Do You Have Any Questions? 5/30/12

I mentioned in my last post a new pocket EKG that connects wirelessly to NFC-enabled devices such as smart phones and tablets. NFC is Near Field Communication. NFC is not that widely used in the US, though its use is increasing. Reader Chris Wasden posted a comment that inexpensive add-ons are available to NFC-enable any smart phone. I was not aware of that. You need a reason to buy one and I don’t have that reason yet, but it’s good to know.

Last week and the week before I wrote about engaging patients at the point of care (POC). It’s a big topic and one I’m not sure I fully dug into, at least to get my point across. Today I’m writing about a related topic: do we want patients to be able to ask informed and pointed questions at the POC?

Away from the point of care, people see the value in helping patients ask questions and find answers. HealthTap, ShareCare, Patient Communicator, and Meddik have slightly different angles on how to do this. I can also think of countless initiatives (Direct, HIEs, etc.) and companies (Avado, MedSeek, Microsoft, Quest Diagnostics, etc.) seeking to provide patients with access to accurate and timely medical records, again, not at the point of care.

Combining access to medical records with forums that make asking questions and finding answers simple is a powerful combination for engaging patients, preventing errors, maximizing the value of patient and physician time at the POC, and ultimately improving outcomes.

In the virtual setting (away from the POC), the combination of timely information and ease of asking questions has several potentially good financial models: eyeballs/ads, reduced overhead from redirected patient calls, and preventing office and ED visits simple questions. Because of the revenue model, almost all the companies I listed above are funded startups poised to grow fast, fail fast, or be acquired fast.

If informed, connected, and presumably engaged patients are so valuable away from the POC, then why aren’t we fully informing and engaging them at the POC for the same benefits (minus a couple of financial ones?) For this post, I’m talking about inpatients and not the ambulatory side of the system.

Patients are often asked at the conclusion of rounds or a meeting with medical team, "Do you have any questions?" If the patient wants a clarification or has a burning question, this is the time to ask before the medical team moves on to the next patient.

The problem is that being an impatient is not terribly informing or empowering. Asking the right questions is a challenge, even if you have a good grasp of the health system and your condition.

Maybe we should start giving patients more timely and complete information about their care at the point of care. Help them more actively participate in the process.

Clinicians and hospitals might not want to do this. Care is evolving, and records or procedures or med schedules for the day might not be the same after morning labs. Clinicians might get inundated with questions. Nurses and staff might be constantly passing along questions.

What are the potential gains from providing patients with up-to-date records and med lists?

The first, though high level and hard to quantify, is moving patients and family toward becoming active members of the care team. This is what we want from patients and families, so we might as well start integrating that concept into all aspects of care.

The second is consistency. Medicine–hospital medicine in particular — is all about handoffs. I can’t remember the exact number, but patients are handed off from physician to physician several times each day (even more at academic centers) and at each nurse sign-out. Patients and families are a consistent presence — they don’t get to hand off.

The third potential benefit is that the patient — by nature of being informed, consistent, and asking questions — might actually help catch errors before they occur. Maybe they ask, "Why am I getting two of these pills today and not one like yesterday?" It’s a simple question that might not indicate an error, but is probably still a question that is worth answering. If that or any other question triggers a second look or a follow-up that prevents an error, that’s a pretty big upside.

This is high level and not specific. We should start by choosing information that’s readily available and exportable (such as like med lists) and providing it to patients daily. Maybe we can integrate it into TVs or iPads down the road, but we could start with paper to test the theory. It’s probably necessary to start by using a nurse or patient navigator/manager to help the patient understand what info are getting and why they are getting it.

From this point, see if patients like it and use it. Check to see if clinicians like it.

I’m curious to know what hospital clinicians think. Should we be helping patients ask better questions at the POC?


Travis Good is an MD/MBA involved with health IT startups. More about me.

  • Greg Park

    This is the one million dollar question. How do providers encourage consumers to take a proactive role in the delivery of healthcare services.

    Perhaps this is answered through other services where we are very involved. Banking, car purchasing, vacations, home purchases and life insurance all have a common element within that drives our deep involvement.

    In these situations we are the direct consumer of services. There are no third parties paying the differences and the cost for services are clear.

    In healthcare we hand the reigns over to our physicians and trust in the best outcomes. We are passengers in the journey that is our healthcare and we must become the drivers.

    Nothing drives change in attitudes like skin in the game. With more and more money coming directly from our pockets in increased deductables and coinsurances, our skin is getting deeper in the game.

  • Kelly O’Rear

    I agree with all of the potential gains you list, Travis, and as a patient I really do not see any downside to being equipped with up-to-date personal health information at the POC. Perhaps I am in the minority; I do believe many patients would rather just take their doctors orders and take their meds without a second thought. But hopefully, there is a growing trend to take your health (and healthcare) into your own hands and to work with and question your care team (not just accept what they say without any thought). Working with your physician(s) should yield much better long term results than simply taking orders without thought or question.

    I have the privilege of working with physicians in the hospital and on the flipside, I do think there might be some concern from doctors on sharing and engaging patients at the POC. It certainly takes more time – more time to sit and listen to questions and then explain facts and options (and likely explain some more). As a busy rounding doctor, it would be easier to just see your patients, write your orders and move on with your day. But again, hopefully there is a growing trend where physicians will take more responsibility in engaging their patients, in encouraging them to question and to get activley involved in their own care.

  • Anonymous

    I’m a hospital based psychiatrist and we work to educate our patients about topics such as medications. Our nursing, social work and activities therapy staff also work extremely hard to make sure that patients understand their medications, the ways that they are supposed to take them and the importance of continuing them after discharge.

    Despite this, providing a daily medication list would be a huge problem. Our hospital EHR (from a commercial vendor) has an extremely confusing medication list display and it’s easier for us to simply write out the medication list by hand. We typically make it into a chart so patients can check off when they’ve received their medication each day and learn what meds they get at various times. (Unfortunately, the hospital formulary items don’t always coincide with the outpatient formulary so this can be confusing to patients.)

    As Kelly notes, however, many patients are not interested in becoming engaged in their own care, despite our efforts. And some reject treatment entirely due to poor insight or psychotic beliefs (e.g., that food or medications are poisonous).

    Another difference on our floor is that our patients are encouraged to leave their rooms, attend activities and socialize with the other patients on the unit. The implications of this in terms of questions are that we are frequently asked things outside of rounds. Patients wait by the door to ask questions when we enter or leave the unit or they go to the nursing station desk to have questions transmitted to staff. Sometimes this is time consuming but it also gives us a chance to know what patients’ concerns are. (We also encourage them to write down their questions over the course of the day, so we can be sure to address them on rounds. And we have journaling notebooks to hand out if patients lack their own paper.)

    If this relatively small amount of my time keeps a patient from relapsing and having to return to the hospital, and also helps them move forward with their lives in a more independent fashion, I see it as well worth the investment.

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