patient engagement

When multiple problems lead to multiple recommendations; how to help patients succeed?

December 3, 2012

How to help patients and caregivers keep track of and follow through on the many things we ask them to do?

I found myself thinking about this yet again last week, after the group of UCSF students I was teaching brought up the following concern:

“We’re worried about the patient getting overwhelmed by our making too many recommendations.”

Good point, learners.

I had to admit to them that I probably don’t think of this nearly as often as I should. But it’s such a good thing to consider. Because the truth is, I think it’s often harder than we realize for patients and caregivers to keep up with the plan for the many problems on an older adult’s list. (It can also be tricky for a clinician to not lose track of everything going on — a topic for future posts.)

In geriatrics, of course, we usually have a lot of problems to address: six or more in a visit isn’t uncommon in my practice. That’s because frail older patients have many ongoing chronic conditions, and often raise additional complaints at each visit.

But even younger Medicare patients often present with multiple problems.

Here’s a common scenario: If you have diabetes, high blood pressure, arthritis, glaucoma, are on eleven medications, and in the visit we uncover uncontrolled blood sugar, too high blood pressure, falls, urinary frequency, anxiety, trouble managing medications, and social isolation, then we are going to have a lot of shared decisions to make. Which will lead to a long list of recommendations.

Furthermore, I consider difficulty managing meds to be a sign of possible
cognitive impairment or possible financial difficulty; if either or both
are present, then plans for every other medical problem will need modifying.

(Also note that this isn’t a very medically complex patient in geriatrics; many present with this stock set of problems plus congestive heart failure, COPD, kidney disease, and complaining of pain and shortness of breath too. Oh and, rash and toe fungus. )

So here we are now with our mutually-agreed upon problem list and care plan. Now what?

The challenge for patient and caregivers: so much to do

My own experience has been that most patients and families have trouble keeping up with more than 1-2 recommendations. The trouble is, for adults with multiple medical problems, a single visit can generate multiple recommendations. And of course, the more action a recommendation requires, the less likely it will happen.

The simplest recommendations ask patients to do something simple, just once. Like “Stop medication X.”

But most recommendations are more complicated: “Increase your metformin to 500mg three times daily” requires a small ongoing change in what a person does every day.

Then there’s “Talk to your daughter about helping you figure out a way to not forget to take your medications.” (This is the kind of amorphous directive that the Heath brothers warn about in Switch, one of my fav books on change management.)

Or, “Check your blood sugar every morning before eating. If your blood sugar is over 150 for three days in a row, increase your Lantus by 2 units.”

Or “Start bladder training. You can review the attached handout for instructions.”

Let’s reconsider the example of the patient above, with her out of control blood sugar and blood pressure, plus falls, anxiety, urinary frequency, difficulty managing medications, and social isolation. Here are the problems we routinely face in helping such patients:

Do we list recommendations for all the problems we uncovered in the visit, or just for a few?
For every problem we make recommendations for, how to help patients and caregivers follow through?
If we focus one just one or two problems, how do we ensure we don’t lose
track of the other issues? (Patients seem to hate coming back every
week for another visit, but that’s often what we suggest, assuming we
have appointment slots available.)
How do we clinicians update the plan for a problem, based on feedback we get from patient and family? (Many problems require a trial of an intervention before we can decide how to proceed long-term, or may require diagnostic results before we move on.)

What kind of technology can help us?

Technology is already helping, in that EHR systems are now creating clinical summaries for patients (it’s a criteria for Stage 1 Meaningful use).

This is a step in the right direction, but it’s not enough.

What patients and caregivers (and the clinicians helping them) really need is something more on the order of a sophisticated task management system. Or possibly even project management tools.

Specifically, we need something that:

Can keep track of multiple problems and recommendations
Helps patient and clinicians identify which recommendations will be the focus now, versus later
Allows us to update each other on the status of problems, and the plan for each problem
Allows us to break down the plan for a given problem into manageable and actionable chunks
Allows us to share information as needed with others involved in addressing a problem, i.e. other clinicians (such as nurses for problem-specific coaching), family caregivers, etc.

