Talking to your Doctors, Getting What you Need

There has been a lot of discussion about patient/provider communication, partially driven by the move to electronic health records and the question of who has access to the contents of that record, and partly driven by a heightened awareness among patients that they must control their health destiny because basically no one else will. 

Some even contend that patients should have access to their lab reports. But let’s face it, most patients do not know how to read these reports, nor do they want to. To resolve this dilemma, and help patients become more empowered and engaged, they need   easy tools such as lists of questions to ask, when they are in front of their physicians and other healthcare providers, and a notebook to jot down answers. Some even need an advocate with them to help them understand and remember the physician’s instructions.

In Chapter one of  my book, e-Patients Live Longer, The Complete Guide to Managing Healthcare  Using Technology,  www.epatientslivelonger.com, I provide  suggestions for the reader to think about regarding what outcome they want from a visit with the doctor; what characteristics make a good patient and key questions to ask during an annual checkup.

Just last week, the Agency for Healthcare Research and Quality announced that they had a Question Builder Tool on its website www.ahrq.gov/questions that outlines the kinds of questions patients should ask when seeing a doctor. Question Builder is a great tool for patients who know where to find it. Unfortunately not many people will search it out or take the time to go through all of the links and choose the questions that are relevant to their care.

 If providers really want to help empower their patients, and make their time with patients more efficient, they have to suggest these resources to their patient population.

Will this format for communication save time and money. You bet it will. The patient will experience fewer redundant tests, medication side-effects will be reduced and fewer errors will occur. Patients will be more compliant about following treatment plans and more educated about their health issues. This has long enough been discussed. Now is the time for action.

E-Patients Need to Strike Out against Hospital Acquired Infections

Empowered patients not only have to be good communicators, who know how to use the Internet for research and networking,  you have to be aware of what is going on around you and savvy enough to take appropriate action in situations where there are no specific  rules. That is what keeps you  empowered and in charge of your health. One example of that is to understand the dangers you face as a patient in the hospital, and   what you can do to address those dangers.  

Hospital-acquired infections (HAIs) are among the top five leading causes of death in the United States, striking 4.5 of every 100 patients admitted to a hospital. As an e-patient you do not want to be one of those statistics. A recent study released by the American Journal of Infection Control, www.ajicjournal.org (Sept., 2011, Vol. 39, Issue 7, p. 555-559)   reports that many of these acquired infections could be caused by bacteria and pathogens that linger on hospital staff uniforms .and other clothing worn by doctors, nurses and hospital workers.

 A team of researchers, led by Yonit Wiener-Weil, MD from the Shaare Zedek Medical Center in Jerusalem, Israel, collected swabs samples from the uniforms of nurses and doctors and found that fifty percent carried pathogens on their pockets, sleeves and waists of their clothing, particularly the scrubs and lab coats that they wore when they were in direct contact with patients. Other studies have found that hospital bed handsets, TV remote controls, cell phones of hospital staff were also found to contain biologic material that could be contaminated with disease-causing microbes.

It would seem obvious that hospitals need to go back to the practice of several years ago when they laundered the scrubs and lab coats used by doctors and other workers.   They also need to make sure that hospital issued clothing does not leave the hospital and come back in the next day,  and that street clothing worn by individuals who have direct patient contact need somehow to be sanitized each day. Additionally hospitals need to adopt programs to sanitize equipment such as bedside remotes, cell phones, and other electronic devices that patients and workers use, so they will not carry these pathogens around the hospital and spread the incidence of HIAs.  

There is also the issue of hand hygiene. Following the H1N1 scare, hospitals, doctor’s offices and other institutions, instituted stricter hand washing policies and installed hand sanitizer dispensers in key locations. They launched a major campaign encouraging people to be more diligent about hand washing, especially healthcare professionals who were in contact with patients or with lab equipment. 

There are steps that e-patients can take to avoid exposure, including:

1.    In your bag that you take to the hospital pack a large bottle of hand sanitizer and a disinfectant or wipes that you can use to clean the equipment around your bed. If you are too ill to do this, ask your advocate (family members or friends) to oversee this task.

