Archive for category Poor Communication

Good & Bad Patient Portals — improving communication

patientportalA good patient portal is wonderful; a bad patient portal is a waste of time.  A recent post by Dr. Yul Ejnes suggested portals may not be patient centered and don’t get much use.

An alternative view is that all patient portals NOT are the same.  Some have great features and are supported by the providers offering them.  Other portals are not much more than advertising — generally something a patient does not revisit.  Sadly, many businesses have the latter type of portal — no wonder people don’t flock to medical portals.

Check out your health care provider’s portal.  If it does not really provide a benefit then TELL THE PROVIDER, complain, and say other providers do a better job.

Admittedly, a poorly functioning provider office will likely have a poorly functioning portal.  Just because the portal lets you send a message to the nurse or provider is no guarantee the response will be helpful.

Large vertically integrated health systems or ACOs have the best chance of a good patient portal.  The portal needs monitoring and rules for providers — rules that require questions to be answered the same day.  And, that the portal will display lab results within 48 hours, regardless of whether the provider has or has not seen the results.  Responses from nurses need to be monitored for accuracy and timeliness — the lazy but profitable response to just make an appointment is not adequate.  Integration of pharmacy functions is essential.

Here is a checklist of possible portal features — how does your provider’s portal stack up?

  • Responses to online requests take less than 24 hours
  • Ask a medical question
  • Ask medication related question
  • Make a follow up appointment
  • Make a same day urgent care appointment
  • Get refills on a chronic medication
  • Get a message from your provider about test results
  • Report drug side effects or drug allergies
  • Send a picture of a skin rash.
  • Diabetics can send blood sugar results
  • Asthmatics can send peak-flow measurements
  • Look at your list of medical diagnoses both active and inactive
  • See a list of current medications and the diagnosis for which they are prescribed
  • Links to drug information about the drugs on the medication list
  • Review the providers notes
  • Review any test, x-ray or consultation report
  • Your provider can send questions to specialists and forward the response to you
  • You can print your lab, pathology and x-ray reports
  • See your most recent medical summary including past medical history, social history, family history, medications list allergies — and be able to print the report if needed for consultations or to take on trips.
  • Request a summary of billing and payment information  — including when bills are sent to insurance and when payment is received.
  • Pay your bills on-line
  • Links to reliable on-line information sources about tests, treatments, drugs, immunizations and diseases.  Include a symptom checker — a computerized diagnosis based on symptoms — something to discuss with your doctor.
  • Provider office provides training to use the portal.

A provider might say:  “I’m not paid for running a portal or answering questions”.  That is very true for many providers in the US health care system.  But, in systems without fee-for-service billing then portals are a huge driver of efficiency.  If a patient’s questions or problems can be resolved via the portal so much the better for both the provider and the patient.  The handwriting is on the wall — fee for service is going to go away — the efficiency of portals will be a strong driving force.

 

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Leaving the hospital — what meds to take?

medlistHospital medication errors are very frequent.  A commonly quoted figure is one error every day of a hospitalization.  Meaning: wrong drug or wrong dose or wrong time or missing dose.

Consequently, it should not come as a surprise  the instructions patients are given when they are sent home have frequent errors.  Patients may be taking medications before they are hospitalized, so in addition to new medications those pre-existing medications need to be considered (a process called “medication reconciliation”).

You may ask:  how can this be goofed up?  A person has medications at home, the doctor writes a new prescription just before going home, the prescription is filled by the local pharmacy, and the prescription is taken in addition to the same medications as before.  What could be more simple?

The answer is: there is plenty of room for error!  What if:

  • the new medication is actually a generic duplicate of a brand name home medication
  • the new medication has severe interactions with a home medication
  • the home medication dose is listed incorrectly
  • the new medication prescription and the discharge instructions don’t match
  • a new medication prescription was omitted
  • a doctor outside the hospital is unaware of the new medication and prescribes something that interacts badly
  • the patient get an allergic reaction to the new medication but the prescriber is not available to help
  • the patient forgot to mention some of the home medications
  • unnecessary brand name drugs are prescribed that are not covered under the outpatient insurance plan
  • the prescriber forgot to tell the patient to stop some of the home medications that were causing symptoms prior to hospitalization

NOT SIMPLE AT ALL.