A bonus in my view would be technology that allows the clinician to enter several recommendations all at once (when the clinician is thinking comprehensively about the patient), but allows patient and caregiver to work through them over time.

So for instance, let’s imagine that for the patient above I have recommendations for the following problems:

diabetes management
blood pressure management
urinary urgency
falls
anxiety
medication management
socializing

Let’s also assume that the recommendations for these problems are NOT interdependent (often they are, but we’ll go for a simpler scenario).

I’ve actually discussed and provided management recommendations to patients and families on this many problems within a single 30 minute visit (it’s a bit of a hustle, but possible). But asking the patient to take action for each problem would probably be overwhelming.

However, imagine a platform in which I propose recommendations for all problems and prioritize them. On the patient’s side of the technology, he or she gets to work through a problem for a period of time, and then later is given recommendations for the next problem. (These could be staggered based on time, such as weekly, or based on completion of the previous problem’s plan.)

Such technology could allow us as clinicians to be more comprehensive, with less risk of overwhelming patients and families. This would enable clinicians to make best use of their time, and help patients be more successful in taking the many steps needed to improve their health.

So is this technology out there? I’m not sure. Several companies are working on consumer products meant to help caregivers manage multiple tasks, but it’s not yet clear to me how easy it will be to integrate clinical recommendations into the programs.

On the provider side, patient portals are becoming de rigueur, but as far as I know, they have not yet evolved to support this kind of sophisticated care plan management for patients.

But hopefully that will change. In the meantime, if anyone has come across technology that helps clinicians help patients manage multiple problems, I’d love to hear about it.

In a nutshell

It’s very common for older adults to present to a primary care clinician with multiple problems, which can generate multiple recommendations for patients and caregivers to implement at home. But patients often have difficulty managing more than 1-2 recommendations, so a comprehensive approach is often too overwhelming.

We need technology to help patients follow through when there is a lot to do. Specifically, we need help making multiple recommendations more manageable for patients and families. Something along the lines of sophisticated task management (or perhaps project management?) would help.

The ideal technology would facilitate and reinforce effective collaboration between clinicians, patients, and caregivers, and would allow all to work through a longer problem list together over time.

If you can suggest any such technologies that might work for older adults with multiple problems, definitely let me know.

Free the lab data and bring us OpenLabs!

November 16, 2012

OpenNotes is an interesting and promising idea, but what I really need is for my patients to have OpenLabs.

As in, I need them to have the right to eventually access all their own labs online, regardless of which provider ordered them.

So that then, they can give me access when they ask me to help them.

Better yet would be if patients could easily import their labs into their own personal health record. This way all their labs would be together, regardless of which laboratory or facility performed the testing.

And these labs should be in an interactive, searchable format. That
way, when I’m trying to help them out, I can query the entire dataset,
and find whatever is needed to address the problem at hand.

Recently, I was called to consult on an elderly patient who’s been declining. His labs seem to have been mainly done through Quest.

I’m a Quest provider, and the patient has given me permission to get medical records from the other involved providers.

But when I asked Quest if I could access labs ordered by other providers, the answer was no. According to my Quest representative, if another provider orders labs and wants to share them with me, they need to include an instruction to cc me on the results.

Otherwise, I need to contact the provider directly to get results.

Which I have done, and what I get are crummy fax copies of whatever the other provider’s staff thought were fit to send.

So to summarize this common situation:

Quest has all the results ordered by various providers, but won’t let any single provider view them, even if the patient gives permission.
Getting all labs for a patient who sees multiple providers means making multiple requests.
The data is then delivered by paper or fax, hence hard to turn into structured data in my own EHR.

I’m a bit frustrated by this. Although I’m generally not a fan of asking doctors to log-in to a company’s web interface (next thing you know you’re keeping track of umpteen websites and passwords; much better to have the info you need easily pushed or pulled into your EHR), I would make an exception for a large repository of lab data, especially if it allowed me to review labs ordered by other providers.

This is because I can provide better medical care to patients when I’m able to review and query all their labs. Specifically, I like to:

Look at trends for certain results. So many lab values really require context in order to properly interpret them. Is that creatinine of 1.5 new, or chronic?