2.    Be diligent about cleansing your hands and ask your doctors and nurses directly if they washed their hands  before examining you

3.    Check out the hospital where you are planning to stay. There are websites for that purpose such as: www.hospitalcompare.hnhs.gov or  www.qualitycheck.org

4.    Take direct action. Send messages to you hospital officials to advocate for safer hospital practices; Volunteer to work with hospital officials on initiatives that address this problem. Solicit other patients to get behind this effort.

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E-Visits Foster Continuum of Care and Communication, but there is a Price

The quest for the right communication formula and balance that will satisfy doctors and e-patients who want to experience continuous care can be partially resolved with the spread of virtual clinical electronic messaging or e-visits. The e-visit is a specific encounter between a provider and his or her established patient over a secure online connection. It is an asynchronous communication reserved for non-emergency issues.

 A 2009 Manhattan research study of 8,600 healthcare consumers found that a majority of these individuals were interested in having electronic online consultations with their physician. Patients who have engaged in e-visits claim that  these encounters are particularly useful for monitoring chronic conditions such as diabetes, chronic bronchitis, and high blood pressure or for discussing minor ailments that occur during the months following their annual visit, such as sore throats, stomach pains and colds.  However, although 42% of U.S. physicians report having discussed clinical symptoms with patients online, only 5% of physicians said that they were paid for these online consultations.  This is clearly a barrier to advancing this digital communication technology.

http://www.ihealthbeat.org/articles/2010/6/7/more-patients-doctors-pursuing-online-visits-but-challenges-remain.aspx#ixzz1VgDfAYJ7.

In 2008, a billing code was approved (Current Procedural Terminology (CPT) code 99444) that would enable doctors to charge for e-visits. But often these online communications have not met the criteria required for the code.  Several of the  large payers  such as Cigna, Aetna, a number of Blue Shield plans, WellPoint and Humana now recognize the value to patients and the cost savings to the system of paying for e-visits, rather than have the patient come to the doctor in the office, and  are reimbursing doctors for online clinical consultations. They require that the  e-visit take place through a secure Web portal with encryption, and  that the providers  comply with Health Insurance Portability and Accountability Act (HIPAA) privacy rules. Payments average $30 per e-visit, about the same as the cost of a patient visiting a retail clinic, as compared with $75 to $100 for an in-office consultation. 

The Center for Medicare and Medicaid (CMS) is considering e-visit reimbursement. As a result of the Healthcare Reform law, CMS is reviewing innovations that would help facilitate doctors’ meeting with their patients through video chats, telephone checkups and in-home monitoring devices. This could prove to be a real game-changer for online remotely delivered healthcare.

There is another barrier to the expansion of the e-visit. There is a pervasive lack of sufficient infrastructure to provide meaningful online communications, including back-end technology to capture and store data from the visits, templates on how visits be presented to patients;  agreement of what  interface will be best for doctors to use in delivering care; questions about whether  e-visits be text-based or video, or  IP video? There are also bandwidth issues for supporting the technology and a lack of resources to install the necessary equipment and train providers in conducting effective e-visits.

There are a few  larger healthcare institutions and payer companies that have either developed their own infrastructure to handle e-visits or outsource those services to an organization such as the RelayHealth webVisit®. Beyond those isolated examples, it is unlikely that e-visits will expand to the general patient population in the near term. I would argue that the e-visit can have a tremendous impact on a patient’s overall well-being and positively affect the cost of care. It behooves the medical establishment, public and private, to find the ways to make this happen sooner rather than later.

Communication, a Challenge to Participatory Medicine

Communication or the exchange of thoughts, opinions, or information by speech, writing, video or signs that include body language continues to be a hotly debated,   difficult to execute practice in healthcare. There have been hundreds of studies over the years that reinforce the correlation between good communication among patients and providers and improved health outcomes. Health information gathered from patient interviews, laboratory tests, face-to-face exams email interactions, and e-visits, is essential to guiding strategic health behaviors of patients and providers, enabling them to collaborate on treatment decisions and ongoing health monitoring. Participatory medicine depends on the availability of health information to all members of a care team.

