Tag Archives: test results

An Indecipherable Patient Visit Summary Does Not Engage Or Empower Anyone

John Moore, of Chilmark Research, graciously allowed me to use the the following post.   I hope you find it as interesting as I did.  If you are not farmilar with his work be sure to check it out.

Recently upon leaving my doctor’s office I was presented with a print-out of my visit summary. Knowing I worked it the HIT space my doctor proudly stated that this was one the ways that they planned to meet one of the menu objectives of Stage One meaningful use (MU). This is great I thought, until I began looking over that visit summary.

A significant portion of the summary listed the basics such as who I was, why I paid them a visit etc., all pretty boiler plate – nothing new. Then I turned the page to see the lab results of the routine blood-work – YIKES! nothing but acronyms, values and acceptable ranges. I think I was able to decipher about 10% of those lab results and I work in this industry! I can only imagine how difficult and mind-numbing these figures may appear to an “ordinary” patient/consumer.

So seeing some out of range values I began asking my doctor:

What does this acronym stand? Why is this out of range? Is this something I need to worry about?

Being the great doctor that he is, he took the time to explain my results (some of those out of range values are the result of meds) but also expressed a certain level of frustration stating: “I’m not a big fan of passing this information on to a patient for I worry that they won’t understand results such as these and then I need to take time out to walk the patient through their results which can be quite time consuming. Is this another contributor to physician burnout I wondered?

Now I am all for patient/consumer empowerment and do believe that providing patient’s access to their personal health information (PHI) as a critical component of such empowerment. But does providing a patient a visit summary really empower them or does it simply make them confused (as I was) and resigned or worse endanger?

Stage 2 meaningful use rules released last week state that an eligible physician or hospital will be required to:

Use Certified EHR Technology to identify patient-specific education resources and provide those resources to the patient.

But what will that “patient-specific education resource” look like? Will it solve the problem I encountered?

I want more than a generic here is what these type of acronyms and values mean that litter the internet. I want personalization. I want a system that will take my lab results, my problem list, match it up with my meds, allergies etc. and provide me with personalized knowledge of what these results mean to me and my future health. I then want to be provided suggestions as to how to improve those values? This is what I see as true patient/consumer empowerment.

Unfortunately, what I have actually experienced as a result of this grand HITECH effort under Stage One falls far short of empowerment, if anything, it is closer to disempowerment.

Getting a bunch of data in a visit summary without putting it into context is not meaningful, it is meaningless.

My hope is that there are some novel, creative solutions now being developed that will leverage the new concept in Stage Two, the Base EHR, and provide a module that automatically digs into a patient’s PHI and presents the patient with an empowering visit summary. This is one of the ultimate intents of the HITECH Act, I now want to see it happen.

Patient Portals – What Do Patients Really Think About Them?

There seems to be an inverse relationship between the amount of spin one hears about “the next big thing”…and reality.    First it was EMRs and virtual e-visits, then social media, and now patient portals seem poised to be next big thing.   The drumbeat of vendors and pundits is unmistakable….physician that don’t adapt will be toast.   It can all sound pretty convincing until you ask to see the evidence.  What do patients think?

Take the physician patient portal.   If you read between the lines, patient portals are frequently being positioned as the new “front door” to physician practices.   By signing on to a secure website patients will have real time access to the electronic health record and will be able to communicate with their physicians by e-mail.   Additional patient features include being able to schedule an appointment with their doctor, reading their test results and refilling prescriptions.  But despite these features, according to John Moore at Chilmark Research, “nationwide use of patient portals remains at a paltry 6%.”

Ok… so now we know what vendors and pundits think about patient portals. What about patients – what do they think?

They would love it right?  I mean who at this very moment isn’t at home trying to e-mail their doctor.  Yeah right.

If a qualitative study of primary care patients in Journal of Internal Medicine is any indication, those most interested in using a patient portal were patients who were:

  • Dissatisfied with their physician
  • Dissatisfied with their physicians communications ability
  • Dissatisfied with their ability to get medical information from their physician

Those patients least likely interested in using a patient portal offered by their physician are patients who are:

  • Satisfied with their physician
  • Satisfied with their physician’s communication abilities
  • Difficulty in using the portal

Of significant note, patients who reported good relationships with their doctors were afraid that the patient portal would potentially undermine that strength of that relationship.    In other words, patients were afraid that e-visits would replace face to face visits.  Researchers were surprised that not one patient in the study identified encrypted e-mail communication with their doctor as an advantage of patient portals.

While the findings from this study are not generalizable, the study does highlight a potentially significant unintended consequence of encouraging patients to use a new patient portal.   Patients may interpret the move as a signal from their physician that they will have less face-to-face time with their doctor…which in their mind is not a good thing.

To be sure, there are notable exceptions to the cautionary tale described here.  MYGroupHealth , the patient portal developed by patients and providers at Group Health Cooperative in Seattle, is perhaps the best example.

Take Aways

  1. Patient Portals are not going to go away.  Having a patient portal is expected to be a requirement in the final  Stage 2 Meaningful Use (MU) Requirements (June 2012) and is listed as a condition for advanced Patient Centered Medical Home (PCMH) accreditation by NCQA
  2. Ask patients what they think about a patient portal – what services should it offer, would they use it, how should it be promoted and so on.  After all, it is supposed to be patient-centered.
  3. The real value of the patient portal lies in physicians providing  patient-centered, clinical support to patients rather than promoting products and services.
  4. Integrate the patient portal into the primary care physician’s work flow and practice.  If you collect patient data on the portal then make use the physician actually uses the information during the patient visit.

