Tag Archives: Electronic medical record

First Principle of Patient Engagement & Patient Portals– Be “Relevant” From The Patient’s Perspective

One of the biggest challenges facing health care providers today when it comes to engaging patients is RELEVANCE…or more specifically the lack of it.   I say “engaging” because any one presenting in the doctor’s office, visiting a patient portal or using a smart phone health app is already engaged in their health.   By engaged I mean they are already cognitively involved in their health to a certain extent with an end Relevantpoint or goal in mind, i.e., learn something, do something or decide about something.   Face it, who do you know that goes to the doctor’s office just for fun.  There is always a reason…and behind that reason is cognition, e.g., intellectual engagement.

Fact – 82% of U.S.  adults see their personal physician at least once a year (avg. is 3 visits/year) and yet experts tell us that most of us are still  unengaged in our health.  What’s with that?

Relevance Is Important In The Doctor’s Office

Now imagine a 55 years old person going into their doctor’s office because of a persistent headache and back pain.  Before deciding to see the doctor they probably talked with their family or friends about their concerns. Maybe they went online to research their concerns before making a doctor’s appointment.  Now imagine that same person in the exam room and all the doctor wants to talk about is the patient’s risk for colon cancer and the need for an overdue colonoscopy.  Bam. Instant patient disengagement.

AdoptOneBigButtonTo be sure, the clinician in this scenario is legitimately trying to “engage” the patient by getting them to comply with a recommended, evidence-based screening.  But there is a disconnect in this scenario between what the person (patient) wants to talk about during their office visit…and what the clinician wants’ to discuss.  The disconnect? A lack of relevance.  What the clinician wants to talk about is not nearly as relevant to the patient as it is to the clinician and that’s a problem.

Here’s another example of a common physician-patient disconnect.  Using the same scenario, imagine that the person/patient concerns regarding their headache and back pain have to do with how these symptoms are affecting their vision (ability to drive), their gait, their ability to sleep at night and their appetite.  For the person/patient, their quality of life is suffering as a consequence of their complaints.

Now consider that physicians – at least those with a physician- or disease- oriented style of communicating with patients (which make up 2/3s of primary care physician) – will focus during the medical exam on the biomedical causes of the patient’s complaints rather than the quality of life issues of concern to the person/patient.  Also realize that most patients are now very good or willing to interrupt or correct their physicians.  Bam. Bam. Instant patient disengagement.

Once again, while what the clinician focuses on may be the cause of the patient’s problems, it’s not relevant to the patient that wants to know how the doctor will fix their loss of vision, gait, sleeping and appetite.

This same scenario is played out every day in physician offices across the country.  Disagreement over the visit agenda isn’t the only reason for communication disconnects or gaps.  Lack of physician-patient agreement is also common when it comes to:

• What’s wrong
• Diagnostic tests needed
• Accuracy of the diagnosis
• Severity of the diagnosis
• Cause of diagnosis
• Appropriateness of the recommended treatment
• Expected efficacy of the recommended treatment
• Need for a specialist referral

Relevance Is Just As Important To Patient Portals

Finally, imagine that the Electronic Medical Records and Open Notes detailing the above scenarios are available to the person/patient via a patient portal.   Imagine also that the HIT folks used the patient’s diagnosis and doctor’s notes to “trigger” personalized, tailored health information for the patient.   That means that the patient is sent messages about this risk of colon cancer, information about diet and colon health and a coupon for a colonoscopy.

Now ask yourself…how in God’s name is the information provided via the patient portal in this scenario relevant or engaging from the person/patient perspective?  Explain to me how the information in the EMR and Open Notes is relevant to the patient if its ignored?  It’s not…and people/patients need only look at their patient portal once to figure that out.

The Take Away?

HIT’s current attempts at patient engagement remind me of the parable of “putting old wine (same old information) in to new wine skins (patient portals). The wine’s going to go bad and few will drink it. The solution is to add relevant, “patient-centered” wine into the new wine skins.

