With all the things our patients have to do to get and keep themselves healthy, I'm struck over and over again by how inefficient we are, how low the rates of getting these really important things done for them ends up being.
Over and over again, we as providers get reports on rates of certain screening and health maintenance items that are being done for patients across our practice. We learn about how many patients are missing recommended colon cancer screening, breast cancer screening, vaccines, disease-specific interventions, and so much more. That even includes things like healthcare proxies and living wills -- incredibly valuable end-of-life tools and instruments that can help our patients get the care they need and avoid things they definitely do not want.
Building a Smarter System
Perhaps it's time, since we've been unable to move the needle on these things for so long (partly because we are so overwhelmed and burned out in the system we have now) that we flip things on their head. Instead of just a reminder in the electronic medical record, one that the patient sees when they log on when they're trying to do something else, or instead of a "best practice" alert that pops up for us that tells us that our patients are overdue for something, maybe we can build a smarter system.
I know that for almost all of these things, if we all had the time (and we know we don't) we would get to all of these things; we would engage our patients in a meaningful and heartfelt discussion about all these items and figure out what was right for them at this moment, at this point in their lives. But far too often in our brief visits with patients they have a series of issues that they need to address, and we often have an agenda that conflicts with theirs, sometimes for the better, sometimes for the worse. Wouldn't it be better if we can help design a system that ran autonomously, that churned away in the background helping patients get the care they need?
I'm reminded of the system in place in Finland, where under a national healthcare plan every woman of a certain age is invited in for a regularly scheduled Pap smear. This is an active process -- one that requires action on the patient's part, but much less effort to get it started on the side of the healthcare team. Patients apparently appreciate this outreach, understand that this is something important they need to do, and with the assistance of multiple navigators built into the process, women in Finland accomplish these screening exams at an incredibly high rate. This fairly simple national intervention has resulted in a dramatic decrease in the incidence of cervical cancer and cervical cancer deaths in that country.
Wouldn't it be amazing if we could apply this sort of smart system to everything our patients need?
Sometimes I have very engaged patients who, after logging onto the portal to request a refill of their cholesterol medicine, will "by the way" send me an additional message that says, "I noticed that the system says I'm overdue for a shingles vaccine and a tetanus booster. How can I get these done?" Sure, much of this could wait until they come in for an office visit, but having an intelligent active system working on these things with the patients, and with the providers, might be a better solution. Strike while the iron is hot.
Start With a Message to the Patient
I can foresee a system where a patient gets a message from their doctor's office that says, "It looks like you are due for your (insert screening or healthcare maintenance item here). How can we help you get this done?" If the patient says they need to know more about it, that they would like some more information before deciding, we could direct them to clearly written patient information that would help them get to an informed decision about whether or not to proceed -- great information on the reasoning for why this intervention may be right for them, all the risks, benefits, and alternatives, maybe even some comments from their personal doctor about why we think this is so great for them to get it done.
Once they've decided, they can click "yes" or "no". Clicking "no" would lead to the item being marked as (temporarily) deferred by the patient within our system and maybe lead to a future discussion during an office visit, or even maybe a way for the system to re-address with them later if they've had further thoughts or would like more information. If they click "yes", we should have a smooth system in place that just helps this get done.
For example, suppose they decided they want to get a shingles vaccine. Once they've clicked "yes" to this vaccine recommendation, the system could send me a queued-up order for them that I simply sign. All the right codes would be entered, the patient would be queried about where they'd like to get it done, either the pharmacy or in some other location -- for some reason, our hospital simply will not carry the shingles vaccine in our practice -- and then the system could possibly even coordinate an appointment time with the pharmacy. Then the system could electronically report to us that the vaccine had been administered, satisfying the health maintenance field within the electronic medical record.
If the patient is due for their mammogram and they are ready to do it, there shouldn't be a need for a lot of electronic messages back and forth between the patient and radiology. It should simply result in a queued-up task for me to sign, a screening bilateral mammogram order with the correct diagnosis code of breast cancer screening, already sent to their insurance company for approval, then the patient can coordinate an appointment time with radiology. And again, once it's done, it comes back into the system with the results. If it's normal, that satisfies the health maintenance modifiers in the system. If it's not normal, then perhaps we can build in sophisticated pathways to take us down the next steps of diagnostic imaging and testing needed.
But let's not get ahead of ourselves just yet. A lot of the necessary follow-up could be done with electronic systems that are smart enough to figure out what to do next, based on rules we will give it, but some of this ultimately may need a human touch, navigators and community-based organizers helping patients coordinate getting these things done. However, I do think we have a powerful enough system already in place that should be able to help build these modules onto what we already have.
Extending the Model
For all the years I've been doing this, I've seen reports generated by insurance companies and by the practice itself that show that we're not getting all our patients all they need. Perhaps it's time to accept that the model we have of trying to take care of all of this during a very brief office visit is just not enough, is never going to cut it. It's never going to overcome the inequities and the access issues that so often stand in our patient's way.
But if we can fix this -- and if we can do it for vaccines, health maintenance items, and even disease-specific interventions like annual ophthalmology visits for people with diabetes, then maybe we can extend this out and go on to create more and more systems to help patients get control of their medical conditions. Think of a future where a patient with hypertension gets started on a medication in our office, and then things get handed over to the system that helps them monitor their blood pressure, and perhaps even dose-escalate in response to home readings on pathways we design. A person with diabetes could have their oral medications or insulin dose titrated up or down based on glucose readings from a continuous glucose monitor they wear at home that connects back into the system we have.
This would go a long way to creating a more engaged system, more empowered and informed patients, and help these patients get all they need to get and stay healthier, while not just simply dumping this all back on the overworked and overburdened healthcare system we have right now.
The possibilities are endless, while our time is not.