Yet, hospitals and prescribers often don’t take much time to get the medications right at discharge (there is a big push to get the patient out the door as soon as possible).  Here is an actual example from 2 weeks ago:

A patient was admitted from a care center with an accurate list of medications.  The admitting nurse transcribed the list into the medical record but made a mistake on one dose.  The physician’s plan was to reduce the does of another medication which seemed too strong but the patient was not taking any medications by mouth at that point so no medication orders were written.  A few days later the patient was ready to leave the hospital.

Unfortunately, a different physician discharged the patient rather than the one that admitted the patient.  The nurse’s list of home medications was used to generate the discharge medication instructions — no new medications were ordered.  But, the transcription error of the nurse was included with the instructions and the plan to reduce the dose of another medications was forgotten.  Two major errors.  The family actually realized the errors but the nurse the family informed forgot to call the doctor so no change to the list was made so the care center followed the flawed instructions.

So what went wrong?

  1. Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
  2. The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
  3. The planned change in home medications was not made because there was no place to put such a reminder for discharge in the hospital chart.
  4. The prescriber did not review the medications with the patient or family personally.

Worse yet, although errors happened there was no plan to change the system to prevent similar errors in the future.

So, as a patient or family member what can you do?

  1. ALWAYS bring multiple copies of an accurate list of home medications to the hospital — give a list to anyone that asks to review the medications.
  2. Expect the attending physician to review the discharge instructions with the patient or appropriate family member — if this does not happen immediately complain and make that expectation known.  Good physicians plan ahead and sometimes do this review the day before discharge!
  3. Use one of the copies of the home medication list to compare to the discharge instructions.  Make sure to understand ANY changes.  And ask — does the new medication, if any, interact with home medications?
  4. Find out who to call if questions or problems with the medications arise after getting home — get a name and phone number.  Often the discharging nursing unit will take the call and find the right person.

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Communication Skills — you’re not listening

warning not listening

Laura Landro of the Wall Street Journal wrote an article “The Talking Cure” which appeared today (4/9/13).   She makes several good points:  1) 39% of patients feel doctors communicate poorly,  2) better communication improves health and reduces cost and  3)  there are ways to help doctors communicate more effectively.

These points are difficult for doctors to accept, especially the 39%.   Yet, the data is undeniable;  the oracle of Wall Street speaks truth.  Although, most physicians do not like to hear such comments from the lay media the message has been communicated well and with empathy.

Many years ago the Iowa Health System had doctors at one clinic participate in a communication study.   The patients were told that at the end of the clinic visit they would be given a test about what was wrong with them and what instructions they should follow.   A ton of bricks fell on the clinic.  The patients all had a pencil and paper and they would not let the doctors leave the exam room until the they had the answers to the impending quiz.  After all, the patients did not want the doctor to look bad.  The doctors tell the story of the experiment with fond memories and a feeling of gratitude for the lesson in communication.   The patients did pass their tests!

The Wall Street Journal article comments on the “4 habits” of good communication for health care providers:  1) create rapport  2) elicit patient views (and listen), 3) demonstrate empathy, and 4) assess patient ability to follow a treatment regimen.  It takes a lot of practice to think about the evidence-based practice-guidelines and simultaneously do those 4 things.

Doctors in training generally find video recording of patient interactions both  stressful and time consuming.   Video-based training takes time away from the operating room and clinic — but is that bad?   College communication majors become very comfortable with video training — they see themselves in the video recording and they use the sessions to hone communication skills.  Perhaps physician training programs should take a lesson from the department of communications.

