Building a Better Health Care System: Patient-Friendly Orders

Here’s another technically easy and culturally hard product: Patient Friendly Orders.

My version of this idea was born when I was admitted to the hospital for pneumonia about 5 years ago.  Even though I had previously worked in that hospital, the quality of communication about my care between the patient and the medical team was poor.  This got me thinking…

There should be a touchscreen by my bed that lists all the current doctors’ orders.

They’re not hidden in the chart.  They’re not explained only in ephemeral conversations that occurred without me present.  And of course, if they’re in front of me, they’re going to have to get written in English.

Let’s organize the orders, too.  Imagine a loved one is hospitalized for a severe skin infection which also caused his diabetes to get way out of control.  He has difficulty sleeping in the hospital and also needs pain control.  All the orders — whether for diabetes, infection, sleep, or pain — are organized according to the problem they address.  (While doctors’notes are generally organized by problem, their orders are not.  I bet if we implemented Patient Friendly Orders, they’d be useful for doctors if only just for this reason.)

When the doctor or nurse or physical therapist comes in, the patient and family can have a conversation about the current plan, with that plan laid out in front of them.  They make a shared decision, and the doctor can update the plan on the same touchscreen.  “Sounds like a plan,” the patient says while actually looking at it.  When you visit your loved one, he can show you the plan, too.  If a question comes up about a given order, or why something is missing from the plan, you can make a note on the touchscreen so the medical team knows to address it when they next come by.

What about all the loved ones who can’t be in the room, the patient’s broader community?  When I was in the hospital with pneumonia, for example, I wish I could have tweeted: “Switched from ceftriaxone plus doxycycline to zosyn. Does that make sense?”  This of course raises important questions.  Certainly, any such broadcast requires truly informed consent of the patient.  I don’t think such a tweet would violate my doctor’s privacy assuming I don’t mention him or her by name.  It would be fascinating to understand what a doctor might think: “Switching to zosyn — oh [bleep], what are they going to say on Twitter?”

Is that a bad thing?  I suspect the good would outweigh the bad.

But more important, it’s a conversation the patient and his or her loved ones must be allowed to have with their community.  Indeed, we’ve probably all been a part of conversations about whether someone we care about is getting the right care.  It’s just time the patient’s medical team and the patient’s community can be part of the same conversation.

Roni Zeiger is a physician and entrepreneur based in the Bay Area.  Most recently  he served as Google’s chief health strategist, leading the company’s efforts in health search and  related health care projects. He can be followed on twitter at @rzeiger and on his blog, where this post first appeared.

28 replies »

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  2. Most patients do have the ability to access the best doctors, however history tells us that ability won’t always translate into motivation & action. However, with an EMR such as that offered by Health2Me (for those of you who haven’t seen this, the platform is quite simply phenomenal & 99% dummy proof) it would change the scope of this entire conversation and thread. Look for this cutting edge EMR to revolutionize patient access to medical records on a global scale.

  3. I would like to respond to this thread from the perspective of a patient, as well as a medical social worker.
    *I very strongly believe, as Shirie Leng, MD, noted that communication in medical settings MUST improve. It must improve Between the team itself and WITH the patient and family. It must because this is right. It must because this is respectful. It must because this is most efficient. It must becuase this is most effective.
    *I have large concerns about the role of patient access to charts for many reasons: cost, confusion and disagreements amongst staff that can be confusion or upsetting to patients, looking at a list of orders does not really provide enough info to most people, potential for confusion, upset and anger due to misinterpreation due to lack of knowledge.
    *As a person concerned with family dynamics, social issues and issues of abuse and neglect, not being able to candidly and clearly address these in the chart would be inappropriate and unnessarily prohibit good care, but would certainly happen if access to all charts became open.
    *Lastly, though I suspect Determined and I have wildly different political views, I do agree that the culture of dictating medical treatment to providers has gotten out of hand. I may work in a medical environment, but I am not a doctor. I trust my doctors to use their expertise to help me when I am ill. The current problem of drug resistant organisms is partly due to patients who demand antibiotics, even when not warranted, becuase they think they know better and providers who give them for the sake of appeasement. Unfortunately, letting patients dictate their whole course is dangerous. However, patients, I believe have become this demanding due to long standing lack of communication from the medical team, which leaves them feeling confused, belittled and left out of their care.

