Sunday, December 24, 2006

clinical innovations, size and structure, Twenty Clinical Innovations to Build Patient-Doctor Trust: Eleventh in a Series

On Health Care Size, Scale, and Structure

This essay is overly structured for this season of the year, but here goes anyway.

The importance of size, scale, and structure of health care organizations has always fascinated me.

In The Age of Discontinuity (Harper and Row, 1968), Peter F. Drucker observed,

“Today’s society is pluralistic. Every single social task of importance today is entrusted to a large institution organized for perpetuity and run by managers. Where the assumptions that govern what we expect and see are still those of the individualistic society of eighteenth century liberal theory, the reality that governs our behavior is that of organized, indeed, over-organized, power concentrations.”

Big organizations dominate health care. Look at U.S. News and World Report’s annual list of top hospitals and specialties. Or read America’s Top Doctors. Most of the 3000 top specialists listed practice at academic medical centers. Power and prestige comes down to size, scale, and structure. Academic centers are large (over $1 billion in revenues), salary their specialists (in more than 30 different specialty departments), and have thousands of employees (5000 to 10,000 is common.)

Hospitals control care in most communities. There are 5000 hospitals in the U.S. Most have more than $10 million in revenues, are large employers, have marketing and outreach departments, and are structured hierarchies with everybody reporting to the CEO and the hospital board. Because of structure and size, hospitals have decided advantages over doctors, who often function as disorganized level democracies, with most partners having an equal say with veto power.

Big payers – Medicare and managed care plans – have the size, scale, and structure to call the tune for hospitals and doctors. CMS (Centers for Medicare and Medicaid) has the world’s fourth largest budget. CMS consumes roughly one-half of all U.S. health care spending.

The managed care industry, consisting of HMOs, PPOs, Point of Service Plans, and High Deductible Health Plans, covers nearly 200 million Americans . Blue Cross plans, which include Anthem, insure over 100 million Americans. Medicare and Medicare, covering about 95 million Americans, have size, sale, and structure of government on its side.

Managed care plans are mostly investor-driven, and usually possess a regional or nationwide corporate structure to keep in check (pun intended) hospitals and doctors. The United Health Group, a $80 billion operation, for example, has the AARP account, which the largest membership organization in America after the Catholic Church.

Everybody knows the big drug and device manufacturers are titans in Corporate America (Pfizer has revenues of $51 billion). These firms pervade every nook and cranny of the American health system. Together these manufacturers constitute the health care “supply chain,” the fastest growing segment of hospital costs, now making up 35% to 40% of hospital expenses in the form of stents, prostheses, drug formulary inventories, beds, intravenous fluids, sterilizing equipment, and countless other items required for modern care.

Everybody knows, or think they do, that large multispecialty or single specialty groups, the latter often existing as heart, lung, or eye “institutes, ” will grow and prevail in the future. After all, these physician organizations, sometimes in concert with hospitals and health systems, have size, scale, and structure to impose “enterprise-wide”, “standardized,” and “scalable” systems and solutions on physicians and suppliers. Moreover, large enterprises can demand “transparency” and “accountability.” By their very size and structure, they can employ management experts, deploy the latest technologies, and demand large discounts from suppliers.

Multispecialty clinics can work as management and clinical “teams” to bring order out of chaos. One of the more articulate spokesperson for this point of view is David Lawrence, MD, chairman emeritus for Kaiser Permanente (From Chaos to Care: The Promise of Team-Based Medicine, Perseus Publishing, 2002.)

Lawrence maintains doctors in solo of small groups simply can’t cut it when it comes to modern health care. Using the hypothetical example of a fictitious solo practitioner, Dr. Adam Landers, here is how Lawrence explains the dilemma of doctors in small practices.

“In spite of his motivations to be high-quality physicians, Dr. Landers can’t deliver on the promise of modern medical care. He lacks the time, the money, and the organization to do so. And he will fall further and further behind if he continues to practice as he does today. For the simple and routine illnesses, he provides a valuable service. But for more complex illnesses chronic conditions, neither he nor his colleagues in other solo and small group practices are prepared for what medicine now requires and patients demand. The forces are too strong and the changes too profound.”

