As I posted previously, I was honored to present at the Institute for Family Centered Care’s intensive training seminar, on the leveraging of health information technology to promote patient and family centered care. Bev Johnson, the Institute’s CEO continues to impress me with her boundless energy - I include her in the class of individuals that probably has more energy than I do.

I enjoyed great interaction with the rest of the attendees, many who came in teams, with either a record of change in their institutions, or about to create one. What I haven’t really appreciated to date is the fact that this type of care is still not the norm in most medical institutions. I should say that I appreciate it, but maybe I don’t have the best understanding of the challenges of transforming to a system that involves patients and families in all aspects of care. This includes family presence in all rounds (physician and nursing), 24 hour access to their loved ones in the hospital, ability to access all information generated as part of the care experience. A lot of the seeds of this transformation come from the pediatrics arena; it is slowly making its way into adult health care. There is a significant leadership presence in the nursing community. Imagine a family being present during nursing rounds where a nurse discovers that a scheduled dose of antibiotics has not been given. This seems challenging on its face, but turning it around to create an opportunity for Poka-yoke is far less challenging than allowing an event like this to happen again. I noticed that a lot of nurses and physicians understood this, and it is terrific.

In my own environment, I also reflect on the fact that I’ve been supported in promoting patient-centered health information technology. Yet at the same time, if even a greater percent of the organization’s activities was devoted to promoting this method of care, there are things I might not have to “nemawashi” about that I do now. Regardless, I am happy to do this; if IT is going to be the nidus of patient and family centered care in some organizations, so be it (for now). In the end, though, I’m going to continue to work for IT be the support for patient and family-centered care philosophy, rather than the lever.
Thanks to Bev and the IFCC team for continuing to move into ambulatory care, and to understand the changing landscape of HIT and the opportunities to use it for its true customer, the patient.

I am in Besthesda, MD, attending the Institute’s intensive training seminar. The quote above is from Roslyn Marshall, RN, Nurse Manager for the Neurosciences Unit at Medical College of Georgia, who placed a sign with the words in the title near the place where nurses used to do their shift changes. They now do shift changes at the patient bedside. The other quote I liked was from Terry Griffin, who said:

No one more than parents wants to make sure their baby’s care is error free

In reference to including parents in hospital rounds and nursing rounds. I also learned to not call “Carts on Wheels” “COWs” - “WOWs” (”Workstation on Wheels”) is better.

The quote in the title of the post is from David Kibbe, MD, MBA, who co-taught a workshop on the ASTM Continuity of Care Record Standard with Steven Waldren, MD, MS, in conjunction with the TEPR Conference in Fort Lauderdale, Florida.

I took the workshop on behalf of my work with the Calfornia Healthcare Foundation to look at creating a connectivity ecosystem for patients, families, and health stakeholders in a community, which I’ve started to blog about here.

It was a good workshop, with a nice step-through of the CCR standard, which for me was fairly straightforward to follow. Here’s a screenshot of the XML schema of a sample (test) CCR XML file. If you’re medically inclined, you’ll see that it’s an XML representation of a prednisone taper. I didn’t put this XML file together, but I consider this a sort of “hello, world” - to show that a clinical summary can be represented with a human and machine-readable file.

CCR is figuring into many well publicized Health 2.0 applications and I am of course a fan of anything that has its genesis in engaging patients in their care.

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?

Let me know what you think!

Ending Secrecy: Physician Makes Case for Full Disclosure of Health Records - iHealthBeat

If you are interested in innovation, I think this is a good podcast worth listening to - and the actual audio is more useful than the printed version.

I listened to it the day before I attended the latest Patient Centered Primary Care Collaborative, in Washington, DC. At the meeting, I was fortunate to run into one of my role models, Susan Edgman-Levitan, PA, and we talked about the idea that the Medical Home is about improving the care of patients where they spend most of their time - where they live, work, and play. We can help patient-centered care flourish by including ideas from everyone involved in the care, including nurses, doctors, allied health practitioners, eye care, oral health care, behavioral health care, just to name a few.

I liked what Jack said in the podcast, that in a company, there has to be

a sense that in every soul of the company, the idea that everybody innovates.

Toward the end of the podcast, Jack gets quite fired up about the idea that innovation can’t be regulated to the chosen few. My experience reinforces this. In the area of health information technology, this is critical. When most people think about implementing HIT, they think about the implementation period. The most powerful part of HIT is what happens after implementation, and using a management system like the one developed by Toyota Motor Company (as we are) can allow an organization to turn HIT into an organization wide innovation engine - if they capture all of the ideas of everyone involved in providing care and put them to use. To not do so is to waste one of the most valuable raw materials for growth - ideas and time (and most importantly our patients’ time).

