|
|
|
|
|
|
 |
 |
 |
|
 |
|
 |
|
 |
|
 |
|
 |
|
|
Operational supports to improve adherence
|
|
Earn Category I CME credit by reading this article and the articles "Evidence-based strategies to foster adherence and improve patient outcomes", "How effective communication promotes better health outcomes", and "A patient-centered approach to chronic disease management" and successfully completing the post-test. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of November 2004. |
Learning objectives
|
For most patients, the clinician is a barrier between what the patient wants and how he or she goes about getting it. The current relationship paradigm between clinician and patient is an unfortunate vestige of the managed care system, in which the primary care practitioner is largely seen as a gatekeeper. The paradigm needs to be flipped around so that the clinician is perceived as a sage advisor—a coach, mentor, and trusted friend. The new relationship should be one where the patient would not even consider accessing the health care system or going to see a specialist without first contacting the primary care provider. This clinician must be responsible for the overall picture of what is happening to the patient and should be the first one consulted when a problem arises.
Improving the patient's adherence to treatment regimens requires a combination of information about the regimen, counseling about the importance of adherence, reminders about appointments, rewards and recognition for the patient's efforts to follow the regimen, and enlistment of social support from family and friends.1 Health care professionals must increase their focus on the systems that support how care is provided and information is communicated, whether by personnel or technology. Adherence can be enhanced substantially, especially for patients with chronic illnesses, when the care they receive combines trusting relationships, accessible services, and high-quality treatment.
GreenField Health is a general internal medicine practice that provides primary care to adults with all levels of health care needs (see www.greenfieldhealth.com ). It is a prototype practice that is designed to provide patients with three essential, interrelated elements—a long-term relationship with clinicians and the office team that is built on mutual trust and respect; a level of service and convenience similar to what patients experience in the rest of their lives; and medical care that is simply and reliably the best.
Numerous activities occur during patient visits—taking a history, gathering information, building rapport, performing a physical assessment. The time spent during the average visit is only 8 to 10 minutes, but even during that short period of time, clinicians tend to interrupt patients and prevent them from telling their stories completely—in part to try to keep the visit short. Research shows, however, that interrupting the patient actually lengthens the visit because the patient will return to the original agenda if the clinician does not allow it to be completed in the first place.2
As part of establishing the relationship between clinician and patient, GreenField allots 60 to 90 minutes per patient for the initial visit and 30 minutes for each follow-up visit. Having a lengthy conversation up front, a significantly longer conversation than occurs in most practices, is seen as a critical investment of time.
Information that is transmitted from the patient to the clinician and back again within the standard office setting usually involves multiple exchanges between the patient, the clinician, and office personnel. Within this scenario, numerous opportunities for error, miscommunication, and misinterpretation arise. For example, a patient who calls to report symptoms and to ask about an appointment may wind up talking with as many as three or four people, and the average interaction includes two or three written phone messages—all of which provide opportunities for error.
Although traditional communication systems limit the patient's access to the clinician with the goal of saving the clinician time, in fact these systems create barriers to communication and require extra work. In addition, when more people are added to the mix as information is being communicated from one place to another, no value is added to the patient's experience. These attempts to protect the clinician's time are misguided, based on the belief that patients will waste this time if given the opportunity. In contrast, GreenField's experience is that when patients are given unfettered access to those providing their care, they respect that access and do not waste the clinician's time.
The health care industry is increasing its focus on the importance of training its workers to become better service providers, but the real emphasis should be placed on improving the patient's access to service. Much of the waste of rework is engineered out as patients are allowed to make more of their own choices, under the direction of their clinician. GreenField promises that office appointments will always be available on the same day the patient calls or on the next business day. This improved access inevitably results in a reduced expenditure of time, less frustration, and fewer opportunities for error.
In the primary care setting, the standard time frame for scheduling follow-up visits is 3 months. Usually the clinician fully intends to see some patients sooner—within 2 to 3 weeks, for instance, for patients being treated for depression—but there is a backlog in scheduling in most busy primary care office practices. Furthermore, even if the patient is expected to return in 3 months, the clinician does not know in advance either the date or the time of this visit. Quite often the appointment may need to be rescheduled to accommodate the changing obligations of a busy practitioner, further burdening the system.
