Archive for the ‘the practice of medicine’ Category

The Ultimate Patient Experience

Tuesday, March 29th, 2011

My father passed away with metastatic prostate cancer on March 16th.  He was living in my house for the last four months of his life so that we could assist my mother in caring for him.  We were fortunate to have Hospice guiding us along the difficult and foreign path toward death.

He had a series of complications toward the end.  He had a colostomy as well as two nephrostomy tubes.  Most of the work for the colostomy could be done at home but the nephrostomy tubes had to be surgically re-inserted periodically.  On his last visit for the procedure, two weeks before he died, my dad looked at the nurse as she was preparing him and said, “You won’t keep me here, will you?”  Even though it took three of us to get him out of his bed at home and into the car via a wheelchair, my dad did not want to be in the hospital and preferred the physical strain it cost him to return home.

Knowing what I know now about dying — and dying from cancer, I can still say that dying at home, without the fuss of hospital policies/standards/protocols etc. provided a more comfortable and private place for my dad and my family.  For us, the ultimate patient experience was a quiet and private passing.  Hospice nurses and aides took great care to make sure my father was comfortable, clean, with limited pain and in good care.  They took extra steps to help my mother and me know what to expect and what we could do to help my father.  They stepped out when our questioning was done but stood ready to help, steward and comfort us.

According to the Journal of Clinical Oncology as reported by Reuters (September 13, 2010), at-home hospice care saves money, reduces emotional distress for caregivers and leads to a more peaceful end-of-life passing. While most cancer patients indicate they would prefer to die at home, more than 36% will die in an acute care setting.  Over 25% of Medicare expenditures are spent in the final month of life, most often in intensive care even though there is limited evidence of benefit for the patient.

Physicians and healthcare organizations can help patients and their families in this final quest for a positive patient experience by providing more conversation around the planning for the end of life.

Research conducted by the Agency for Healthcare Research and Quality (AHRQ) indicates the following:

  • Less than 50 percent of the severely or terminally ill patients surveyed had an advance directive in their medical record.
  • Only 12 percent of patients with an advance directive had received input from their physician in its development
  • At least 2/3 of physicians surveyed whose patients had an advance directive were not aware that it existed.
  • Care at the end of life sometimes appears to be inconsistent with patient preferences of forgoing life-sustaining treatment.

As health care professionals and as family members, let’s not leave out the important conversation about end-of-life issues.  Talk it over, ask questions, review with each other and make sure that when the time comes, you AND your loved ones understand what is important.  Knowing that my dad died in the manner he hoped makes his absence more tolerable.


Communication Tool to Enhance Patient Satisfaction

Monday, February 21st, 2011

Communication can really break down when a patient or family member is worried or not feeling well.  Add the element of age and hearing loss and that communication pathway is further impaired.  On the provider side, you may be running behind or still thinking about your last patient’s care and deliver instructions too fast for the average 80-year old to find 100% comprehension.

Building infrastructure around the communication process will improve engagement and most likely compliance.  Adding to your communication pipeline might be good medicine as well as good marketing.

Kaiser Permanente has 3.3 million online PHR (personal health record) users.  Recent research has been done by Kaiser to find data to support the theory that greater access leads to greater engagement.  Some of that research will be shared this week at HIMSS but a preview by Valerie Sue at Kaiser, indicates that patients who can use email with clinicians, can check lab test results, schedule appointments, refill prescriptions and review visit information are simply more engaged.  They have an alternative route to communication about their health that goes beyond the fast moving office visit.

PHRs can be a significant tool to empower patients, communicate more meaningfully and help patients take more control of their own health status. Jan Oldberg, practice leader for internet services group at Kaiser, states that there is clear evidence that PHR use in positively correlated to increased patient motivation.  Oldberg also indicates that PHRs have also led to a drop in calls and visits.

Going back to the communication issue in a busy practice.…a PHR can serve as a communication device and help physicians provide their patients with the ability to access accurate and timely information and help their patients keep track of their health issues.  Patients don’t have to rely on remembering everything the physicians said during the office visit.

A Step Toward Coordination

A recent survey conducted by the Markel organization indicates that physicians would also prefer a computerized method of sharing information with each other. In the 2010 survey, only 17% of the physicians queried use a computer-based method for communicating with referring physicians and yet 74% indicated they would prefer a computer-based method when sharing patient information with each other.