In short, solo practitioners or those in small groups lack the size, structure, and scale to perform and compete. Well, maybe. Many of doctors in types of practices disagree. They believe they are closer to their patients, in human, neighborly, and personal terms, to deliver care patients want.

The countervailing view is that there are fewer complaints and mistakes among physicians in group practices. In Minnesota, where most doctors’ practice in large groups, Steven Altschuler, MD, President of the Minnesota Board of Medical Practice, says the reason for dropping number of complaints in Minnesota is: “We don’t practice in isolation anymore – the percentage of single-doctor practices in Minnesota is small.”

That may be, but many solo doctors feel that the Internet, and even their small size and proximity to patients, helps level the playing field between small and impersonal large groups. With the Internet and with physician websites, with links to all sorts of health care information site offering specific information on chronic and rare conditions, even small practices are part of a larger virtual world, operate on a larger scale, and create a new structures of practice.

The Web may erase the image of solo practitioners stuck in their offices – armed with nothing but a black bag, a cold stethoscope, a mirrors on their forehead, and nothing but an all-knowing good nurse Friday to assist them.

But, says Joseph Heyman, M.D., physicians who practice solo have to be on top of the latest technology to make solo practice work. Heyman, a gynecologist, runs his own practice in Amesbury, Massachusetts. where patients can ask for appointments and medications at his website. Heyman represents a breed of doctors who have left large practices, where overhead is high and autonomy is limited, to strike out on their own.

Since April 2001, he's maintained an electronic medical record and prescribed electronically. He runs a paperless office and does his own billing. With one employee, Heyman keeps costs down and makes a decent living. He also has more time to spend with patients.

Heyman and others are creating new business models and changing the structure of practice to survive and cut costs of care by minimizing administrative costs, which consume 30% to 50% of total health costs.

•Dr. Michael Stein of Homestead, New Hampshire, practices medicine with a small office, one employee (his wife), long appointments, and short waits. For $1,000 a year, patients get unlimited access to Stein and his care. Stein says by doing so, he has reduced his overhead from $350,000 to $50,000 a year.

•Dr. Robert Berry, a solo practitioner in Greenville, Tennessee, is president of the PATMOS (Payment at the Moment of Care) emergency clinics. He posts his prices in his front office, doesn’t deal with health plans, and says most of his clients are “insurance-free,” i.e, are uninsured.

•Dr. Vern Cherewatkeno, a family physician in Renton, Washington, co-founded SimpleCare, company now made up of hundreds of doctors across America dedicated to helping patients “gain control of health care payments and care.” SimpleCare charges for Short ($35), Medium ($65), and Long Visits ($95) visits. By using these three simple codes, rather than the usual 750 codes in primary care and dealing in cash only, SimpleCare claims it can cut medical costs by at least 50% for most patients.

As Drucker noted, Americans live in a pluralistic society. We still entrust most care to large organizations. But there is always room for small organizations, where consumers can find more choice and lower costs, and entrepreneurial physicians can find more satisfaction, if they are willing to change their practice structure by creating new practice models.

Merry Christmas. I won't be entering another blog until the New Year. Have a wonderful holliday. My best wishes for a prosperous and healthy New Year.

Richard L. Reece, MD

Saturday, December 23, 2006

clinical innovation, bottomup websites for transparency, Twenty Clinical Innovations to Build Patient-Doctor Trust: Tenth in a Series

“Tis The Season

The end-of-year holidays is the season for fierce fearless forecasting for next year.

Speaking of fierce forecasting, it is fitting that Fierce Health Care, a notable and quotable health care newsletter, has come out with its top five trend predictions for 2007.

1. Transparency takes center stage

“During 2006, employers, managed care plans, trade groups, state governments and federal agencies took a new and aggressive role in bringing pricing and outcomes data to the public, in many cases by posting aggregate hospital and physician data to publicly-accessible websites.”

