Kemp EC, Floyd MR, McCord-Duncan E, Lang F. Patients Prefer the Method of “Tell Back- Collaborative Inquiry” to Assess Understanding of Medical Information. J Am Board Fam Med. 2008;21(1):24-30. [Accessed April 17, 2008].

One of my patient centered health-care mentors, David Sobel, MD, from Kaiser Permanente passed this study on to me in the context of work we are exploring in the area of self management. Since I haven’t mentioned David on this blog before, I’ll point out that his impact in my career and many other health care professionals has been significant. David is the physician that taught me that the primary care giver is the patient (and their family, community). Because of this, when I think of “medical home,” I don’t think of the primary care provider’s office. I think of the true medical home, the place where the patient lives, works, and plays (with their family and community).

I digress, but back to the article, it puts together the call to action to involve patients and families in their care, before they leave the exam room.

First, the paper starts with a very helpful literature review of the “elephant in the exam room,” as I call it, the fact that patients don’t remember most of what doctors tell them during visits. When they are tested afterward, they typically don’t remember things correctly (correct treatment was relayed back by patients to researchers in only 49% of cases after immediately leaving the emergency room). I use this data to support the idea of a written summary of every visit that patients can use by themselves, and with their families and communities. As colleagues of mine have pointed out, the written summary is not the product, the process of preparing it is.

The study itself examines three different ways of inquiring about patient understanding, in a specific and potentially scary situation, a deep blood clot in the leg. The approaches are “Yes-No” (Which most physicians will relate to as the “hand on the door knob to leave the exam room), “Tell back-collaborative,” and “Tell back-directive.”

Here’s the content of the “Tell back-collaborative” approach:

I imagine you’re really worried about this clot. I’ve given you a lot of information. It would be helpful to me to hear your understanding about your clot and its treatment.

In testing the three approaches using standardized video clips, this approach was significantly more preferable by patients, and there’s a nice discussion of what this means.

The study brings up a lot of compelling issues for me at the same time:

1. This collaborative approach could easily be worked into the after visit summary process: “I’ve given you a lot of information. Let’s compose the summary of what we talked about, together, so that your treatment is successful.”
2. In the era of secure e-mail between patients and providers, what a wonderful tool to support an approach like this and provide continuity of care. Imagine saying (in addition to the above): “I would like you to e-mail me your understanding of the condition tomorrow in the event any questions have come up, and also let me know how you’re doing.” The days of depending on the visit to ensure understanding are hopefully over.
3. As a practitioner of LEAN (Toyota Management System), this approach also speaks to the value of “getting inside” the clinical encounter, to standardize things that should be standardized (but not things that shouldn’t be standardized, like personal preferences). In health care systems, we have been anxious about scripting parts of the physician visit. I think we should move past that and use approaches that work, for every patient, every time. If every patient in a care system could expect the same approach to confirming understanding, it could change interaction during the visit, to something like, “I know she/he is going to ask me my understanding of things, so I should ask questions now, or note which areas need more explaining.”

The study does not measure whether patients were able to understand the treatment regimen from the various approaches, just which they preferred. It’s possible that their preference for an approach at the very least would have an impact on their satisfaction on the visit, and in turn on the satisfaction of the provider in helping patients understand (the “happy providers come from happy patients, not the other way around” hypothesis). At the most, a return visit, or a devastating complication could be prevented.

Our profession has incredible and incredibly complex therapies at our disposal - this is about making sure they actually help the people that we ask to use them to achieve their life goals through optimal health.

To the patients out there (all of us) - what approaches have you seen used at the end of the visit? To the providers out there - what are you willing to try during your next patient visit?

The quote in the title is from Mark Snyder, MD, Associate Medical Director, Information Technology, Mid-Atlantic Permanente Medical Group, who once again, volunteered to demonstrate how Kaiser Permanente improves medical care for patients using the latest technology. This happened at Kaiser Permanente North Capitol Medical Center, which takes great care of a community that includes the United States Capitol.

Mark was demonstrating the After Visit Summary, in this case, to a group of leaders from the District of Columbia Primary Care Association, which is currently undertaking an impressive program to implement health information technology in safety net medical centers in Washington. Senior Project Specialist Lauren Mardirosian was in attendance, along with Tracy Knight, NW Social Services Director from Bread for the City, and Deborah Parris, Health Information Manager from Family and Medical Counseling Services.

I set up the visit, with Kaiser Permanente’s help, because I am excited by the fact that our members’ experience can help patients in every care system, locally and nationally. It’s a virtuous circle - sharing our experience brings other experience back that we can use to do even better, and the cycle continues. I have really learned the reinforcing power of sharing in this journey. It’s even more enjoyable when I get to work with colleagues like Mark and Medical Center Chief Doug VanZoeren, MD, who willingly give their time alongside me.

What about the After Visit Summary? Mark showed that by involving the patient in its development, he makes the creation as important as the delivery in achieving its goals - involving patients and families in their care. In an era where we talk about Web2.0, Health2.0, and focus on user generated content, I think this is a great example - we create the record of what happened today, together.

DCPCA is implementing a modern electronic health record system, manufactured by eClinicalWorks, that has this capability. A care system that I visited in Sonoma, California, is already generating these for patients. Sometimes a piece of paper (albeit one that is also available on the Web in real time, on Kaiser Permanente’s personal health record, kp.org) can be as revolutionary as the people who put it together.

Thanks again to DCPCA, Mark, Doug, and Kaiser Permanente North Capitol Medical Center members and staff for their interest in helping patients everywhere.

Pictures: Click on any to see larger. Note: The patient displayed is a test patient. No actual patient information was demonstrated during the visit.