Open access enables the practice to schedule an appointment for a patient closer to the time when the appointment will occur. With this method, the clinician has an internal system reminder of the need for this appointment at the end of the 3-month time frame and can schedule the patient's visit at that time. This allows the scheduler to take into account other real-time obligations. Although the same number of patients can be seen under either call-back system, open-access scheduling may increase that number because it is not encumbered by the inevitable no-shows when patients forget their appointment. Because the management of the schedule in a practice does not provide added value for patients, as little energy as possible should be expended on this activity.
The personal health record is a crucial component of patient care because it contains the patient's health summary. Electronic medical records (EMRs) have revolutionized the practice of outpatient medicine because of the amount and type of information they contain. The health summary contains the patient's medical problems and the treatment plan, test results, educational material, important contact information, and other relevant documents. Patients can be given their personal health record on paper and encouraged to take it with them when they go to a specialty visit or to the emergency department. This record helps bridge the gap between what the primary care clinician knows about the patient and what the specialist or emergency practitioner might need to know—the results of recent tests, for instance, or a list of current medications and allergies.
Health care systems have always needed reliable data, but never more so than now, in our high-tech medical environment. Approximately 10% of practices in this country use EMRs, which means that 90% are still shackled with the paper chart. The leap of faith that needs to be made when implementing an EMR is in trusting that it will actually improve the quality of care that can be provided to patients by reducing the opportunity for human error. When data must be transmitted between systems, waste and error can be reduced when those transmissions are completed by a computer rather than by a human. For instance, the crucial importance of checking for drug interactions is a perfect task for a computer, as it provides a correct answer 100% of the time.
Treatment protocols with reminders can also be built into the EMR. The beauty of using EMRs is that each patient's chart can be structured to have a "to do" list of what is needed, such as what tests this patient should have and at what time intervals. The EMR can identify the patient as having diabetes, and the computer, using a predetermined protocol, can search to identify the care that has already been given and to determine what more is required. This information is available to the clinician whenever the patient "touches" the system, and it helps the clinician to determine if the patient is being well managed and receiving the right kind of care. The one caveat with treatment protocols, however, is that they are only as reliable as the quality of the data used. Ideally, the system makes it easiest to do what is right and more difficult to do what is wrong.
The unfortunate financial reality today is that health professionals are reimbursed solely for providing care within the construct of an office visit. Clinicians do not get paid for talking to patients on the telephone or for communicating by e-mail but, instead, are locked into the tyranny of the office visit. If patients want anything of substance from their clinicians, they can get it only during a standard medical appointment. Practitioners have had to contend with confusing telephone care codes and usually have had to write off the time they spent on these calls. They are understandably reluctant to give away e-mail care, as well. The current reimbursement system should not force clinicians to give away their time and expertise.
Experience has shown that clinician-patient encounters need not always take place during a face-to-face office visit, which has traditionally been the only way to provide service. E-mail and telephone care can, in fact, be effective methods of communication in the primary care setting and can have just as much or more influence than the office visit. Frequently, patients are more comfortable communicating sensitive information about their family or medical history in e-mail.
At GreenField Health, the choice to use either e-mail or the telephone is left to patients, but the practitioner is always the final arbiter of which will be the most the clinically appropriate mode of care. Obviously, there are times when the clinician must see a patient in the office, but otherwise, patients can have the option of choosing how they would like to communicate. GreenField Health's experience with established patients is that when medical issues arise, 20% of these result in an office visit; the remaining 80% can be resolved either by phone or by e-mail.
Patient care in the primary care setting has much to recommend it and much that can be improved. Practices and clinicians wishing to improve access for and service to patients can do so by investigating technology use, implementing scheduling process changes, and improving their focus on the systems that operate within their offices. Many such positive changes can be made easily through a bit of discussion with staff, although others will require months of planning. When even some of these changes are implemented, however, patients and clinicians will be able to work more closely together in a setting that serves everyone well.
REFERENCES
1. Haynes RB, McDonald HP, Garg AX. Helping patients follow prescribed treatment: clinical applications. JAMA. 2002;288:2880-2883.
2. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA. 2000;284:1021-1027.
Jill Arena. Operational supports to improve adherence: Strategies from the field. JAAPA November 2004;17:29-31.
Copyright © 2004, Advanstar Medical Economics Healthcare Communications at Montvale, NJ 07645-1742. All rights reserved.