One other conversation that has come up in the last several days is about generational changes in approach. Many of the Generation X and Generation Y colleagues I have been talking with were raised in a professional environment where we were not going to have all the answers, and we are uncomfortable being accountable for them. We want to share the power of coming up with the answers with our provider colleagues and our patients. This is not to say that our baby boomer colleagues don’t have this desire, too. I think we are stimulating each other to do what they’ve always wanted to do, and involving patients, their families, and all practitioners, all specialties and roles, is really going to make a person’s medical home special.

Feel free to take a listen and let me know what you think:

Finding Innovation Where It Lives

The quote in the post comes from Roslyn Marshall, RN, Nurse Manager of the 3West Inpatient (Neurology and Neurosurgery) unit at Medical College of Georgia, in Augusta.

Images: Click on any to see larger

Just as with several other organizations I have visited, I did not imagine that I would be heading to Augusta, Georgia to learn about how to involve patients and families in their care, but I’m glad I did. This is a place where so many things that are seen as abnormal in the rest of health care, are normal (see this paper for a description of patient centered care, with a focus on MCG). In an environment like this, it’s okay to ask “why?” when it comes to issues of involving patients and families in their care.

The occasion of my visit is related to a grant that Medical College of Georgia has received to study the use of a personal health record to improve hypertension care. With respect to the idea that being as close to the patient as possible is important, Ms. Pat Sodomka, Senior Vice President of Patient and Family Centered Care, hosted my visit on behalf of the organization.

Part of my study included watching the excellent program, The Remaking of American Medicine, which featured Medical College of Georgia in its last hour, and it was amazing to see how much has been accomplished both in involving patients and their families, and in transforming the organization.

Today, I’ll post about what I saw clinically. Tomorrow, I will post about what I saw systematically in this leading edge care system.

I began in Family Medicine and Internal Medicine, where practitioners and patients are both busy, and integrating one or two electronic health records in the care that they use. This is what I observed when shadowing family medicine specialist Bill Phillips, MD.

Besides data from their own organization, they need to integrate the needs of patients working to stay healthy in a system with an affordability crisis. In my own practice, I had not had to think about which big box retailer offers which drugs for $4 , or even free, as a loss leader. However, this is a big issue for patients. I reviewed the formulary for Wal-Mart’s $4 program - it’s extensive.

I was able to shadow the Director of the Osteopathic Medicine Program, Julie Dahl-Smith, DO, who is also board certified in Family Medicine, as she performed a manipulation visit and acupuncture visit for a family. This made me think about the value of patient involvement through a personal health record. The treatments that Dr. Dahl-Smith provides are distinct from the allopathic treatments that I have been trained to do. There’s an opportunity for patients to become more knowledgeable about the treatments that work best for them through patient access.

I spent time with Shilpa Brown, MD, who manages her own faculty practice as well as a residency practice and extensive student teaching. Patients in each have distinct needs. I also observed some key differences in workflow between private practice and academic practice. Faculty are ultimately accountable for 1, 2, 3 or more residents’ care, whether that care is provided in person or virtually. There is much that MCG will contribute in this area as an innovative academic medical center.

In between, I visited with the Neurosciences Interdisciplinary Rounding Team, which includes nurses, pharmacists, students, residents and attendings, led by Dr. David Hess. This is a unit, 3W (which I will talk more about tomorrow) that serves patients and families not just locally but regionally. What would it be like if a family member who is based far away from Augusta could connect with their family’s care team electronically? The team was open to this idea.

This organization is unique in my travels because it is a full academic medical center with many top notch training programs, which include a family medicine residency and an osteopathic residency. It is also special in the way it involves patients and families in the care, through its advisor program. The program reaches all the way into undergraduate medical education, and every new program seeks involvement. Patient advisors are free to visit MCG facilities and talk to patients and families about their care.

As I was being guided to the Internal Medicine clinic by Bernard Roberson, Director of Family Services Development, we passed by one of the “commons” (a different way of thinking about a waiting room that’s more patient centered) and a patient waiting to be seen said to us, “Tell me more about patient and family centered care.” It turned out it was one of MCG’s Patient Advisors, and I think we both saw it as a welcome sight. That’s how things are different here.

Tomorrow, a post about the system-ness of Patient and Family Centered Care at Medical College of Georgia.