Tag Archives: empowered patients

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.

Engage Your Patients And Members Where They Are…Not Where You Wish They Were

Not long ago, Lloyd Dean, president and CEO of the San Francisco-based health care-system Dignity Health announced the Dignity Health and Box Patient Education App Challenge. In the course of the announcement, Dean is quoted as saying:

“We recognize the immense potential that (health information) technology has to enhance our patients’ care and overall experience.”

Dean’s use of the term “immense potential” with respect to patient-facing technologies like health apps and patient portals got me thinking. Immense potential compared to what? [pullquote]Dean’s use of the term “immense potential” got me thinking. Immense potential compared to what?[/pullquote]

With all the hype in the health press about the patient engagement potential of patient-facing health information technologies, one could be forgiven for thinking that HIT is the best if not only path to patient engagement. But in fact there is another way. Another more immediate, less costly and proven way. And its potential to engage patients, enhance care and improve patient experiences dwarfs the “immense potential” of patient-facing HIT by comparison.

PC Communications vs HIT
Rediscovering the Power of Physician-Patient Exam Room Conversations

Here’s what I mean. The average office-based physician engages in some 4,224 face-to-face visit-related conversations with patients each year. Depending upon their communication skills, each of these conversations represents an opportunity for physicians to engage patients, enhance care and improve patient experiences.

In the case of Dignity Health’s 11,000 physicians, assuming they see an average of 20 patients/day/physician, this comes out to:
220,000 patient visit per day , 880,000 patient visits per week 45.7 million patient visits per year

Now factor in the 3-4 complaints each patient brings to the visit along with a myriad of beliefs, fears and expectations for service (tests, referrals, new medications, and so on). I hope you are starting to realize that each patient visit is pregnant with opportunities for clinicians – your clinicians – to engage, empower and excite patients…. sometimes by doing nothing more than listening to what the patient wants to say. Remember these are real opportunities that exist in the here and now…not some promise or dream of possibilities to come.
3-4 Complaints + 2-3 Requests + 4-5 Expectations = Lots Of Opportunities To Engage Patients

At this point you might be thinking that your physicians are already leveraging these exam room opportunities to build your organization’s brand, to refer patients to your specialists and ancillary services, and to direct patients to health information on your their/your patient portal. You would probably be wrong. Not because of the limited time available during the office visit…but rather because many physicians have never been trained or provided with the communications tools needed to recognize or facilitate these kinds of opportunities. But that is the topic for a separate post.
The Patient-Facing HIT Opportunity

Now consider the opportunities in Lloyd Dean’s brave new world…a vision shared by HIT professionals health developers, vendors and their respective professional organizations.

Staying with the Dignity Health example, let’s assume that each of Dignity Health’s 11,000 doctors have patient panels of 2,300 adults and that 10% of these people use their respective patient portals or smart health apps 5 times per year (a generous assumption). This comes out to approximately 12.6 million opportunities for Dignity to engage, empower and excite patients/consumers per year.

It’s doubtful that the opportunities for meaningful engagement afforded by a patient portal or health app compare qualitatively to the opportunities possible with a face-to-face physician visit. Being able to check one’s lab tests, schedule an appointment, or refill a prescription while convenient are do not afford the same therapeutic benefits of a listening ear or the touch of a clinician’s hand.
The Take Away

The real “immense opportunity” for engaging patients, enhancing patient care and improving patient experiences lies behind the closed exam room doors of physicians. That is the most frequent point of contact health care consumers have with the health care system. It is also where truly meaningful patient engagement and memorable patient experience take place.

Engaging patients, enhancing care and improving patient experiences is not an either or choice between more health IT or better physician-patient communications. Providers will need both in the long run. HIT will enable clinicians with good patient communication skills to touch more patients and get more done. Physicians in turn will recommend that patients go to their patient portals and smart apps for health information.

Imagine the ROI that organizations like Dignity Health’s could realize from their investments in patient portals and health apps if all 45.7 million annual patient visits were given a tailored information therapy prescription directing them to one or the other or both.

