Chapter 11: Listening to the patient

Leslie Kelly Hall, Senior Vice President, Healthwise
Don Kemper, CEO, Healthwise

The greatest untapped resource in healthcare is the patient. More often than not, an engaged and activated patient can make the difference between healthcare success and failure.

Through EMR systems, we have begun to tap that resource by prescribing information to the patient just in time to help him or her make a better health decision or to support a higher quality of self-care. Still, there is something important to consumer empowerment that is missing. Consider this:

• Its true that people can pull a full array of medical . information and decision-support tools from the Web.
• And, increasingly, doctors can push the most relevant . information and tools for each individual patient through their electronic medical record systems.

But today, there is no good way to get the patients voice captured within the medical record. Until we can pay better attention to the patients perspective, much of the patients potential will continue to go untapped. Pull, push, and pay strategies are all needed to maximize engagement.

Patient response is a new way to ensure that the patients voice is well heard in creating care plans, in deciding among treatment options, and in advancing the doctor-patient partnership. With patient response, patient-centered care becomes possible. Only by paying attention to the values and preferences of our patients can we achieve sufficient patient engagement to put the patient at the centre of care.

Patient response defined:

• Short definition: Patient response is the documentation . of the patients preferences and responses to physicians requests within the clinical record.
• Full definition: Patient response is the documented . record of a patients treatment, care plan, self-management, and health education preferences and responses to clinical and administrative questions, presented in the clinical record using HL7 standards, to help the clinicians support shared decision making and patient activation. Such a patient response is usually, but not always, in direct reply to a clinicians information prescription or query to the patient.

Patients who are actively involved through information prescriptions and patient response will make better care plan decisions with their doctors and be more successful with self- management actions at home. Physicians who ask their patients to do more self-management and shared decision making can achieve better clinical outcomes, raise patient satisfaction, and reduce the cost of care. When patients are involved and informed, they can ask for the care they need, say no to care they do not need, and do as much for themselves as possible. There is no better way to engage patients than to assure them that their voice will be heard in treatment and care plan decisions.

The stage is set for patient response

One-way information is not enough

While informing patients is a key step in unlocking the patients potential, one-way information, by itself, is not enough. Until the physician can see, in the clinical record, the patients response to a query or decision aid, there is little chance that the patients voice will be heard. Patient-centered care will never be attained until the patients voice is in the clinical record and the doctor pays attention to it.

A patient response is much like a medical test result

You can think of a patient response as being much like a medical test report that comes back into the record for the clinician to use in making a better diagnosis or treatment plan.

• Just as the test is done at the clinicians request, so, too, is the patient response done in reply to a physicians request, query, or information prescription.
• Just as the test results come back to a predictable place in . the patients record and in an expected format that is easy for the clinician to quickly scan within a time-limited workflow, so, too, is the patient response presented in a predictable place and expected format.
• And just as an automated analysis of a medical test . highlights test results that are out of normal range, so, too, does an automated analysis of the patient response flag any aspects that are important to the care plan development.

Physicians are often unaware of what their patients are thinking. Did I answer all her questions? Is he planning to change his diet to prevent diabetes? Does she agree with the care plan? Did she have important symptoms that I didnt ask about? Is she also using complementary medicines to manage her complaints? Too often there is just no time in a clinic visit to probe for the answers.

Patient response can improve the doctor-patient relationship and care outcomes by promoting empathy. With patient response, the doctor gets to learn the patients perspective in a short time, and the patient gets the satisfaction of knowing that his voice was heard. Both enjoy the rewards of improved medical outcomes.