Search to see if a test has been done before ordering it myself. Hm, has someone already checked TSH and B12 in this patient with cognitive impairment?

Quickly gather the relevant lab results related to evaluation of a given condition. Let me think about this anemia. Let’s see what the ferritin, B12, retic count, etc are.

Elderly patients are especially likely to see multiple physicians, and to have labs ordered by various clinicians.

When every provider has to play gatekeeper to the patient data he or she ordered, this makes coordination of care harder than it has to be. Which is why providers often end up ordering duplicate tests: it’s usually easier than going through the hassle of requesting results from another doctor. (Clinicians often don’t really notice the extra hassle to the patient and extra cost to the system.)

If we are serious about empowering patients to get the best care they can, we should remove barriers to patients accessing their own information, to consolidating their own information, and to sharing their own information.

Why should Quest treat lab results as if they belonged to the provider, rather than to the patient?

Well, I haven’t yet researched the issue extensively, but apparently the 2009 law allowing patients to get electronic access to their medical records exempted lab data. In 2011 a new federal rule was proposed (search page for “CLIA”), to allow access, but seems it has not been approved yet.

If you want to learn more on this topic, here is a good recent commentary by Tim O’Reilly, and here is a NY Times article on the subject. There is also a JAMA commentary here, which highlights concerns about patients rapidly gaining access to abnormal results prior to provider counseling, and also comments on how direct access to labs might change the provider-patient relationship.

In a nutshell:

Effective medical care for elders often requires reviewing laboratory results ordered by multiple different providers. Even when all the tests have been done at Quest, it’s currently surprisingly hard to get all the results, because Quest treats the results as if they belong to each provider. Each provider then becomes the gateway for other providers to access the data.

I say patients should have easy access to all their lab data, regardless of which provider ordered it. Just as some clinics are pioneering the model of OpenNotes, we should consider moving towards OpenLabs. Patients should then be able to share those results with whichever additional providers they choose, and transfer their lab data into their personal health record. Technology should facilitate this process. Sending a provider copies of labs by paper/fax is using antiquated technology and prevents the receiving provider from searching and filtering the lab data effectively.

Would love to hear from clinicians who have found ways to work around this problem.

Am also interested in learning about any personal health records that have been able to import labs from multiple providers and facilities.

Micropractices, IMPS, and Improving Primary Care

October 30, 2012

This past weekend I attended my first IMP Camp. IMP originally stood for Ideal Micro Practice, but now stands for Ideal Medical Practice.

I went because after years of being an ardent supporter of team-based primary care, I decided last spring to switch to practicing geriatrics in a solo micropractice.

This is a career development which I still consider with mild surprise. I was after all (and continue to be) a huge fan of Tom Bodenheimer’s work proposing that primary care should be delivered by high-functioning teams, rather than by overwhelmed clinicians trying to do everything themselves.

However, finding a high-functioning team to join is not so easy. Part of the problem is the still-predominating fee-for-service payment system, which generally doesn’t reimburse medical work that isn’t provided face-to-face and by a “billable provider” (i.e. physicians, NPs, PAs, but not RNs). This can really cripple outpatient geriatric care, which I believe ideally would involve plenty of phone follow-up, care coordination, and nurse-led coaching interventions.

Of course we now have a move towards accountable care organizations (ACOs) and value-based payments, but it’s not yet clear how this trend will mean for the experience of the average on-the-ground primary care clinician. (Will ACOs be yet another stakeholder complaining about what we didn’t do? Or will they lead to substantive support in helping us do our work well?)

Furthermore, even when funding mechanisms support a team-approach to primary care, one still needs the team to be high-functioning. As most people who’ve worked on teams can tell you, not all teams work well. This is especially true in primary care, where healthcare providers may be asked to take on very different roles without getting adequate coaching and support in making the requested changes. (To his credit, Bodenheimer is well aware of the rhetoric-reality gap when it comes to teamwork.)

What’s a clinician to do when she wants to provide high quality outpatient care but is worn out by primary care as usual?