The 2011 Markle Survey on Health in a Networked Life also compares physician and patient preference on information dissemination.  Summary findings as reported by the Markle organization indicate:

  • Nearly all physicians indicate that their patients sometimes or most times forget potentially important things they are told.
  • Both physicians and patients indicate important information is sometimes forgotten or lost in their interactions.
  • Nearly half of the public perceives that their ‘main doctor’ is the one who should keep the patient’s most accurate, complete health and medical records.
  • And yet 2 out of 5 physician groups say it is the patient and not the physician who should perform such a role.
  • 15% of the general public believes that no one is performing this role.
  • Both physicians and patients alike believe that patients should be able to obtain and keep a copy of their own personal health information.
  • 93% of the public rarely or never request copies of their health information in an electronic format

The Markle Survey of Health in a Networked Life also has interesting findings on preferences:

  • For physicians, 74% would prefer computer-based means of sharing patient information with each other.
  • 47% of the physicians surveyed also indicate they would prefer to have a computer-based means of sharing records with their patients while only 5% do so today.
  • 70% of the general public favor patients receiving a written or online summary after each medical while only 4% of physician indicate they currently provide patient summaries.

Providing access to a PHR takes the pressure off the office visit communication and provides  tools that can help your patient become more engaged and informed about their own health concerns.  Seems like a no-brainer method to improve upon the patient experience.


Prevention! The Food We Eat

Friday, February 4th, 2011

One of the very best things we can do with all of our patients is to have a candid conversation about food.  Seriously!  And I don’t mean, “I’m going to refer you to a nutritionist” kind of conversation but just one that simply outlines very important information about the American diet.  If you are uncomfortable taking the time to focus on this prevention oriented discussion, then print up Mark Bittman’s column, A Food Manifesto for the Future from the New York Times on February 2 and hand it out to patients as they leave your emergency room, your clinic or your practice.  Help your patients take responsibility for their overall health condition simply by thinking about where their food comes from and how it impacts all of us.

If you think I am stretching the content of this blog, and wondering how food can be related to healthcare marketing, think about cooking classes as an added offering for your community outreach as one simple tactic to engage your patients and help them focus on prevention.  Okay…Mr. Bittman’s column is well worth reading in its entirety but I have included some key points below:

The typical American diet is unhealthful and unsafe.

Here are some ideas — frequently discussed, but sadly not yet implemented — that would make the growing, preparation and consumption of food healthier, saner, more productive, less damaging and more enduring:

    • End government subsidies to processed food. We grow more corn for livestock and cars than for humans, and it’s subsidized by more than $3 billion annually; most of it is processed beyond recognition.
    • Begin subsidies to those who produce and sell actual food for direct consumption. (Think farmers’ markets.)
    • Break up the U.S. Department of Agriculture and empower the Food and Drug Administration. Currently, the U.S.D.A. counts among its missions both expanding markets for agricultural products (like corn and soy!) and providing nutrition education. These goals are at odds with each other…
    • Outlaw concentrated animal feeding operations and encourage the development of sustainable animal husbandry. The concentrated system degrades the environment… and produces tainted meat, poultry, eggs, and, more recently, fish. Sustainable methods of producing meat for consumption exist.
    • At the same time, we must educate and encourage Americans to eat differently.
    • It’s difficult to find a principled nutrition and health expert who doesn’t believe that a largely plant-based diet is the way to promote health and attack chronic diseases.
    • Encourage and subsidize home cooking.  People make better choices when they cook their own food.
    • Tax the marketing and sale of unhealthful foods. Another budget booster. This isn’t nanny-state paternalism but an accepted role of government: public health. If you support seat-belt, tobacco and alcohol laws, sewer systems and traffic lights, you should support legislation curbing the relentless marketing of soda and other foods that are hazardous to our health…

Healthcare Reform: Impact on Primary Care

Wednesday, January 12th, 2011

It is encouraging to think that Americans are bringing reflection into the mix with the recent events with Rep. Gifford and the other shooting victims. Maybe it is the media that is pushing this national conversation, but any time we can be more reflective and less reactive in our dialogue, we all win, eh?