This is a “top-down” forecast. It foretells those who pay will demand transparency from those who deliver care. Givers of care will have to cough up data to justify what they charge. Anybody with a transparent crystal ball knows much of this data will be transmitted via “publicly-accessible websites.”

One set of “bottom-up” websites not mentioned are physician practice websites. These are in the rise. No one knows how many doctor websites are out there, but probably 20% of doctors have websites, just as 20% have electronic health records. Medem, Inc, a San Francisco-based company supported by the AMA and seven leading specialty organizations, and other werb developers are making it easy for doctors to build these sites.

The websites are designed for transparency – how to get to the office, services offered, backgrounds of physicians, plans covered, and yes, in some case, prices charged. The idea is to market the practice by building trust through transparency expectations. Prices charged may soon become a common feature since managed care plans, led by Aetna, are already, in many sections of the country, posting physician charges on Aetna websites.

2. Universal health gains traction

“The drumbeat is getting louder: Massachusetts, Pennsylvania, Maryland, Illinois, San Francisco (and possibly California) took action on the issue of covering the uninsured this year, gaining traction for reforms that might have been shot down with comment a few years ago.”

Universal health is, of course, the quintessential top-down promise. With rising prices and turnover of control to Democrats, voices for universal health will grow shrill. Republican governors in Massachusetts and California supporting the movement will add to the clamor. But we are not there yet. There will be action at the state level but not the federal level. As I pointed out in my 2005 book Voices of Health Reform, the U.S. remains a conservative nation with deep distrust of centralized government and deeply embedded special interests. In the short and maybe even the long run, our desires for choice, competition, and enlightened consumerism may trump universalism. On the other hand, choosing between the two is not an either/or proposition.

3. Retail clinics shift care delivery assumptions

“The Minute Clinic that opened up across town may be too small and specialized to pose a direct threat to your facility…Most observers believe that the no-frills, high-convenience retail care delivery model began to have an impact on traditional providers in 2006, pushing consumers to expect cheaper, easier-to-access primary care than they were used to in the past.”

This is a superb example of “bottom-up” American entrepreneurialism and innovation at work. I commented on this at length in my December 21 blog and said, among other things, that there are signs physicians will soon get in this game. I foresee that hospitals and doctors, together and separately, will soon be opening retail clinics in local and national retail outlets, as marketing funnels to their main facilities.

4. Officials say "Prove It!" on charity care

“Over the past year, regulators kept up the pressure on voluntary hospitals to prove that they were providing a reasonable level of charity care. Not only did the IRS continue to scrutinize tax-exempt hospitals, state tax authorities and federal legislators got their licks in, too. Overall, over the past 12 months the hospital industry has taken a pounding on this issue.”

This issue is beyond my competence to comment upon, except to say the issue has been inflamed by outlandish bills by hospitals to the uninsured as a means of compensating for bad debt. These bills have aggravated the issue. This is issue is closely tied to the transparency issue, and you could look for Democrats to highlight the problem to show that they are four-square behind “reform” as a lead-in to the 2008 presidential election. Hospitals, and physicians, are likely to concentrate more on “consumer-friendly,” i.e. understandable medical bills.

5. Patients, employers choose overseas care

“If it costs $12,000 less and offers similar results, why not get your orthopedic surgery done in India? During the past year, some employers, and healthcare intermediaries like Raleigh, NC-based Indus health, have begun to encourage this line of thinking. Employers have played an important role in this trend, with some offering their employees hefty bonuses if they voluntarily agree to head overseas for expensive procedures.”