  4. Wow. Some vitriol going on about this post. I think patient/doctor communication in hospitals has to improve. It just has to. This is not to threaten doctors’ authority but to give the patient some kind of understanding of what’s going on. It’s their disease. They are the ones living it. I am the last person on earth to be touchy-feely, but anger, frustration, and ignorance lead to bad outcomes and lawsuits. The writer of the post has an interesting idea of how to facilitate this communication. I’m not sure broadcasting things into the larger community is such a great idea for a host of legal and privacy reasons, but a beside guide of some kind would be great.

  5. Thanks for illustrating exactly why the business model FAILS health care.

    No, I don’t work FOR you, I work with you and give you my best expertise how to navigate care and help you help yourself. Jeez, you business manipulators really think patients are now solely customers, and your pathetic adage of “the customer is always right” is the only application to health care. And what the hell is this trust issue, I doubt strongly you have ever been my patient, and if you have and understand the philosophy that I was trained to provide care, you either wouldn’t make such ludicrous statements as above, or, you would tell me to shove it the first time I would challenge your “customer” philosophy with me and go find someone else to serve you.

    Just to remind readers here who are trying to figure out what the health care system is really about in a responsible, effective manner, it starts with clarifying the physician-PATIENT relationship. If you want the business-customer relationship, let’s start by ending the concept of medical school and just rename them “Biological Correctional Training Facilities”.

    Works perfect for your king Barry O and his minions who want to end health care as a profession and make it another element of the Leftist agenda. Sorry, Docs like me who learned it the right way will not be sucker punched further into submission by this business dogma.

    Oh, and civisisus, you’re fired!

  6. “Determined” to what, exactly? Tell us how YOU are at the center of health care, rather than people – who just happen to be patients at the time Almighty YOU come on scene?

    You work for ME, DeterminedMD – get used to it. Persuade me and other people I trust that you’re doing no harm, for starters. Because I don’t trust you enough. Not any more.

  7. 1) People willing and able to use the internet will look at the orders. Most people will not. The very large percentage of my elderly pts wont understand them if they read them.

    2) Who pays for this and how?

    3) I have not seen any EMR that could do this reliably. I tend to think people extolling EMRs dont really have to use them. Every hospital in my area is on at least their third iteration of an EMR. Why cant they have real working doctors test these things?


  8. True. But it occurs to me that all these mammoth inpatient EMRs have ambulatory products that can and often do show the same type of information in portals. I bet it would take a couple of days to port this to inpatient…. if their hospital clients are willing to pay for it, of course….

  9. The road to hell is paved with good intentions. Tell us all how wonderful it is patients are coming in and telling us what their diagnosis and treatment needs are, after reading up on their own on the internet.

    Yeah, go along with what the patient suggests, real good care plan. No one here is arguing that patients should be educated and up to date on their treatment needs, especially if hospitalized. The problems are moreso that other ancillary care staff and consultants coming onto the patient’s case are up to date and aware of limits and appropriate needs. And let’s have a moment of brutal candor here, what percentage of patients are going to be able to fully understand and be able to dialogue about their treatment needs? What, 50%, 60, 40, other number?

    The people who dialogue here have better cognitive skills and abilities to discern medical information, just blindly applying it to the general population is naive at best, clueless further down, and I have to offer, trying to shackle doctors even further?

    Care can be better, no argument from me. Just turning it into a touch screen care process, well, good luck with that!

  10. It seems self-evident to me that granting patients in hospitals real-time access to accurate information about their orders and medications would improve their care. I’m puzzled and surprised that this common-sense idea generated such heat, even anger, on this site.

    As a patient and as a family caregiver, I can see a myriad of ways in which in-patients would benefit from accurate knowledge. Errors could be caught. Alternative treatment methods could be considered. Some patients would adjust pain meds that are in their control better if they can readily know what they’ve been taking. Patients could be included in analyzing their own possible diagnoses and making treatment decisions when such are unclear.

    For example, once I was hospitalized with a very unusual infection that wasn’t responding to antibiotics. Difficult choices had to be made about which to pursue next, given that I was getting worse and time was getting short. My infectious disease doctors at UNC were outstanding about including me openly in their discussions, even their internal disagreements, about which course to pursue next. In the end, it was their decision, not mine, but I was informed and involved, and they also welcomed input from my external doctor friends. All that said, there was no bedside record, let alone internet access, so of course, it was up to me – in a very sick state – to try to scribble down correct spellings of medical terms and keep track of it. all. Having an accurate record at my fingertips would have been quite helpful.