The Arizona shootings have led Congress to delay their agenda and to delay the House’s vote to repeal the healthcare reform bill.  While the House’s intent will most likely be symbolic, it seems that there should be more thought into what exactly the reform act does instead of just a visceral reaction.  Hence, my point on reflection.

Key Areas of Impact on Primary Care

The Commonwealth Fund offers a sound briefing on the Affordable Care Act’s impact on primary care. Since primary care serves as the foundation of our healthcare “system,” and is fundamental for efficient delivery, this is an appropriate place to apply focus.  I have supplied the link, in the hope, that you will review the brief directly, but here are some of the key points provided in the briefing:

  • There are provisions in the Act that will temporarily increase payments to primary care providers for both Medicare and Medicaid:  10% bonus for Medicare (2011-2015) and Medicare level rates for Medicaid (2013 and 2014).
  • There are incentives to support innovation in the delivery of care.
  • There are incentives and an emphasis on improving outcomes and enhancing patient care experiences.
  • Recognition and funding exists in the Act to incent more individuals to become primary care providers.

Value of Primary Care

Studies demonstrate that greater access to primary care typically results in better prevention, more adroit management of chronic diseases and even improved mortality rates.  Since our current system of reimbursement for medical providers is fee-for-service, the emphasis (and incentive) is placed on procedures not on coordination of care or management of care or even outcomes.

Nearly half of all healthcare visits are for primary care and yet primary care providers comprise just over a third of our physicians in the United States.  Just as our population is aging and we are increasing access for millions of uninsured individuals, we will be losing nearly one fourth of the primary care providers to retirement.  Currently there are not nearly enough primary care physicians in the pipeline to replace those who are retiring.  Only seven percent of medical students choose to go into primary care.


The Affordable Care Act allows places some emphasis on prevention.  Beginning this year (2011), co-payments, coinsurance and deductibles for approved preventive services are eliminated.  This includes blood pressure screenings and many cancer screenings as well as immunizations.  Seniors will also have a free annual wellness visit and should receive a personalized health prevention plan.

More Providers

If you live in a rural area, you may already be feeling the impact of fewer primary care providers.  The Affordable Care Act provides incentives to battle this serious deficiency through loan forgiveness programs, scholarships and other programs aimed at increasing the supply of primary care providers including nurse practitioners and physician assistants.

Just the Start

The tenets within the Affordable Care Act positively impact primary care, but they do not fix the problem.  There is still much work to be done and the Affordable Care Act is just the start of fixing our healthcare delivery system.


New Year, Same Healthcare Delivery

Wednesday, January 5th, 2011

Thank goodness we have new years to force reflection and to consider our direction.  As you may have noted, I have been anything BUT regular in my blog posts for the past six months.  You may have guessed, it is because of my father’s terminal illness.

Since his health started to take a nose dive in June 2010 and I moved him and my mother to live in my community, I have been forced to see the healthcare industry as a “family member” and have considered our culture’s struggle with morbidity and mortality.

My dad is still with us but the prostate cancer is voraciously taking over.  And even though my dad is 82, he is fighting death.

I don’t know what direction my future posts will take but I just want to offer up some bullet point thoughts for now:

  • I am thankful to Northern Berkshire VNA + Hospice for their continuing care and guidance for my father and our family.  We would be lost without them.  And I am so thankful that my father’s primary care physician recognized the value of hospice sooner rather than later.
  • We have encountered several physicians and nurses who extend their knowledge and care by their grace and kindness.  Berkshire Medical Center has several providers in their medical community that work hard to combine true compassion with competency.  It is these individuals who are the heroes in healthcare delivery.
  • Insurance and payment continue to drive the “system” in interesting ways.
  • Medicare, supplemental insurance, out of network, transferring care into a new state – how complicated does it need to be for our seniors?
  • Our “system” of delivering care is fractured enough that the actual delivery of care becomes problematic and certainly expensive.  Why is the primary care physician essentially out of the information loop during hospitalizations?  Why does one man dying from prostate cancer need a primary care physician, an oncologist, an urologist, a surgeon and an interventional radiologist?
  • Testing, testing and testing?????  And an end of life, how much do we really need to know?
  • Patient-centered care is about the individuals delivering the care, the organizational system structuring the care and the overall corporate culture.  As an industry, we still struggle with the delivery of patient-centered care.  Try being a patient for one day in your organization and see how well you do.