This is yet another example of a “bottom-up” revolt by consumers and the U.S. marketplace. The global marketplace and Internet accessible information are at work here. According to the National Coalition on Health Care, 500,000 Americans have gone abroad for dental care, cosmetic surgery, heart bypass, joint replacement, and other costly care. Favorite destinations are India, Thailand, Singapore, Costa Rica, and Malaysia. Bangkok’s Bumrungrad International Hospital counted 55,000 American patients. The New York Times published an article on the subject in its travel section (Jennifer Alsever, “Basking on the Beach, and Maybe on the Operating Table,” October 15. 2006), and cited these price comparisons by GlobalChoice Healthcare, in Albuquerque, coronary artery bypass, $75,536 in the United States but $11,438 in India; a $36,664 knee replacement versus $17,824 in Singapore.

A rich mix will always exist between top-down (government and big management) and bottom-up (consumers and markets) forces. There will always be thrust and counter-thrust between the two. This swing and counter-swing is a good thing. We need balancing forces.

Friday, December 22, 2006

clinical innovations, retail health clinics, Twenty Clinical Innovations to Build Patient-Doctor Trust: Ninth in a Series

How Should Doctors Respond to Retail Health Clinics?

How should doctors respond to retail health clinics? The number of these clinics is exploding in outlets at Wal-Marts, Walgreens, CVS drugstores, Bartell Drugs, Rite-Aids,and Publix grocery stores. 1

Should doctors wait and see if retail clinics, largely run by nurse practitioners and physician assistants, impact their practices? This may not be a bad strategy. After all, walk-in clinics in the 1980s and 1990s had little effect on traditional medical practices.

Should doctors take the position of the American Medical Association, expressing concern about quality, urging more oversight, recommending doctor supervision, and formal referral relationships with local physicians?2

Should doctors follow the lead of the American Academy of Family Physicians. The Academy recommends that retail health clinics have these “desired attributes” – limited scope of services, evidence-based and quality improvement protocols, collaborative relationships with local physicians, and electronic health systems that allow them to transfer patient data to local physicians.?3

Or should physicians take the bit between their teeth, set up retail health clinics on their own, enter the retail market place, and compete head-on with commercially backed clinics? 4

The last path is the one chosen by ProHealth Physicians, Inc., an organization of 200 primary care physicians, nurse practitioners, and physician assistants spread across Connecticut with corporate headquarters in Farmington, Connecticut. ProHealth opened its first clinic in July 2006, in Putnam, Connecticut at a Price Chopper grocery store, plans to open another clinic before the end of the year, and add 6 to 8 more outlets in the first half of 2007. 5 ProHealth Physicians researched its plans for more than a year before deciding to make its move.

Its executive director, Jack Reed, says, “We decided to go with the flow of the market rather than resist it. We will insist upon connections with local physicians who are part of our network. This kind of expansion is not for the faint-hearted. It takes new staffing, new administrative staffing, and new managers. It requires beefing up of privacy policies to handle issues new issues arising in off-site setting and learning how to operate in the retail space, which is different than anything we’ve done before.”

Reed and ProHealth Physicians sense the consumer landscape has changed, and consumers are looking for convenience, greater access to care in off-hours, and lower prices.

ProHealth Physicians may be just taking a hard look at a new reality. The consumer-driven revolution is at hand, and experienced entrepreneurs are moving fast to take advantage of windows of opportunity to expand retail health clinics as quickly as resources and the market will permit. 1

Backers and owners of these clinics project their numbers will grow exponentially over the next decade. The ACP Observer, a publication of the American College of Physicians, contains these projections.4

• MinuteClinic, acquired in June 2006 by the CVS Corporation, which has 6150 stores nationwide, now operates 117 stores and expects to have 250 by the end of 2006. The clinics are currently located in CVS stores, Bartell’s Drugs, QFC, and Cub Foods.

• Solantic Inc, now has 13 outlets in Florida, and anticipates growing to 1000 clinics in the next five years. Their outlets are now a mix of free-standing clinics and clinics located with Wal-Mart stores.

• RediClinics, owned by the Revolution Health Group, Inc., plans to expand from its present 75 locations to over 500 in the next three years. These clinics will be placed in Wal-Mart stores and other retail stores.

• Take Care Health, Inc. now located mostly in Walgreen drugstores, expect to go from 16 to 1400 clinics by 2009.