However, low expectations regarding teamwork and communication have for many years encouraged a culture where teamwork and collaboration are difficult to achieve. It’s ironic that ever since the publication in 2000, of the original IOM report, To Err Is Human,  healthcare  organizations have worked hard to improve  patient systems and patient safety  but most have failed to address poor communication habits that  would enhance  information sharing. It is clear that when health care professionals do not know what their colleagues are doing to manage a patient they are seeing, and when patients do not have the opportunity to share the information held by their providers,  all the patient safety rules in the world cannot compensate.

During the past 25 years there has been a lot of talk about the need for training medical students in communication skills. It was not until June, 2004, that a communication skills component was added to the U.S. Medical Licensing Exam to test medical students on their ability to gather information from patients, perform a physical examination and communicate their findings to patients and colleagues.

 The Agency for healthcare Research and Quality has developed CAHPS,   (Consumer Assessment of Healthcare Providers and Systems) a public-private initiative to develop standardized surveys of patients' experiences with ambulatory and facility-level care. These surveys ask consumers and patients to report on and evaluate their experiences with health care in areas such as the communication skills of providers and the accessibility of services. The results of these surveys help determine where there are strengths and weaknesses in the system.   CAHPS also publishes guidelines for patients to help them understand the important communication skills they need to improve their ability to share information with providers. These guidelines include four areas:

1. Record Sharing- patient access to the electronic health record
2. Patient Question Lists – what to ask the doctor at a typical visit
3. Feed Forward – a questionnaire filled out by the patient prior to receiving care
4. Coached Care- teaching patients how to ask the right questions and be more assertive during a face-to –face visit with their physician

www.cahps.ahrq.gov

Other organizations including many hospitals and medical centers strive to enforce good communication habits among their physicians and encourage their patients to participate in their care and collaborate with their providers. Many payers work with enrollees to help them understand communication skills needed in their increased participatory role. 

As e-Patients become more invested in the partnership model they have to improve their own ability to share information. Health care consumers are inherently well-equipped to judge the ability of their clinicians to communicate with them effectively. Helping them understand when and how to ask the right questions and be more aggressive about speaking up when they do not understand an explanation is a leap forward toward better communication for better healthcare.

Patient Safety, A First Hand View

It is a known fact that more people die annually from medical error, in both in-patient and out-patient healthcare settings, than die from motor vehicles accidents, breast cancer or HIV. Nearly 100,000 reported medical errors occur each year. As an e- patient, there are actions that you can take to insure the safety of your care. They include:
•Do not assume anything! Make sure that all health professionals involved in your care have all the important health information about you. Talk with them about what additional data they might need.

•Ask questions. If you have a test, insist on getting the results. If you are given medication be sure to ask what it is; what it is for; is it the right dosage. If there are pills you do not recognize, do not take them until you talk with your doctor. This is your right.

•Learn about your conditions and treatments. Discuss your healthcare with your doctor, nurse practitioner, physician assistant and/or pharmacist. Check the Internet to see what information you can find. A few of the helpful, unbiased web sites include:

1. Google or Bing search for the most general compilation of available data.

2. http://www.healthfinder.gov/, or institutions sites such as http://www.mayoclinic.org/ or http://www.clevelandclinic.org/. for general information on a variety of health conditions.

3. http://www.noahhealth.org/,  and http://www.medlineplus.gov/,  for the most comprehensive health information in one place.
4. http://www.qualitycheck.org/ , a website of the Joint Commission on Accreditation of Healthcare Organizations that provides extensive information on hospitals, sorted by geographic location and including accreditation criteria, special citations and programs.

I have been away from this blog for a while because I spent some real time as a patient, having hip replacement surgery. Although I had complete confidence in my surgeon, I made sure that I fully understood the parameters of my problem, the solution, and the recovery by asking the right questions and conducting my own research to find answers to all of my concerns. Much to my surprise, my hospital experience completely changed from previous in-patient encounters. Everyone diligently washed their hands at one of the antiseptic soap dispensers located in patient rooms and on every floor. That alleviated my biggest fear of staph and mersa infection so prevalent in the hospital environment.

Another concern was the potential for a fall as I knew that the hip replacement would incapacitate my movement for a while. However I was told to absolutely call for help when I wanted to get out of bed, and the nurses and aides were most pleasant about assisting me. The last time I was in the hospital after surgery the nurse told me I had better learn to get out of bed myself and not bother them. What a turnaround in patient safety!