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

Sources:

Zickmund SL, Hess R, Bryce CL, et al. Interest in the use of computerized patient portals: role of the provider-patient relationship. Journal of General Internal Medicine. 2008;23.

How Good Are Your Doctor’s Diagnostic Skills? A Simple Test.

[tweetmeme source=”Healthmessaging” only_single=false]We have all been there.   It often starts with some kind of recurring pain or dull ache.  We don’t know what’s causing the pain or ache.  During the light of day we tell ourselves that it is nothing.  But at 3:00am when the pain wakes you… worry sets in – maybe I have cancer, heart disease or some other life ending ailment.  The next day make an appointment to see your doctor.
 

Ok. Now you are sitting in the Exam Room explaining this scenario to your doctor.  Based upon your previous experience, what’s the first thing your doctor would do?

  1. Order a battery of lab tests and schedule a follow up appointment
  2.  

  3. Put you in a patient gown and give you a thorough physical examination, including asking you detailed questions about your complaint, before ordering any tests.

If you answered A you have a lot of company.  A recent post on KevinMD.com by Robert Centor, MD reminded me of yet another disturbing trend in the doctor-patient interaction.  The post entitled “Many doctors order tests rather than do a history and physical ” talks about how physicians today rely more on technology for diagnosing patients than their own "hands on" diagnostic skills, e.g. a good patient history and physical exam.

Prior to the technology revolution in medicine over the last 20 years, physician training taught doctors how to diagnose patients using with a comprehensive history and physical exam.   More physicians today are practicing “test-centered medicine rather than patient-centered medicine.”   Medical schools focus on teaching doctors to “click as many buttons on the computer order set as we possibly can in order to cover every life-threatening diagnosis.”   The problem is that medicine is still an imperfect science and technology is not a good substitute for an experienced, hands-on diagnostician.

The result of this move to “test-centered” medicine include:  1) more unnecessary tests are ordered, 2) patients are exposed to unnecessary risks (radiation, anxiety, etc.) and 3) health care costs go up.

Get Your Physician To Listen Or….Find A Physician That Knows How To Listen

Sir William Osler (1849-1919), considered the “most influential physician in history,” believed that the best diagnosticians were those that listened to their patients.  The following quote attributed to Osler says it best – “Listen to the patient – he (or she) is telling you the diagnosis.”

So the next time you are sitting on the exam table provide a clear, before your doctor can interrupt you, present an organized history of your complaint.  Ask your doctor to examine you before referring you out for x-rays or lab tests. If you doctor can make the case for tests after your doctor has heard you out…fine.  This way you can be more likely of getting the correct diagnosis.

Sources:

The Fading Art Of The Physical Exam. R. Knox, NPR September 20, 2010.
http://www.npr.org/templates/story/story.php?storyId=129931999#commentBlock

DeMaria, A. Wither the Cardiac Physical Examination? Journal of the American College of Cardiology. Vol. 48, No. 10, 2006.

Patient-centered Care and Physician Use of Social Media

[tweetmeme source=”Healthmessaging” only_single=false]I came across a piece in USA Today this week about “Doctors who are not on Facebook, Twitter and blogs risk becoming irrelevant” by Kevin Pho, MD, author of the KevinMD blog. This article prompted the following post.

The Patient-Centered model of care is predicated among other things on physicians factoring in knowledge of the “person behind the patient” into their treatment.   That’s means understanding and, where practical, honoring the patient’s beliefs, values and preferences.   In order for a communication between a physician and person (patient) to be “patient centered,” it must be congruent with patient preferences for how they want their physician to communicate with them.

So Just How “Patient Centered” Is Social Media?

Let’s consider test result reporting to patients.   If you are among the 5% of patients who (in very recent large-scale studies) indicate they want to receive normal test results by e-mail for example, e-mail results reporting is very patient-centered. Only 1% of patients prefer receiving abnormal test results via e-mail.   Social media, e.g., e-mail, is not very patient-centered however if you among the other 95% of patients that prefer to be notified of normal and abnormal test results by telephone, snail mail, or in person visits with your doctor.   I understand that e-mail is not necessarily considered “social media” like Twitter, Facebook, or blogs, but it is the only “indicator” we have to date in the research literature.   I also acknowledge that non-physician blogs and social networking sites such as PatientsLikeMe show great promise in building self care management skills, confidence and support among people with similar chronic disease conditions.

Implications?

This is not to say that physicians should avoid social media when communicating with patients.   I am just saying that, according to the evidence, social media is not for everyone at this point.    No doubt patient preferences involving social media will evolve with the development of new applications and privacy protections…but we are nowhere near that point yet.

From my vantage point, when it comes to communicating with patients, physicians’ time would be much better spent by:

  1. Learning what their patient preferences are (with regards to communications, medications, exercise, nutrition, etc.).
  2. Tailoring conversations with patients during office visits to their preferences and concerns. The evidence shows that by doing, physician can more effectively engage patients, increase patient adherence, reduce cost and improve outcomes and satisfaction.

I have yet to see large scale studies that shows how social media can do that.