• Little Clinic, Inc, now in the process of opening five clinics in Publix grocery stores in Orlando, Florida, expects to expand to some of the other 884 Publix stores in the Southeastern United States.

Driving Forces

What is driving this unprecedented retail health phenomenon?

Well-heeled entrepreneurs perceive Americans are seeking legitimate , convenient, low cost care, in their neighborhoods and in retail malls in stores that are open for long hours.

The entrepreneurs include:

•Dr. Glenn Nelson of Minneapolis, surgeon and former senior executive at Medtronic, now serves at chairman of the board of MinuteClinic.

•Rick Scott, who was chief executive officer of the Health Corporation of America until 1997, founded Solantic in 2001.

•Steve Case, who co-founded American Online, left Time Warner in 2005, and put $500 million of his own money into the founding of Revolution Health, which promptly acquired Houston-based RediClinics.

•Hal Rosenthal, who sold his travel business to American Express, founded Take Care Health.1

What do these entrepreneurs share in common?

1)Business or personal experience in the health care arena.

2)Access to capital.

3) The ability to assemble corporate teams to expand, manage and market their new enterprises, in conjunction with established retail outlets who welcome the opportunity to attract more walk-in traffic, sell more prescription drugs, and co-pioneer a new vista in American health care.

As doctors watch these events, they should be aware that the American health system is uniquely innovative and entrepreneurial Here are the late Peter F. Drucker’s comments on the subject,

““The entrepreneurial economy is purely an American phenomenon. Innovation is the specific tool of entrepreneurs. There are fast-growing hospital chains. Even faster growing are ‘freestanding’ health facilities, such as hospices, medical and diagnostic laboratories, surgical centers, maternity homes, ‘walk-in’ clinics, centers for geriatric diagnosis and treatment.”6

The retail health clinic market is another American health phenomenon. This development may be an offspring of the growing consensus that the consumer driven revolution, which puts consumer choice at the center of the health system, is at hand. The Medicare Modernization Act, passed in December 1993, contained a provision that made health savings accounts potentially available to 250 million non-elderly Americans Health savings accounts have been growing slowly, and are now held by 4 million Americans, but their holders are expected to grow to perhaps 21 million by 2010 and will cover 40 to 45 million people. 7,8 The basic premise of HSAs that people spending their own money in from their own account and rolling over unspent HSA monies until the next year. will seek lower cost care.

In addition to the HSA population, there are 47 million uninsured Americans out there looking for convenient, lower cost care. The retail clinics report that 20 to 45% of the patients they see are uninsured. Clinic surveys also indicate that 20 to 40% of patient attending their clinics say they would have gone to emergency rooms had clinic care not been available and 10 to 20% said they would have gone without care entirely.4

One champion of retail health clinics is Uwe Reinhardt, the oft-quoted Princeton-based health economist known heretofore for his advocacy of a single-payer system. This is ironic because in the past Reinhardt has frowned on private and commercial sector care.

Here are some of Reinhardt’s remarks endorsing retail clinics.

“The American medical profession hasn’t made it particularly easy for even insured consumers to get access to them. It’s all on the doctor’s terms. Illness is not a nine-to-five affair.” 4

“Primary are is a neglected field in the United States, lagging other economically advanced countries. The clinics can teach the rest of our health system how primary care could be done and brought to the public."1

“Store chains, with their reputations on the line, will insist that the clinic maintain high standards and low error rates.”1

“That's the beauty of markets. They're forcing doctors, who've historically arranged the world to their convenience, to be more customer-friendly. They see the handwriting on the wall. It's taking patient demand to upgrade primary care in the United States.”9

“Doctors should ask, 'How can I compete with these clinics ? How have we failed the consumer to allow this gap to come about?' “Try not to control or patronize it. Cooperate with the clinics.. See if you can turn the trend. to your advantage. But don’t fight it; it’s a losing battle.” 4

So much for Reinhardt’s opinions. America’s primary care physicians will have to form their own opinions – and act on their beliefs.

