find out why
  7. Pay attention to patient-initiated cues (loss of a job or loved one, sighing…) – they probably are a call for help
  8. Express empathy and support to patients
  9. Find out what your patient’s health goals are and what steps they believe they can take to achieve them, e.g.,  care planning
  10. Ask about or suggest ways that you and your team can support  patients’ long-term care plans

AdoptOneBigButtonThe challenge most physicians and other providers face is not one of how to engage patients.  Most of us patients (people) are already engaged to the extent we:

  • went to the bother of calling your staff to make an appointment (never a pleasant experience)
  • took time off work to travel to your office
  • wait an average of 24 minutes to see you
  • sit for 24 minutes thinking about what we want to talk with you about and how you are too busy to listen

Rather the challenge for providers is how to be engaging to patients.  Health care after all is an intensely personal and social interaction between human beings.   My apology to all the health information technology folks who suggest EMRs, web portals and smart phone health apps are the best way to engage patients (they are not).  I for one am convinced that people would be more engaged in the care (they way providers expect and prefer) if only providers were more engaging…lack of time and reimbursement notwithstanding.

I am sure I have missed something so please feel free to add to the list.

Check out more posts on Patient Engagement:

Patient Engagement Is A Physician-Patient Communication Challenge…Not A Health Information Technology Challenge

 Patients Are Often More Engaged In Their Health Than Providers Think

Patent Portals. PHRs, & On-line Decision-Support Tools Alone Will Not Lead To Greater Patient Engagement

Patient Engagement  Infographic

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.