Medical knowledge is a package within a wrapper.  That wrapper is communication skill which may be as important as the package itself.

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E-Prescribing — if not why not?

e-prescribing 2011

The above map comes from Internal Medicine News.  State by state it shows where doctors are using electronic prescribing.   A simple question for those doctors in the white states:  why live in the past?  Huge numbers of pharmacies accept electronic prescriptions, patients like electronic prescriptions better than paper prescriptions, prescribing errors are much lower, patients get better care, drug interaction checks can be done BEFORE the prescription is sent (so the pharmacist does not have to call),  and a record of the prescription is available as part of the medical record.

The doctor perspective:  “Just more computer work for me”

The patient perspective:  “I like the idea of fewer errors”

How does it work?
The prescriber needs to have several things in place:

  • An electronic medical record
    (without this much of the advantage is lost)
  • An electronic list of the patient’s active prescriptions
  • An electronic list of the patient’s allergies and intolerances
  • A diagnosis associated with the prescription
  • A record entry to document the thought process for the prescription
  • An internal link to the insurance drug formulary

A very good process is to have the computer screen for prescribing where the patient can see the actions of the prescriber.  That way the patient can see what  is being prescribed, whether it is covered by insurance, where the prescription will be sent, the instructions, the amount and the refills.  If there are problems the patient can comment — it is much better to have feedback at the time of prescribing rather than the patient not take the medication or get phone calls later with questions from the patient or pharmacist.  Physicians who use e-prescribing don’t ever want to go back to the old way!  Pharmacists never liked physician handwriting anyway.

So, if your physician is not using e-prescribing give them a copy of this post!

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Rate Your Health Care Provider

The following rating system is intended for adult primary care office visits, but could also apply to some specialty visits.  There are no extra points for famous doctors, university clinics or the only provider in town.  Add up the points to see how your provider’s office is doing.

Performance Points
When I call the office, who answers?
 A real person 2
 A computer answering system that connects to a real person 1
I know the office will provide appointments:
New patient appointments within 3 weeks or
Follow-up appointment for new problem in 3 days
2
Urgent problem (during office hours) on same day 3
 The office designates time for walk-in visits  2
 The office has some evening and weekend hours  2
Moving through the office (assuming you were on time)
 Checked-in within 5 minutes 2
 Checked-in within 5 to 10 minutes 1
 Face to face with the provider
within 5 minutes of appointment time or
within 30 minutes for a walk-in visit
3
 Face to face with the provider
within 10 minutes of appointment time or
within 45 minutes for a walk-in visit
2
Checked-out within 5 minutes of leaving provider 2
Checked-out within 5 to 10 minutes of leaving provider 1
 Provider visit
 I do not have to take off clothes before seeing provider 2
 I can sit in a chair at eye level with the provider 2
 Provider seems to care about me 5
 I am not interrupted while I say the reasons for the visit 4
 The part of my body with problems is examined 3
 The paper chart or the computer is just used
by the provider to find information to help me
2
 The diagnosis of my problem is made clear 4
 I am directed to handouts or Internet sites about my problems 1
 Before I leave, the provider asks if I have any other questions 3
 It is clear when I need to return for recheck 3
 Medication Management:
 The reasons I need to take all medications are explained 3
 My provider sends prescriptions by computer 2
 Possible side effects of medications are discussed 1
 At each visit I receive a list of my active medications 3
 Tests (x-rays, blood tests, EKG, biopsies etc.)
If I need tests I am told why 2
 The office always lets me know test results within a week 2
 I always get copies of test results 2
 Practice environment
 My provider has associates who substitute when needed 2
 Hospital care is done by hospitalists 2
 My provider is part of a system including specialists 2
 Physician assistants or nurse practitioners work at the office 2

 TOTAL POINTS  =  

Score Rating
 60 and over  5 star
 50 to 59  4 star
 40 to 49  3 star
 30 to 39  2 star
 below 30  1 star

Hotels have struggled to get the coveted 5 star rating for decades.  It is not just whether the hotel chef can make a souffle but whether the whole experience of staying in the hotel is superior.   The items in the above score are considered elements of quality for health care delivery.  It’s not easy to get 5 stars.