Whatever happens it will not be easy for primary care doctors to depart from entrenched practice habits, organize a new business, enter the world of retail, collaborate with commercially-owned clinics, set up new communication and referral systems, and, in some instances, or learn how to capitalize, own, manage, and market their own retail clinics. It will take work – and courage.


1.Freudenheim, Milt. “Attention Shoppers: Low Prices on Shots in Clinic,” New York Times, May 14, 2006.
2.Chin, Tyler, “ On-Call Goes Retail: Defining the Doctors’ Role, “, September 11, 2006., American Academy of Family Physicians; Policy and Advocacy, Retail Health Clinics. Desirable Attributes of Retail Clinics, 2006.
4.Palmer, Ingrid, “Quick Clinics Find Niche in Health Market,” ACP Observer, American College of Physicians, October, 2006.
5.Reed, Jack, CEO of ProHealth Physicians, Inc., personal communication.
6.Drucker, Peter, Innovation and Entrepreneurship: Practice and Principles, Harper & Row, Publishers, New York, Grand Rapids, Philadelphia, St. Lois, San Francisco, London, Singapore, Sydney, Tokyo, Toronto, 1986.
7.Bloche, M, “Consumer-Directed Care,” New England Journal of Medicine, volume 355, pages 1756-1759, October 26, 2006.
8.ustreasury,gov, “Dramatic Growth of Health Savings Accounnts (HSAs).”

Thursday, December 21, 2006

clinical innovations, patient relationships at point of care, Twenty Clinical Innovations to Build Patient-Doctor Trust, Eighth in a Series:

Building Trust in Patient-Doctor Relations at the Point of Care, Eighth in a Series

From my perspective as a doctor,“innovation” is about seizing opportunities to do things better, differently, more cost-effectively, and more conveniently for patients. It is also about doctors controlling their own destiny from the “bottom-up,” from the point at which care is delivered rather than waiting for the government or other powerful health care payers to act. It is about doctors controlling their own destiny, rather than having others control that destiny.

My book Innovation-Driven Health Care contains this quote, with which I agree, from Donald Copeland, MD, a family physician in Cornelius, North Carolina:

“When I read about new types of innovative practices they all write about
same day access, better communication with patients, computerized medical
records, "medical homes," "team practices," use of non-physicians for routine care, but none write about the need to strengthen the doctor-patient relationship.

There is no other profession as personal as the medical profession. If physicians continue to allow non-physicians and businesses such as hospitals and insurance companies to control them. they will lose their patients and will be nothing more than over-educated hired technicians.”

There are many organizations dedicated to bringing innovation to the frontlines of care. Among these are:

•The Institute of Healthcare Improvement in Cambridge, Massachusetts. The Institute’s conferences and training sessions include web-based training to reduce waiting times, increase practice efficiency, implement quality improvement, assure reliable services, reduce hazards of prescribing, dispensing, and administering drugs; and creating “innovation communities” to reduce hospital mortality, improve flow through acute care units, emergency rooms, and perinatal units, and reduce surgical complications and hospital infections.

•The International Council for Quality Care in Boca Rotan, Florida. The Council works with hospitals with acquired physician practices. Its mission is to improve effectiveness, efficiency, and quality of these practices. The Council says it has a 30 year old database that allows it to identify 300 variables of practice success. It has benchmarked the ingredients of competitive superior practices and helps physicians introduce systems, subsystems, and processes to raise clinical quality, gain patient trust, and enjoy balanced personal lifestyles.

•The American Academy of Family Physicians in Kansas City, and the American College of Physicians in Philadelphia. These two organizations, representing family physicians and internists, which comprise most of the primary care physicians in America, advocate primary care practices as patient-centered "medical homes.” These homes should be based on patients’ continuous relationships with personal physicians to make care more effective, more efficient, and more equitable. The Academy and the College do not believe this can be done through physicians’ efforts alone. Improved care will require government to pay for more coordinated care, offer incentives to acquire electronic and personal health record systems, and reward physicians by paying for performance. Medicare recently made a step towards rewards primary care physicians by increasing whatit will pay physiciansin 2007 for counseling patients on preventive care.