Okay, this isn’t meant to be a rant, especially because my father has enjoyed exceptional care in North Carolina and now in Massachusetts.    We do need to think long and hard about healthcare delivery. We who dwell in this industry are the individuals who can work to change things. We do need to consider the demographic pressure as the baby boomers age – both in terms of costs and appropriate care.  We do need to consider the lack of primary care that is already impacting rural regions. And we do need to understand that all individuals can impact their own healthcare – simply by the food we eat (plant based, anyone?) and the exercise we have. As the new batch of Republicans vow to dismantle last year’s healthcare reform, should we take the time to communicate to our local politicians about what we know?


Make Yourself Rich

Friday, November 5th, 2010

I am in the process of moving my parents from North Carolina to Massachusetts.  My father has prostate cancer that has diffused into his bones. With no family members in North Carolina, it made sense to help them make this move.  Eventually we all have to face the journey of a loved one’s end stage care and while some situations might be more complicated, the process is not easy.  Our society doesn’t do a good job of talking about death and dying.  And I am finding out that our healthcare providers and payers handle these issues with amazing variance.

While physician offices are usually quite busy, I applaud the primary care provider and the oncologist’s staff who have gone out of their way to be helpful and have given me advice beyond just the job function.  The office staff, even the busy receptionist, have taken the time to be supportive and provide kind words.  These people make a huge difference in the patient experience, or in my case, the family member experience.  While we do expect that a hospice worker will provide that level of warmth, I am pleased and surprised to receive it from staff who have mounds of work on their desks and are not specializing in end of life issues.

I wish I could say the same is true for the healthcare payer.  I have spent well a couple of hours with four different employees trying to find out if we can keep my father’s care from having a hiccup.  He is moving mid-month and that seemingly is a problem.  I can’t seem to get an exception or a person with authority who can handle this request.  I do get transferred – cold and warm transfers – but I will continue to work on this issue.  But wouldn’t you think a customer service department would be more inclined to be helpful and thoughtful when discussing end-of-life care?

If you are a healthcare worker, provider, payer, staff, or otherwise, know that when you take those extra few minutes to help someone – and probably not someone like me but more likely a person who hasn’t worked in healthcare for years and is feeling a little lost and vulnerable – or listen to them or suggest an option, you are making a big difference.  You are sharing your humanity. In these times, the more of us who can step out of the daily routines and the propelling pace that hurdles us through our days, to show that we care, the richer we will be.


Moving Toward an Accountable Care Organization (ACO): The Healthcare World is Changing, Are You?

Wednesday, September 8th, 2010

Yesterday, CIGNA announced the launch of an accountable care organization (ACO) pilot with the Piedmont Physicians Group in Atlanta, Georgia.  The essential intention behind this pilot is to demonstrate how primary care physicians can be rewarded for improving outcomes while also having lower medical costs.

The pilot program will monitor and coordinate ALL aspects of patient care. Patients will not have to do or change anything in this pilot.  All of the adjustments will be done internally.  Patients will most likely experience immediate benefits in the management of chronic conditions, such as diabetes.

The CIGNA/ Piedmont pilot uses a registered nurse as the clinical care coordinator.  This role is specifically oriented to assist patients as they navigate through the healthcare system to manage their health issues.  The care coordinator adds an additional layer of interface that will use data and clinical programs to help support the individual’s needs.  The focus will be on improved outcomes.

In essence, this program, and others like it, are going back to basics on one level and moving forward on another.  The focus will be on prevention – keep an individual well but once the individual needs to access care, the pilot will work to coordinate that care, guiding the patient through the process with knowledge and informing data.

CIGNA will continue to pay the primary care physicians for the medical services they provide but they will also pay a care coordination fee along with a possible reward in a pay for performance structure.  In some ways, this is similar to concierge practices where the physician continues to provide medical services for reimbursement from third party payers but also collects an annual fee for additional services – services not unlike care coordination and an emphasis on prevention.  The responsibility for that additional fee becomes the payer’s in exchange for improved outcomes.  Sounds like a win-win situation.