Because I am familiar with the dangers of medication error, both in the hospital and at the rehab, I also questioned every IV and oral medication that I was given to be sure that the right medication in the right dosage for me was what I received. No one took offense. They appreciated my caution and understanding.

Patient Safety is not an easy goal to accomplish in the stressful healthcare setting. Mistakes are still made. However when an e-patient opts to become an integral part of the healthcare team many unpleasant medical errors can be averted.

Healthcare Reform is Coming with or without Legislation

Let's assume for a moment that the healthcare reform bill currently before the United States Congress becomes permanently deadlocked and does not become law.  That does not mean the issues raised are going away, nor does it presume that our healthcare institutions, including health plans, healthcare provider organizations, and most important healthcare consumers should  forget about the healthcare crisis and merely move on. 

As long as healthcare dollars contine to consume such a large percentage of the GDP ( now at 18% of GDP  likely to grow to 25% in the next few years) the public, various interest groups and those directly working in the healthcare system will continue to discuss, debate, and  examine the issues that have been raised. Our political leaders in both parties have brought the need for healthcare reform  to our attention. Somehow they cannot get over themselves, work together and get the job done. 

We need healthcare reform in this country and we need it now. The average American citizen cannot continue to assume rising healthcare costs that do not cover a catastrophic event and potentially could leave many bankrupt. Furthermore, we have a moral and ethical obligation to cover the uninsured and we owe it to ourselves financially to give them basic preventive care so that their health issues do not precipitate  into complex conditions that land them in the ER which  raises costs for everyone and benefits no one. 

Healthcare reform  is not a Democrat or a Republican issue.  It is an American issue.   There are so many ways that payers, providers and consumers can impact the finances of the healthcare system, starting with the implementation of digital health records, e-prescribing and evidenced-based medicine,  so that repeat and excess tests  are avoided;  medications are not prescribed and paid for only to be tossed because they do not work; and patients are not  shuffled from one procedure to another or from one provider to another to find a cure. The time to reform healthcare payment and practice is now and we cannot let the stalemate in Washington rule the way the system moves ahead.    

Reader Beware: Health Statistics Can Be Misleading

There was a recent article “Patients More Likely to Die While in ICU in U.S. than in England.” http:///The lead sentence of the article states that: "dying hospital patients in the U.S. are nearly five times more likely to spend their last days in the ICU than are patients in England." The article goes on to say that “the death rate among patients who received intensive care in England was nearly three times higher than in the U.S.”

There seems to be a contradiction here. Information extrapolated from a study done by Columbia University researchers who compared data from England to data from seven states in the U.S. points out the need for further investigation to evaluate why so many elderly Americans end up in the ICU and what that says about our approach to end of life care. It is a valid issue that goes right to the heart of how we spend money in healthcare. It also points out how sensational and misleading headlines can affect public perception about the real story. Reading through this article tells us that although more Americans than Brits spend their last days in the ICU, the death rate for intensive care patients in the UK is higher, (in fact three times higher).

There was a similar situation when the World Health Organization rankings of health performance in countries around the world were made public. WHO ranked the United States 37th, in health performance behind nations like Morocco, Cyprus and Costa Rica. Finishing first and second were France and Italy. U.S. citizens reading these headlines were astonished. What was not stated in the media stories is that health performance from country to country is not measured on the same yardstick. Healthcare quality is affected by many things including delivery systems, payment systems, lifestyle choices among the population - even injuries resulting from criminal acts and accidents. Additionally different countries have vastly different reporting and legislated requirements that change the statistics based on what is revealed and what is ignored. In other words the publicity promulgates an evaluation that does not consider structural, cultural and philosophical differences among countries as well as the scope of the healthcare infrastructure.

Statistics that compare the U.S. and other countries are meaningless and neglect to inform us that national health systems portion out care with restraint that the American public might not feel is an acceptable standard. Let us not be lulled into believing that our standards of care are either beyond reproach or are so low that we deserve the media dispersions. We have a lot of work to do to improve care access and quality of care. We also, in most instances, are not as bad as the media would have us believe.