My answer — for now — is to try an independent micropractice. The micropractice is the brainchild of Dr. Gordon Moore, a family medicine doc who realized that by leveraging technology to strip his practice setting down to a minimum of staff (as in, none) and overhead, he could practice better primary care. Better, as in, his patients were happier and he was happier. In particular, Moore found that this model:

Improved access, leading to better care and better patient satisfaction. Being the only one answering the phone means a clinician can respond quickly to patient requests, and is always in the loop.
Allowed more attention to direct patient care. A small lean practice requires less management and coordination, especially when technology is effectively leveraged to handle administrative work.
Facilitated longer patient visits. The average primary care practice spends 50% of revenue to cover overhead. Less overhead means less need to pack in revenue-generating visits every day, which means a clinician can earn a decent salary while giving patients longer visits (often resulting in higher patient satisfaction, provider satisfaction, and better care).

This last point, however, is what makes many primary care wonks nervous. Longer visits may mean happier patients, but if a clinician can make a living caring for a smaller patient panel, many start to worry about exacerbating the looming shortage of primary care providers.

Still, the micropractice model in many cases has led to macrosatisfaction for patients and physicians, and that is no trivial thing.

In fact, in listening to Gordon present this past weekend on the key tenets of Ideal Medical Practices (he has very sensibly broadened the IMP term and focuses on what constitutes ideal outpatient medical care, rather than on micropractices per se), I was struck by how well the IMP concepts dovetail with what I hear patient/consumer advocates saying they want.

What I see patients/consumers clamoring for, and how the IMP model meets the need:

Access: they want to be able to reach their healthcare provider promptly, as needed.

IMPs offer excellent phone access and usually open access scheduling.

Relationship: they want to feel that the healthcare provider knows and understands them, and they want to be able to work with a compatible provider repeatedly.

IMPs prioritize the patient-physician relationship; in small IMPs almost all patient needs are met by the patient’s usual provider.

Patient/consumer centered care: they want the healthcare to be organized around their priorities, and not just what the provider, or healthcare system, thinks should be the priorities.

IMPs emphasize care that is driven by the patient’s needs, goals and values. Many use the “How’s Your Health?” online questionnaire to regularly provide clinician’s with the patient’s self-assessment of health and needs.

Technology: they want healthcare providers to communicate via email and other new technologies, and to keep up with emerging technologies that might improve health and care coordination.

Virtually all IMPs use technology to maintain a high-efficiency/low-overhead practice. Most IMP providers are available to patients through some form of messaging.

Coordination: they want their primary healthcare provider to communicate, connect, and coordinate with other providers.

Technology often facilitates this.

Support in self-management: they want providers to help them feel empowered and confident in their ability to self-manage their health.

By leveraging a collaborative relationship, a focus on patient-centered care, and technology, IMPs are generally able to successfully address this need.

In short, IMPS generally offer a smaller intimate practice setting which is well-suited to providing the close and collaborative patient-physician relationship that historically has been the foundation of good primary care. Just as many of us enjoy patronizing smaller local businesses, especially if we get to know the owners, patients often enjoy a smaller independently owned practice.

So if patient engagement really is the “blockbuster drug of the century,” as David Chase proclaimed in Forbes magazine last month, then IMP practices should certainly be on the radar of those looking for high-quality primary care.

What about team-based patient-centered medical homes? Well, those are a good concept too, but transforming practices may take some time. (You can read about lessons learned from the National Demonstration Project here.)

In the meantime, yours truly is trying out the micropractice/IMP model for herself, and will keep you posted on how it goes. Fortunately for me, the IMP community is largely focused on providing practical assistance to other clinicians trying to start or maintain IMP practices, so I’ve been getting some much appreciated support and advice. ((Disclosure: the IMPs have formed a nonprofit group, and I paid to become a member last April, which gives me access to some members-only informational resources.) I’d certainly heartily endorse this creative and spunky group to other clinicians contemplating a similar practice shift. Thanks IMPs!

Me with Dr. Anna Maria Izquierdo-Porrera, a geriatrician with an amazing practice in Maryland (www.care4yourhealth.org)

Dr. L. Gordon Moore, who is now doing really fascinating work for Treo Solutions (negotiating improved payment models with big payors). Who wouldn’t listen to a man in tie-dye?