Providers need to make way for new incentive programs like this one.  Whether a hospital or a physician organization, preparation for change needs to happen now.  There is substantial information flowing about electronic health records (EHRs), utilization of outcomes data and comparative effectiveness research findings and the ability to provide care coordination.  It is likely that these three tenants will form the basis of a provider’s ability to become an ACO.

The handwriting on the wall indicates that providers will be paid for keeping patients healthy.  Providers should reconsider the value of their outreach programs that seek to motivate physical activity, healthier diets and smoking cessation.  Some early research (Trust for American’s Health, 2008) suggests that funds spent on prevention outreach lead to significant savings in healthcare costs.  This kind of outreach is already in place in many organizations.  If not, the easiest step is to focus on wellness events and early detection programs and begin planning for the other steps (EHR implementation, using comparative effectiveness research findings and coordination of care).  The world is changing and providers need to change along with these new (or renewed) constructs.


The Value of Time-out

Wednesday, September 1st, 2010

You might have noticed that I took most of the summer off from writing.  I could blame it on having two hospitalizations for close family members (while those events served as good market research opportunities, it is good to report that both family members are doing just fine now!) but really…I wanted to spend more time just thinking.

We move too fast in our technologically enhanced world.  With our Blackberries in hand, we can check our emails even while vacationing in the mountains.  Or, if email is too slow and phone calls too cumbersome — fear not — we can text, tweet or just move on without completing the communication loop.

A friend of mine thinks it is just the glamour of new technology that pushes us to unfettered limits.  I am not so sure.  Somehow we have to make decisions about the depth of our thoughtfulness and if we are pressed to answer in a nano-second and move onto the next issue, are we even making good decisions?

I am a baby-boomer by demographic profile, so I know what life was like before we could wake up to our email worrying about what we missed in the night.  Isn’t it important for us to help the younger generations keep what is good as we advance?  Isn’t thoughtful consideration, a time hungry endeavor, worthy of our need to hold on to it?

If you agree that you are spinning too fast whether you are at work or can’t relax while on vacation, it is time to speak up.  We need to push for the productivity of thinking.  We need to remember that good decisions about our work are borne out of planning and considering – not check-offs for tasks that get done.  Let’s take another look at that phrase, less is more.

And while we are pulling back to reflect when the need arises, should we, as those who dwell in health care delivery, also spend some time thinking about how we can do our work better?  Is more specialization the answer?  Should we be alarmed when an urologist tells us that he “only focuses on the plumbing” and if we want to know about the impact on Coumadin on radiation cystitis, we better seek out the cardiologist.  Yes, I understand what he meant but isn’t my father impacted by both his bladder and his heart?  Does the coordination then fall to the patient?  In this case an 81 year-old without any clinical awareness?

Okay, this has been the summer of thought.  And, my intent is to continue with this blog as an instructive device but also one that includes thinking fodder to push us and stretch us to do more than get stuff done but to get it done well as game-changing momentum.



Thinking Fodder for Healthcare Reform

Tuesday, February 23rd, 2010

Okay, I am still thinking about healthcare reform.  I hope you are as well because we need the workers and thinkers who dwell in the healthcare arena to speak up and speak out.  We need to be the problem solvers.  Later this week, President Obama and members of Congress will gather to discuss solutions.  It is important for us to stay tuned but we have much work in front of us, no matter what.

Periodically, I will gather thinkers or information and report on different perspectives to provide fodder for the rest of us to consider, mull and hopefully discuss.  I just heard an interview with the CEO at Cleveland Clinic, Toby Cosgrove, M.D. Check out the link but I have also included some key bullet points below – in most cases, the bullet points below are direct quotes from the interview posted on Fortune, February 17, 2010, on CNN/Money:

  • We do not have a system of health-care delivery in the U.S. It’s a series of mom-and-pop shops all over the country, and it has not been systematized.
  • So regardless of what happens [with reform], we can really only try to contain the rate of inflation. The cost is going to go up over time.

Cost drivers?  Areas to seek improvement?

