ELEVATING THE DIALOGUE BETWEEN PATIENT

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ELEVATING THE DIALOGUE BETWEEN PATIENT PHYSICIAN

• 5TH Annual Information Therapy Conference
• September 26, 2006
• Walter Stewart, Ph.D., MPH

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OVERVIEW

• Communication needs
• Challenges and constraints
• Patient completed questionnaires
• Application example
• Relevance to clinical care

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THE DIALOGUE
Pre-Encounter Reason for visit

• Framed by physician needs
• Simple questions10/hr
• Structured questions 20/hr
• Artful high level questions100/hr
• Orders100/hr
• Unstructured documentation not worth much
• Educationworth a lot to the patient

Check-in and wait
A Typical Visit
Move to exam Room with nurse
X
Physicians encounter
Continuous Care
Orders
X
Patient instructions education
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COMMUNICATION CHALLENGES

• Too little time
• Unlikely to change
• Too little structure
• Tradition and the acute care model
• Low expectations
• Inefficient ineffective use of time

Its not just about having time to talk
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ADDRESSING COMMUNICATION NEEDS

• Effective use of time
• Level the playing field
• Presenting options
• Documenting choices
• Shared decisions
• Documenting outcomes

all at the current price or less
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Is there a low cost, practical, patient-centered
way to improve patient-physician communication?
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A Patients Vision of Centered Care
Personalized, Expert Attention
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A Professionals Vision of Patient Centered
Care Multi-Disciplinary Team Care
Joe learns to manage his diabetes with help from
four specialists, a dietician and a personal
trainer
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PATIENT CENTERED CARE

• Experts view
• Bio-psycho-social perspective
• Patient-as-person
• Sharing power and responsibility
• Therapeutic alliance
• Doctor-as-person
• Most of the focus is on conditions and issues
  that require substantial talk time

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Patient centered medicine is basically a
humanistic, biopsychosocial perspective,
combining ethical values on the ideal
physician, with psychotherapeutic theories of
facilitating patients disclosure of real
worries, and negotiating theories on decision
making. It puts a strong focus on patient
decision making
How do we get from here to something that
physicians would actually want to do?
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MOTIVATION

• Improve service
• Increase customer
• control
• Competition
• Financial pressure

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Driver suffers from directional dyslexia.
Instinctively goes the opposite direction of what
one would expect in getting to a destination.
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Patient decision support
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• FEATURES
• Self-training
• Self-paced
• User preference
• User inputs
• Interactive
• Real-time tracking
• Gets user to goal

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Can patient completed questionnaires enhance
communication and patient centered care?
It depends
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WHY USE PATIENT COMPLETED QUESTIONNAIRES?

• Significant research investment
• Uses
• Diagnostic
• Functional status
• Other outcomes (e.g., pain persistence,
  frequency, intensity)
• Preferences
• Decision support

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WHY USE PATIENT COMPLETED QUESTIONNAIRES?

• Patient centered
• Speaking first before the exam encounter
• Engaging
• Educational
• Can address sensitive issues
• Frees time to discuss other issues
• Can be used to guide the encounter
• Quantitative and concrete documentation
• Can be used to tailor patient education

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If questionnaires are so great then why arent
they widely used?
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LIMITATIONS

• How do you select the right questionnaire
• Reason for visit
• Diagnosis, functional status, patient
  preferences, etc
• Hard to fit to the existing workflow
• A non-starter Physician interacting with the
  patient and questionnaire
• Need for real time access to the right
  information
• Hard to retrieve during follow-up visits

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APPLICATION EXAMPLE LEVERAGING AN ELECTRONIC
HEALTH RECORD
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PEDIATRIC NEURODEVELOPMENTAL CARE

• Complex and heterogeneous behavioral syndromes
• Autism spectrum disorders, language delay, MR,
  psychiatric problems
• Parental burden and skills
• Substantial information demands
• Neuropsychological testing
• Complex instructions to parents
• Detection/referral increasing

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CHALLENGES

• Demand for care greatly outstrips supply
• Reimbursement constrains growth in service (0.60
  reimbursement on the dollar)
• Documentation is unstructured
• High parental anxiety
• Complexity of demands on parents

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SOLUTION

• Distinguish between 20/hr and 200/hr tasks
• Use structured documentation
• Prepare parent for physician encounter
• Display of parent information
• Instant knowledge
• Guided probing
• Address physician needs
• Style differences
• Human factor and workflow demands
• Control
• Parent roadmap

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DIGITAL PEN
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OBTAINING THE PATIENT DATA IS THE FIRST
STEPUSING IT IS THE GREATER CHALLENGE
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ELECTRONIC HEALTH RECORD INTERFACE

• Guides the provider through the form
• Divides the sections into content areas
• Checkmarks show areas already viewed

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Surveys are completed by the patient s caregiver
and then downloaded and transmitted to the EHR.
Survey results display for the provider within
the EHR as well as additional checkbox areas to
collect information. Responses of concern
display in blue.
Icons assist with navigation through the form.
Survey responses and checkbox areas are mapped
automatically into the Progress Note.
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EPIC INTERFACE

• Common behaviors
• Checked behaviors flow into progress note
• Add other behaviors not already listed in a
  free-text box

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EVALUATION

• Pre-post design (n 75 in pre- and post periods)
• Parent Satisfaction with encounter
• Evaluation of patient-physician interaction
• Audio tape sessions
• Semi-quantitative measures of participation and
  content of interaction
• Physician/staff productivity
• Key to future value proposition

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RELEVANCE

• Symptomatic and behavioral conditions
• Reimbursement lt cost of physician time
• Avoidance of certain problems (eg, depression)
• Psychiatry, Neurology, Rheumatology,
  Gastroenterology
• Primary care
• Challenge Building a solutions that work with
  and without an EHR

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WORKFLOW MODEL
After Visit Summary
Validation Transmission
Data Capture
User Interface
SEARCH FOR RELEVANT CONTENT USING CUES FROM
PATIENT DATA
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Is this a generalized model to enhance
patient-physician communication?
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EXPORTABILITY
Validation Transmission
Data Capture
User Interface
AVS

• OPTIONS
• Scan form
• Digital pen
• Pentab, PDA
• Work station
• Kiosk

OPTIONS Linked to data capture technology

• OPTIONS
• EHR
• Non EHR Web-
• interface
• Server specific
• software

OPTIONS Word template or other like interface