Posts Tagged patient-centered
So you think your health system is bad? There are countries where doctors and nurses leave due to the risk of death (their own), countries where health care workers can’t make enough money to pay for their own hospital care, countries that don’t keep medical records, countries where doctors must see at least 100 patients per day and countries where a patient purchases the number of questions they want a doctor to ask — one question is typical — and at very low cost!
As the author of this blog I decided to try an online learning course from edX titled “Improving Global Health: Focusing on Quality and Safety” presented by faculty at Harvard. Overall it is a good course. I am sure everybody who takes the course finds different parts interesting depending on where they live and their background in health care quality and system organization.
Below are the things I found interesting from a US healthcare perspective:
- Errors and harm caused by health, especially in hospitals, is high everywhere. The big categories are hospital acquired infections, adverse drug events, falls with injury, surgical complications, pressure ulcers and deep venous thrombosis. Significant harm happens in about 10 to 15% of hospitalizations. Errors in medical/surgical management are considered preventable.
- Countries have different standards of care. And, countries have different legal systems. The most interesting concept is to eliminate malpractice suits by having a compensation board and strong quality improvement. Thus, patients get compensation much faster and the health care system improves to mitigate errors. Accountability for errors becomes part of the quality improvement process, not the legal system.
- In most countries hospital and outpatient care seem to be in different silos, much to the detriment of patients who transition between the two.
- The PLAN-DO-STUDY-ACT cycle is critical to quality improvement.
- “If you can’t measure it, you can’t improve it“. But, high tech and computerized methods are not always needed. In low and middle income countries the use of simulated patients (in the US called secret shoppers) and text messaging questions by cell phone can collect hugely important data with a minimum of cost.
- Management practices of business in general are more effective than the business practices in healthcare. The same principals apply and need to be followed. For example, managers not meeting expectations need to be changed. Just like measurements of healthcare quality there are measurements of business quality. A culture of blame is a big problem.
- Patient-centered care is critically important. There is a very strong statistical link between patients who feel their needs are being met and almost all other technical measures of quality. Simply asking patients what they expect is a huge first step that is not being done my a majority of providers. Dignity, respect and putting effort into meeting expectations is the essence of patient-centered care. One measurement of patient-centered care is waiting time — waiting time for making an appointment, waiting time in an office, and waiting for surgery.
- Universal healthcare is highly desirable and some countries do a better job than others. The key features are: enrollment (signing up and getting a health card), universal coverage (the funds to pay for care — like insurance), and finally effective application of the coverage. The last element is actually “quality” healthcare. Having a health card is not enough. Having insurance is not enough. Effective care is a combination of prevention (population-centered) and patient-centered care within the financial constraints of a system.
- Politics is present in all forms of health care. But, the focus for patients, providers and the news media should be on the gap between care that is reasonably possible and care that is actually delivered.
A 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.
The U.S. has always been concerned about population health but mostly in terms of clean water, safe food, and safe medications. Outside those areas the art of medicine was left to doctors. There have been lots of medical discoveries in the past 20 years. But, one quiet discovery may be the most important: medical care is not art. It may be industry or business or paint-by-numbers but it is not art. There are rules and there are expected outcomes. And, most importantly, the rules can be applied to populations. For example, there are necessary vaccinations, unacceptable blood pressure levels, excessive weight ranges, best ways to remove gall bladders, and the correct frequency for pap smears. There is a glimmer of hope that a focus on population health management will reverse the trend of rising health care cost.
An article from the University of Rochester Medical Center is a very nice perspective on population health. They see the future of health care in systems of buildings, information technology, and organization of primary care. The theoretical underpinning is reliability, interchangeable parts and operational efficiency. The tools are there for controlling cost. But, those tools currently are used to increase profits, somewhat like letting the fox guard the chickens.
Patient-centered care emphasizes efficiency and satisfaction at the point of care which mirrors our cultural view of individual importance. In some respects this is consumerism or “give the patient what they want”. Quality is the byword and standards for such care have been outlined by the National Committee for Quality Assurance (NCQA). Important aspects of care include evidence-based guidelines, access to care, timely appointments, after-hours care, coordination of specialty care, continuity of care with one provider, cultural sensitivity, and good record keeping. All laudable goals but mostly unconcerned with cost.
Each country must find its own path to good quality low-cost health care. Our neighbor to the South, Cuba, is an interesting case. The Cuban medical system now has twice the number of doctors per person as in the U.S. so Cubans have better access to care than we do. They even have lower drug costs because the government manufactures low-cost medicines. The path they took is not likely the one the U.S. will follow since Cuba has poor sanitation, high poverty, 70% of employment is by the government and doctors are only paid $20 per month.
The cost of care must always be considered. The population health advocates assume good systems and management will lower cost. The patient-centered advocates assume quality care is less expensive care. The path the U.S. needs to follow should include a blend of both, plus guaranteed (not theoretical) cost containment. The cold hard fact is our health systems must be trimmed, our provider workforce must be expanded with less expensive providers, and new drugs must cost less. This is a hard pill to swallow but we just need to take our medicine.