Patient engagement is not an HIT challenge…it is a physician-patient communication challenge. As such, the role of the clinician is to engage patients…but rather to be engaging or at the very least avoid disengaging patients.

That’s my opinion. What’s yours?

Here’s Why You Should Ask Your Doctor To Show You Any “Alerts” In Your Electronic Medical Record

Electronic medical records (EMRs) make a lot of sense.  Ideally they capture, store, and report on all the pertinent information that’s floating around out there concerning your health.   One of the supposed advantages of EMRs is their ability to sort through vast quantities of health data to “alert” physicians to important gaps in your care.

Alerts are triggered when something in your EMR is flagged (think red flag) indicating that something that is supposed to happen to you has not yet happened….and vice versa    For example, EMRs can alert physicians when you are overdue for a screening test.  They can also alert physicians to lab and radiology test results that need to be followed up on.

It Is A Great Way To Engage Patients

Since everyone is so concerned about getting patients more engaged in their health care…why not start by turning the computer screen around and showing patients the “alerts” in their EMR.   I am sure that will get most patients’ attention.

Here’s why this is necessary

A study in a recent issue of the Journal of General Internal Medicine found that care gaps persisted among primary care physicians using EMRs and alerts.   Researchers found that:

  • Physicians failed to follow-up abnormal lab test results in a timely fashion (<30 days) in 7% to 62% of patients
  • Physicians failed to follow-up abnormal radiology test results in a timely fashion in 1% to 36% of patients.

Remember these where practices in which the EMR system was capable of generating electronic alerts telling the treating physicians that action was needed.  These follow-up rates are not all that different from similar studies of physician practices without EMRs.

The lack of timely follow-up by physicians reported in these studies resulted in otherwise preventable hospitalizations and delays in initiating time-sensitive cancer diagnosis and treatment.

In my wife’s case, her Non Small Cell Lung Cancer was identified in a hospital employee health screening when it was Stage 1… yet she was not told of the finding for some 5 years later at which time she was Stage 4.  This despite a “paper copy” of the radiologist report (chest X-ray) being sent to her PCP, OB-GYN and Employee Health Medical Director.

Why The Lack Of Timely Follow-Up?  

Researchers have found that primary care physicians in integrated delivery systems receive an average of 57 alerts per day.  Among the reason given for the lack of timely follow-up, despite the alerts, were the following:

  •  Physicians were found to be less likely to acknowledge alerts when they are behind schedule.
  • Physicians focused their attention on alerts concerning patients with greater “clinical burdens” (e.g., providers were more likely to acknowledge alerts about elderly or highly co morbid patients).
  • Physician lack of knowledge – physician knowledge of EMR alert-management features in one study ranged between 4% and 75%. Almost half (46%) of providers did not use any of these features, and none used more than two.  Put another way, many physicians don’t know how to use all the features of their EMR system.
  • Physicians ignored or turned the alert function off

The Take Away?

If you are a patient in a practice that uses an EMR, politely tell your physician that you would like to see any alerts that pertain to you.  If there aren’t any – fine.  If there are, simply ask your doctor what’s the plan for addressing the outstanding issue.  He or she may well have a good reason for ignoring the alert which I am sure they would be happy to explain to you.

If you are a patient in a “pencil and paper” practice, ask your physician what his/her policy is regarding test result notification, including timeliness.  Ask what their policies and procedures are to make sure that no one – particularly you – falls through the cracks.  Never leave your doctor’s office without a copy of all your test results!

If you are a physician with an EMR system…learn how to use the darn thing. Your patients will appreciate you for it and I dare say you prevent what happened to my wife and me.

That’s what I think.  What’s Your Opinion?

Sources:

Hysong, S.  et al.  Provider management strategies of abnormal test result alerts: a cognitive task analysis.  Journal American Medical Informatics  Association. 2010;17:71–77.

Singh, H. et al.  Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting.  Archives of Internal Medicine. 2009;169(17):1578-1586

Sittig, D. et al. Improving Test Result Follow-up through Electronic Health Records Requires More than Just an Alert.  Journal of General Internal Medicine. 2012 Oct;27(10):1235-7.