  • Let’s take obesity [as a health concern and cost driver.] It accounts for 10% of the cost of health care in the U.S. — we will never be able to control the cost of health care until we begin to control the epidemic of obesity. Two-thirds of the U.S. is overweight, and one-third is obese. We are the fattest nation in the world.
  • [When considering preventive measures for employees,] it’s always been a question of “What’s the ROI on this?” Until very recently, people didn’t realize the ROI is probably 3 to 1: For every dollar invested, you get three back in terms of employees being better.
  • Three things — smoking, diet, and lack of exercise — cause 40% of premature deaths in the U.S. They contribute to 70% of the chronic diseases, things like emphysema and heart disease. And that’s 75% of the cost of health care. It’s huge!

How Cleveland Clinic is different:

  • Very few hospitals are organized the way we are. First, all of us have salaries. It doesn’t make any difference, if I’m a cardiac surgeon, whether I do two heart operations a day or four. I take home the same amount of money at the end of the week. So there’s no incentive to do extra tests or any of that.
  • Second, we all have one-year contracts, and we have annual professional reviews. So the quality of the doctors is controlled, there’s no tenure, and if you don’t make it, you don’t get a pay raise or you may not stay. That is one of the most important things we do. It’s quite different from most places, where doctors can practice for as long as they want to practice.
  • We are physician-led, which is quite different from most medical organizations…

How will hospitals change?

  • There are a lot of very successful for-profit hospitals. I think what we’re going to see is a roll-up of hospitals. I don’t think it’s reasonable anymore to think that each hospital can be independent — have its own financial support, its own purchasing, its own back office. You need efficiency.
  • We have an electronic thing called MyChart, where you can go on the Internet and read your record. Few other hospitals around the country have done it. But we think it’s the patients’ information. It’s about them. We’re working for them. Why shouldn’t they have the data?

Here is the link to CEO of Cleveland Clinic interview once more…it is worth reading Dr. Cosgrove’s thoughts and the interview is well done.  Keep the conversation going!


Creating Relationship Value through the Patient Experience (Part 3 of 5)

Thursday, January 21st, 2010

How high have you set the bar of satisfaction for the patient experience?  Here are what some other healthcare organizations are saying on their websites, this January (2010) about their view of the patient experience:

Cleveland Clinic

“Patients are the purpose of our work, and Cleveland Clinic has embarked on an ambitious plan to examine and improve every facet of the patient experience. This effort encompasses every point of contact between patient and provider, from parking to prescription pick up.”

Johns Hopkins Health System

“Our quest for excellence isn’t limited to the treatments we provide. Several initiatives are under way at Hopkins to help physicians, nurses and staff to deliver the best possible service to customers.”

Gettysburg Hospital

“Gettysburg Hospital is ramping up its commitment to patient satisfaction with the aid of a qualified specialist. Tracy Lee joined the hospital last September as director of patient experience. Lee tracks patient satisfaction survey results and develops strategies for improvement.

Lee explained that many health systems have placed renewed emphasis on patient satisfaction in recent years.  A federally mandated consumer survey known as HCAHPS—the results of which are available to the public—has driven that trend.

“We all know what it’s like to either be a patient or have a loved one in crisis, and I enjoy helping make that experience a better one,” she said.”

These three organizations could not be more different from one another. And yet is placing special emphasis on the patient experience.  Each of them are defining that experience as beyond taking care of a patient clinically:

  • “…every point of contact between patient and provider.”
  • “Excellence isn’t limited to treatments we provide.”

When a patient visits the hospital or a doctor’s office, that individual experiences a series of events that often overshadow the actual contact with the medical provider. On a recent medical visit , I spent 15 minutes with the physician and 45 minutes “in process” once I entered the office – time at reception, time in the waiting room, time with the med technologist, time waiting in the exam room and time checking out after the visit.  It is easy to see how a good interaction with the physician can be overtaken by less than stellar service interactions.

You have heard me say that service is the marketing and that phrase is so true when it comes to the patient experience.  If you patient leaves happy, they will consider the experience positive and likely share that with their friends and family.  They will probably want to be your patient for a long time and will refer others to you. Their positive experience will create a long-lasting relationship value for them.  If your patient leaves grumpy, none of these good things happen.  In fact, a patient is more likely to share bad service news than good news and in telling their friends and family, you are on your way to a poor reputation.

So, think about, how high is your patient experience bar?