Medical and surgical care has focused on diagnosis and treatment for hundreds of years.  To that end individual providers spend years, if not decades, honing diagnosis and treatment (some say, to a fault).   The vast majority of problems in primary care are fairly easy to diagnose (like diaper rash, acne and diabetes).  Treatment is harder because it spans time, is a process and requires patient engagement.  So, as it turns out, the wrapper may be as important as the package.  Providers are well trained and licensed but the wrapper of delivering care is where quality, safety, cost-effectiveness and satisfaction reside.

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Patient Satisfaction (the CMS view)

The chart above is extracted from CMS data.  All US hospitals are now required to collect data on patient satisfaction.  This data is used by Medicare to adjust hospital payments upward for good satisfaction scores or downward for poor satisfaction scores.  This new payment adjustment certainly has the attention of hospitals since the adjustment amounts to a significant amount of money.

If one looks at the actual questions they really are pointed toward the quality of communication.   The questions are not about whether the treatment was satisfactory but whether there was good communication between the patient and the doctors, nurses and other staff.  The focus on communication tends to get around the criticism that sick people are never satisfied because they have some disease.   Even a sick patient can be quite satisfied (or not) with the communication received during a hospitalization.

The above table is the summary for the entire US.  The data is subject to a selection bias because the patient selects the hospital with some intent to select a good one.  But given that bias the results are not all that great — about 20% of patients did not feel they always had good communication with nurses and doctors.

Satisfaction is not the same thing as quality health care.  You might have been given the wrong medication or had unnecessary surgery but you went away happy (and ignorant of the problems).  Doing the right thing and getting a good outcome is what hospitals need to focus on.  Patient satisfaction is a small step in the right direction.

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Empathy in Health Care

Daniel H. Pink proposed a simple test of empathy in business whereby the subject is asked to write the letter “E” on their forehead.  If they write the letter so others can read it then they are empathetic.  Clearly not a scientific test although there are other tests developed by psychologists which do measure how empathetic a person might be.  Empathy is an attribute we all want in our health care provider and some have more of it than others.

The Relationship Between Physician Empathy and Disease Complications: An Empirical Study of Primary Care Physicians and Their Diabetic Patients in Parma, Italy.    Stefano Del Canale, MD, PhD, et al.  Acad Med. 2012 Sep;87(9):1243-1249.

The above article suggests a link between empathy and better results for patients.  Recently the Wall Street Journal published a list of things to be considered when choosing a primary care provider (below).  The first on the list is about empathy:

  1. Does the physician make you feel comfortable and listen to your concerns and opinions.
  2. Does the office seem to function smoothly?  How easy is it to get an appointment or get care outside regular office hours?
  3. Does the practice track your care and alert you to gaps?
  4. Do specialists’ results automatically get sent back to your doctor and discussed with you?
  5. Does the practice accept your insurance, or charge your directly?  Will it help you keep costs down when possible?

When you are looking for a health care provider finding one who will take new patients is hard enough.   Trying to pick one who is empathetic from the phone book is just not reasonable.  In fact, there are lots of traits one would like to have in a provider like timeliness, honesty, communication skills, medical knowledge, and surgical skill just to name a few.   A good recommendation from a friend is worth a lot.  Be careful when picking a highly charismatic provider since charisma  is not the same as empathy or skill.

Health care providers self-select a specialty to some degree based on personality.  Family doctors and nurses tend to have good interpersonal skills.  Nurse practitioners often are very empathetic people.   Pathologists and radiologists don’t have much (live) patient contact for a reason.  Some surgeons (who work while your are asleep) don’t always have high empathy scores — but in that circumstance surgical skill really is what you want.

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