Here are five examples of patient response with benefits for both doctors and patients:

Pre-visit summaries:

• 1. Pre-visit summaries are patient responses to a set of questions sent to a patient in advance of a visit. The questions are specific to the reason for the visit and interactively probe the patients symptoms, concerns, level of knowledge, and expectations for the visit. By starting with a succinct summary of the patients responses, the doctor can get to the point of the visit faster and serve the needs of the patient with more time available for education, motivation, and joint care planning. Pre-admission summaries can do much the same for improving the quality and efficiency of hospital admissions, so patients dont have to waste time filling multiple forms. A patient response to acknowledge patient readiness, including receiving necessary forms and consents, increases patient involvement and improves the hospitals efficiency
• 2. Patient-specific education materials and self-management learning programs: When a clinician sends the patient an information prescription or self-management program, it is important to know if the information or program is making a difference. If requested, patient response provides information back to the record regarding:
  
  
  • Whether the material was read;
  • Whether the program was completed; and
  • What self-care actions were started or planned.
  
  Patient response allows the physician to appreciate successes, empathize with struggles, and provide motivation for additional efforts.
• Patient decision aids: Shared decision making has been shown to improve patient outcomes and satisfaction while lowering costs. However, the value of a patients use of a decision aid is diminished if patient insights gained from the decision aid never get back to the physician. With patient response, physicians can quickly assess if the patient is ready to make the treatment decision and what patient preferences and concerns should be considered in the decision process.
• Medication and preventive services adherence: Patient response helps the physician know if and why a patient has either not filled or not taken a prescription medication. It also allows for fast, structured reporting of symptoms related to drug interactions or reactions. Without learning why a patient is not taking a prescribed drug, a clinician has little chance of achieving adherence. Patient response to preventive service reminders can also alert clinicians about why they are declined and whether additional information is needed.
• Advance care planning: Advance directives are another form of a patient response. By implementing advance directives using patient-response standards, this documentation becomes more accessible to the patient, more available to the clinician, and more easily transferred to those who have a need to know them.

Patient response implemented across a spectrum of uses such as those described above will enhance the doctor-patient partnership while encouraging patient inputs to a shared care plan. And with a bit of creative thinking, we can motivate higher degrees of patient accountability by tracking patient responses.

Patient response and quality

Patient response supports quality initiatives in many areas of policy, reform, and health improvement. Consistent with the governments Partnership for Care initiative to provide better care at lower costs, patient response provides a concrete way to bring together patients and their caregivers. Patient response can validate that the patients and their families understand how to be safe from hospital-acquired diseases; that the care plans are understood; and that instructions given to patients are acted upon as they transition between care settings and home.

Standardizing patient response

To maximize mainstream adoption, the existing HL7 technology standards and interoperability framework must be enhanced to integrate patient response into the clinicians current workflow. The case for building on existing standards is a strong one:

• Ease of integration: Contextually aware, patient-specific data is already available and easily transitioned to incorporate patient response.
• Existing practice: Orders, observations, and results are already widely adopted and familiar. They are easily enhanced to incorporate patient response.
• Mapped to episodes of care: Just as medical test results are matched to a specific episode of care, the information prescription and corresponding patient response can be matched as well.
• Automated analysis and flagging: Automated analysis and flagging will make patient response an added blessing to the workflow of a clinician. A quick glance at the flagged responses will tell much of the patients story that is now available only through extended conversation well beyond todays workflow limits.

At last, a reason for the public to embrace EMRs

Conclusion

At this point, patient response is just a gleam in the eyes of a handful of healthcare innovators. However, the path from idea to reality can be travelled quickly. It took less than 10 years from the publication of Information Therapy to the publishing of the meaningful use rules that took information prescriptions mainstream. And now that Information Therapy has paved the way for patient response, its road can be travelled far more quickly.

To make this happen, work is needed in three areas:

1. Standards enhancement: People who have HL7 standards experience can join in an effort to modify existing standards to allow for the new functionality of patient response.
2. Policy development: People who have the ear of the government can promote the value of patient response as being essential to real meaningful use; patient-centered care; and the triple aim of better care, better health, and lower cost.
3. Application development: People who have an interest in each of the cases described above can develop and test applications that can be integrated into EMR systems to achieve breakthroughs in the evolution of accountable care.

If we want patients to behave as empowered partners in their own healthcare, we need to respect them. Patient response is a great tool that allows patients to speak up . and doctors to listen!