Now that is what I call IMMENSE POTENTIAL!

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

Helping physicians, hospitals and health plans do a better job of engaging patients, enhancing patient care and improving patient experiences in the exam room is the goal of the Adopt One! Challenge. The Challenge is a great way for physicians to get a comprehensive baseline assessment of their patient communication skills, find out how their communication skills compare to best practices, and get access to online skills development tools.

Be sure to sign up for the Adopt One! Challenge Newsletter for more information. Health plans and hospitals are invited to sponsor the Adopt One! Challenge for physicians in their provider network, including PCMHs and ACOs.

Is The CEO Of The Cleveland Clinic Serious When He Says “No More Passive Patients”?

If a recent blog post by the CEO of the Cleveland Clinic is representative of how health care executives (and physicians) really think about patients – aka consumers –aka people like you and me…we are all in big trouble.  In it Delos Cosgrove, MD, talks about how under health care reform there will be “No more passive patients.”

Here’s my a quote from the post by Delos Cosgrove, MD:

“For too long, healthcare has been something that was done to you. Now it’s going to be something you do for yourself in partnership with your doctor and care giving team. You’ll need to monitor your food input, get exercise, and avoid tobacco. ”

Let’s examine what’s disturbing about comments like this particularly when made by high-profile leaders like Dr. Cosgrove.

First, this statement is factually inaccurate.  Here’s why.  82% of US adults visit their PCP every year at least once a year (often more) for their health.   Think about the trip to the doctor’s office from the patient’s perspective… 1) chances are they have discussed their health problem or concern with family members or friends, 2) they may well have looked up information on their condition to see if it merits a doctor’s visit, 3) they make the appointment, 4) they show up for the appointment and 5) wait in the waiting and exam room thinking about the questions they want to ask their physician.

What about any of this suggests patient passivity?

Second, this statement misrepresents the true nature of the patient passivity of which Dr. Cosgrove speaks.  You see patients (aka people) are socialized by physicians beginning in childhood visits with Mom to the pediatrician to assume a passive sick role.  We are supposed to be passive! Otherwise the doctors gets irritated and ignores or dismisses what we have to say.  While it’s true that patients (even the most empowered among us) ask very few important questions during the typical office exam…the reason isn’t that we are passive.  Rather it’s because we don’t want to be too assertive, confrontational, and argumentative or are simply afraid.

Rather that blaming patients for not being more engaged…why don’t doctors try and become more engaging (e.g., patient-centered) to patients?

Third, patient non-adherence is often not the patients fault…but rather the result of poor communications on the clinician’s part. One recent study found that 20% of medication non-adherence is the direct result of poor physician communication with patients. Poor patient communication skills top the list of complaints people have with their doctor. Poor patient communication is also the leading cause of medical errors, non-adherence and poor patient experiences.

AdoptOneBigButtonFourth, how exactly are patients going to learn all the skills necessary to “do everything” for themselves?  The work of Lorig et al. has shown that simply providing patients with information – the “what” of self care – is not enough to change patient health behavior.  Patients also need and want to develop the skills and self efficacy for self care management – the “how” of self care.   Right now for example clinicians spend on average <50 seconds teaching patients how to take a new medication…and we wonder why patients are non-adherent.

Given the poor patient communication skills of physicians today how exactly are patients supposed to learn how to do it all themselves?

Finally, the Dr. Cosgrove reminds us of the kind of paternalistic, physician-directed thinking and communications which has gotten the health care industry into the mess it’s in.

The following statement says it all:

“If your doctor prescribes a medication, preventive strategy, or course of treatment, you’ll want to follow it.”

What if I don’t want the medication or don’t believe it will help me? Why should I be forced to do something I don’t want to do? Will you drop me as a patient?
What happened to the IHI’s Triple Aims?  What about the need to be more patient-centered as called for in Crossing the Quality Chasm and the ACA reform legislation?