    The critics here are missing the point about the touchscreen at the bedside. The technology used is irrelevant – even a paper copy spit out by an EHR would be fine, provided it is current and accurate.

    One more point – other professionals DO have to keep their clients and customers closely informed about how they “do their jobs.” In fact, lawyers have to fulfill strict legal mandates about how to inform clients (and failing to properly inform clients is grounds for Bar sanctions, as well as malpractice lawsuits). As with medicine, some clients want more detail, others less – but the point is that the clients (patients) have to come first, and if they want more information and involvement with their own legal matters (treatment), they should be entitled to it.

  11. I think that this indeed is a right approach. Being more transparent with the patients and carefully explaining every detail will further help in enhancing patient-doctor relationships

  12. Speaking without knowledge of the project, I will go out on a limb and venture a guess that what they are building will likely be a good bit better than Siri or Bonzi Buddy.

  13. OMG, are you kidding me? Try some user friendly orders and EMR systems for the doctors. What an experiment! No consent, no IRB, nothing. The IT experiments are being run by madmen, mesmerized by the greenback, but not by patient care and safety.

  14. Maybe because having someone dissent from the usual failed agenda may give some fair and balanced readers some idea that health care is not JUST what the patient WANTS, but what treatment NEEDS.

    Notice the words PROFIT and FINANCIAL GAIN aren’t part of that agenda.

    Again, do those of you preaching this patient driven agenda of setting the health care precedence expect this in other professional realms? Do you really tell your lawyers/accountants/plumbers/mechanics/etc how to do their jobs?!

    Certainly can’t tell your politicians how do to their job. And to think they allegedly not only represent you, but, you are the constituency, so that is your f—–g job to do exactly that! Boy, they listened to you well when concocting this bs legislation PPACA.


  15. And what is stopping the educated patient from logging into the patient portal and seeing all those things on his/her touchscreen tablet? Are hospitals not allowing Internet access? If so, that’s a different problem….
    Not sure what EMR they used 5 years ago, but good EMRs have portals and have a diagnosis associated with each order including meds. This shouldn’t be just a hope, since it is perfectly doable with very little effort.

  16. Hi rbaer, I’m actually not selling a product related to the Patient Friendly Orders idea. It’s just something I want to see happen. I have been approached by potential collaborators, so maybe I will get to help bring this to fruition, but for now it’s just a hope.

  17. Sorry, I find this disingenuous for a doctor to advocate for himself to review his orders. Like 80% of the population would utilize this appropriately.

    Keep telling those lies and half truths folks here at the THCB.

    Fast forward to this future of patients dictating their care: can they sue themselves and get the providers guilty by association!?

  18. The problem is that not the entire treatment team is always on the same page, esp. when I deal (as specialist) with uncommon conditions. In the ideal world, all professionals would have extensive conferences bringing everyone on the same page … and in reality, such conferences are not always possible and some team members do not understand everything or have different ideas …

    … and apart from the fact that it is unclear how many patients and families are able and interested in reviewing orders, of course there is conflict of interest here. “There should be a touchscreen by my bed that lists all the current doctors’ orders.” Why, Dr. Zeiger does not happen to work on similar devices, does he? I am a woodcarver and think that the availability of woodcarved objects would revolutionize the healing process. Wait for my post at THCB next week.

  19. I have been patient advocate for elderly and patient myself.

    More often than not, physicians expect patients to walk in lock-step with the medical system. Hospital generalists (hospitalizes) that I have encountered refuse to communicate, cooperate or even coordinate health care with the patient’s pcp. And that would be the pcp that recommended hospitalization.

    Hospitalists at Duke Hospital have told me that they are there to save the hospital money by triaging the patient and getting them out (especially the elderly). Hospitalists say talking with pcp or oncologist would “muddy the waters.” Result – quick readmissions, death.

    Transition and coordination of care are major problems when docs don’t talk to one another.

    And then as patient advocate, I am refused healthcare. It is like being blackballed.

    The healthcare system is imploding from within.

  20. Wow! Brilliant!

    Current CPOE is such a cesspool of waste and gibberish, chaotically mixed by vendor designed silos, anything like that would be a help, even for the doctors.

    However, they should beta test it on the doctors, first!

    I am sure Epic and Cerner would just love to run new code to make their devices user friendly.

  21. As a physician, I have to admit that my first inclination is to say this would cause too much confusion, need explanations, etc. But having helped care for family members in the hospital, I know how many communication errors happen and how much it helps when everyone is on the same page. I agree that the overall good would outweigh the potential issues.