I’ve spent the last two days in a huge planning conference for Ascension Health, a Catholic multi-system (or multi-Ministry) chain that’s looking to transform its future. In fact they have a huge ongoing project they term their Call to Action and they have a system wide commitment to providing Health Care That’s Safe, that Works and that Leaves No One Behind. It’s a very ambitious program, and it’s great to see a provider system do something big and proactive. One arena that they are looking at transforming is their relations with consumers. I spent yesterday with a group of hospital marketing folks who essentially admitted that their organizations have not to this point made the patient experience their hospital’s central priority. And that is pretty typical of hospitals and providers across the country. For this system at least, that is going to change over the coming months and years.

This is not to say that the folks in the room don’t have shining examples of great patient-centered programs in their own facilities. One example is the Breast Cancer Center at St Agnes, Baltimore which provides a dedicated nurse to each patient to work as their advocate, and also puts together an immediate cross-specialty team to give each patient and their family the full range of information about available treatment choices. Longer-term observers of the health care scene may recall the experience of Andy Grove, then CEO of Intel, when as a newly diagnosed prostate cancer patient had to traipse around visiting multiple physicians, none of whom could give him accurate information about the relative likely outcomes of the procedures they offered.

Well as the WSJ’s Informed Patient column reported yesterday (sub req’d) there’s a new report out from a conference on Disease Management Outcomes sponsored by Johns Hopkins and American Healthways on the patient-physician relationship. Many of the informed consumer issues are reflected and it’s worth reading the full report. Here’s the executive summary/recommendations:

1. All parties should acknowledge patients as most knowledgeable about their symptoms, and patient self-assessments should guide the nature and timing of both the physician’s response and of scheduled visits.

2. Patients should recognize the importance of providing feedback for improving their care. Physicians and their offices should welcome patient feedback and establish safe ways that patients can provide it.

3. Physicians should implement a social questionnaire as part of the initial intake, allowing the patient to communicate essential, non-medical information about their lives. This information should be integrated into ongoing care. Information captured on the social questionnaire should include: marital status and/or significant others, education and occupation, hobbies, religious preference, preferred methods of communication and the patient’s preferred level of involvement in health care decisions. Understanding what makes each patient unique can help personalize care and reduce the risk of misunderstanding, error or loss of rapport.

4. Physicians and support staff must recognize the role of patients’ gender, age, race and religion in their treatment and ongoing care.

5. Delivering traumatic news to the patient demands that physicians find an appropriate environment with adequate time and ample consideration for the concerns of the patient, family and/or advocate.

6. Physicians must respect and incorporate the patient’s designated advocate into the care relationship. Patient advocates, caregivers and family members should be present when appropriate, so that their roles are integrated into the care plan from its outset. In recognizing the legitimate role of advocates and caregivers, physicians should be prepared to fully discuss (1) limitations imposed on their participation by privacy laws and other statutory and regulatory requirements and (2) how other legal instruments (such as durable powers of attorney, living wills and advance directives) may enhance their roles.

7. Physicians are responsible for providing current, scientifically based “best medical practices” in an ethical and timely fashion. They should instruct patients on benefits and risks and inform them of all reasonable diagnostic and therapeutic options, even if an option isn’t covered by insurance or requires referral to another physician.

8. Patients should seek–and physicians should promote–active, collaborative discussions with patients. They should take care to express medical information in laypersons’ terms to ensure full comprehension by patients. The
stresses of illness can impair a patient’s ability to absorb details of the visit. Effective physicians summarize their recommendations and assess patients’ (and/or their advocates’) level of understanding, leaving time for additional
clarification.

9. The patient-physician relationship must mirror our daily lives by relying on methods of communication that are not limited to inflexible, one-on-one visits but may include e-mail and phone communication, disease management
services, Internet access, written or verbal agreements, group visits and universal medical records that are accessible at the point of care.

OUTCOMES
The outcomes we expect from improving patient-physician communication include:
–Improved patient adherence to recommended therapies
–Improved patient self-care
–Improved comprehension of information given by the physician
–Increased patient satisfaction and more word-of-mouth referrals from happy, established patients to potential
new patients
–Increased physician satisfaction
–Improved capacity for physicians to see patients as whole persons, rather than diseases or organ systems
–Improved ability for patients to see physicians as people who also want and need mutually satisfying, therapeutic
relationships and are doing their very best to help patients

By any stretch of the imagination this is an ambitious set of goals. But nothing on this list is impossible, and if it’s all implemented successfully, those outcomes (and they are not purely clinical outcomes) will be the reward. Of course, as the group I met with yesterday acknowledges, health care organizations need to make some big changes to accomplish these goals.

The San Francisco chronicle had a couple of interesting pieces that I read on the plane east this morning.  The first was an interview with Robert Wachter about his new book Internal Bleeding. He has a lot of sensible opinions that are mainstream in the Quality movement, but are yet to really make it into public consciousness.

The reason he’s getting good press is because the book tell stories.  A "fun" one is this about a physician’s poor hand writing causing a little problem. The prescription is reprinted in the book

We asked 159 physicians to look at the handwritten prescription. Half thought it was for Plendil, a calcium channel-blocker; a third said Isordil, a longer-lasting version of nitroglycerine taken for angina; and others thought it was Zestril, a blood pressure medication. We reproduced the prescription in our book. … Take a look. What do you see?

Plendil.

Wachter: You would have killed the patient. The prescription was for Isordil, but the pharmacist thought it said Plendil. The daily dosage for Isordil is 80 milligrams; for Plendil, 10 milligrams. The pharmacist read Plendil, the patient took 80 milligrams. He had an eightfold overdose.

(The patient, Ramon Vasquez, suffered a severe drop in blood pressure, and 24 hours after starting the regimen had a massive heart attack. He died several days later. A jury awarded his widow $450,000.)

Maybe if word gets around we might find some progress on the eRx issue, but recall that this case was in 1991 (or at least that’s what it said in the dead tree edition–edited for space in the electronic version).