I am sorry if I seem to come down hard on Dr. Cosgrove. But my original point remains…too many health care leaders still think and talk like this.  While they may “talk the talk”…employees, patients and physicians all see how such leaders “walk the talk.“  And as Cosgorove’s comments suggest we have a long, long way to go.

I would like to extend an invitation to Dr. Cosgrove and the physicians at the Cleveland Clinic to see just how “patient-centered” their communication skills really are by participating in the Adopt One! Challenge.   You will not only be able to assess the quality of your team’s patient communication skills but also see how their skills compare to industry best practices.

All physicians are invited to participate in the Adopt One! Challenge.

That’s my opinion…what’s yours?

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.

Offloading Work To PatientsSam 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?

AdoptOneBigButton1Note:  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”:

Would Increased Reimbursement And Longer Visits Improve Physician-Patient Communications?

In a word…no.

It has been said that a physician’s patient communication skills are just as important as their clinical knowledge.   After all, it is only by “talking to and listening patients” that physicians are able to accurately diagnose and treat their conditions.   I have yet to meet a physician who did not agree with the importance of effective physician-patient communication…in principle.

In practice, a surprising number of physicians tell me that they “lack the time” and “don’t get paid” to communicate with patients.  Physicians euphemistically explain to me how current reimbursement schemes fail to incentivise physicians  to spend time talking to patients.

At face value, these objections appear to make sense.  After all we know that physicians, particularly primary care physicians, are already overextended.  We also know that the traditional fee for service model, which pays physicians on a kind of piece work basis, is not well-suited to managing “episodes of care” for a burgeoning chronic disease population.   In other words, today’s reimbursement is not properly aligned with the realities of care delivery.

The conclusion one draws from these two objections is that doctors would communicate better with patients if they simply had more time and were paid more.   But is that what would happen?

I don’t think so…and here’s why.

Many physicians, until recently, were never taught (in medical school) how to be good patient or person-centered communicators (the gold standard for physician-patient communications).   Studies show that the majority of primary care physicians today employ a physician-directed, paternalistic style when talking with patients.   This is the same style of communication practiced by physicians for the last 80 years.  This style is characterized by the physician control of the medical interview by asking the questions, focusing patient input, and providing pertinent information.  Some physicians now limit patients to asking one question per visit.  Over the course of their career, the typical physician will employ these same “conversational habits” in 120,000 to 160,000 medical interviews.

Patients, for their part are trained as well – socialized from childhood to assume the “sick role” wherein the doctor does all the talking and their job is to passively respond to questions when asked.  The average 60 year old for example will have experienced 180+ visits in which they were likely expected to assume the sick role.   Even the most engaged and empowered patient finds it difficult to avoid reverting back to this passive role.

What’s My Point?

The “communication habits” developed by and employed by physicians and patients took years to develop.   Simply increasing the length of the office visit (more time) and increasing reimbursement alone will not compensate for nor change the way physicians and patients communicate with one another.   Physicians will continue to be physician-directed and patients will continue to play the passive sick role.  Absent interventions aimed at breaking this cycle of unproductive communication by promoting more patient-centered communications, longer visits and more reimbursement will mean that physicians have more time for and get paid more for perpetuating the same physician-directed communications challenges we face now.

Patient-Centered Communication Can Lead To More Productive Visits

Physicians are concerned that patient-centered communications will increase the length of office visits.  Initially it probably will.  But imaging how much more productive office visits could be over time if patients came in focused and prepared, i.e., with a prioritized agenda, clearly articulated expectations, realistic requests for referrals, tests and medications, understanding of time limitations, and so on.  The average patient makes 3 visits to the doctor a year.  Patients with chronic conditions see the doctor up to 7 times a year.   Research shows that the adoption of specific patient-centered communication techniques in your practice could “reset” the physician-patient dynamic in ways that could increase visit productivity as well as patient outcomes and satisfaction within the course of a few consecutive visits.

That what I think…what’s your opinion?

Source:

Frankel, R. et al. Getting the Most out of the Clinical Encounter: The Four Habits Model . The Permenante Journal. 1999.