The following text is from the American Academy of Family Practice’s 2006 web site. It is entitled “Tips on Building Doctor/Patient Relations,” and gives solid advice on the human dimensions of practice.

Demonstrate to your patients that you understand their situations and feelings by showing empathy during patient interviews. Empathetic communication is one of your most valued modalities and goes along way to ensure a trusting relationship between you and your patients. The following steps will strengthen your patient communication skills:

1. Seek to minimize distractions and interruptions when visiting with your patients. For example, try putting your beeper on a silent mode during your visit. Close a door if outside noise is a distraction. (However, ask your patient’s permission first.) Remember, too, that patients can offer you a great deal of insight into their condition just from what they tell you. So limit the number of times you ask questions or otherwise interrupt when your patients are presenting their chief complaints

2. Engage in active listening. Concentrate on what the patient is communicating verbally and nonverbally. Take into account both facts and emotions.

3. Be deliberate about the nonverbal cues you send. Lean forward, maintain eye contact, nod appropriately and don’t cross your arms.

4. Offer concrete feedback. When you summarize what you’ve heard, frame your responses by saying, and “Let me see if I have this right…” Seek to identify or clarify the patient’s feelings by saying “Tell me how you’re feeling about this” or “I have the sense that…”

5. Allow the patient to correct or add to your responses until he or she confirms your understanding – “Did I miss anything?” According to several sources, the effective use of empathy promotes diagnostic accuracy, therapeutic adherence and patient satisfaction.

• Enhance your counseling and listening skills by using a simple five-step process. Gather information about the context of the patient’s visit by asking: 1) what is going on in your life? 2) How do you feel about that (or how does it affect you)? 3) What about the situation troubles you most? And 4) how are you handling that? Then show understanding and empathy by observing: 5) “That must be very difficult for you.” This technique is identified by the acronym BATHE (which stands for background, affect, trouble, handling and empathy).

• Remember to ask about any alternative treatments that the patient may be using. More and more patients are turning to complementary and alternative medicine (CAM) providers for help with their symptoms. Knowing this information will help you make an accurate assessment and develop a treatment plan for the patient. Do you need more information about this growing trend? Some schools include information about CAM in their curriculums, but many do not. The National Center for Complementary and Alternative Medicine, part of the National Institute of Health, has a Web site at that includes fact sheets, consensus reports, complementary and alternative medicine databases and more.

• Talk with your patients about lifestyle issues. Many students and physicians alike are hesitant to bring up unhealthy behaviors with their patients. Remember these tips to guide you in this process:

1. Expect resistance to change. Solicit feedback from your patients on their thoughts about changing their behavior and use these conversations to gauge how important changing is to them. (Understand and appreciate the fact that many people derive pleasure from unhealthy habits, such as smoking.)

2. Avoid merely listing the negative effects of your patients’ actions; instead highlight the positive effects a new lifestyle could bring.

Wednesday, December 20, 2006

Clinical innovations, apologies, Twenty Clinical Innovations for Building Patient-Doctor Trust: Seventh in a Series

Offering Apologies and Reconciling Differences to Avoid Misunderstandings and Malpractice Risks

In this series of blogs, I have sought to spell out ways to innovate to build trust between hospitals, doctors, and patients. This is not easy in the current environment Health costs are rising. To cut costs, hospitals and doctors are rushing patients through their facilities and offices. In this rush, with too little time to think things through, mistakes and misunderstandings occur.

These problems can partially be compensated for through more information, better patient education, clearer communications, and concentrated public relations efforts. But adverse events will still happen and lead to mistrust.

Two ways of dealing with mistakes and misunderstanding are through reconciliation and apologies.

I’m a fan of the Truth and Reconciliation Commission, put together in South Africa at the end of Apartheid to heal racial wounds. Victims of violence could come forth to testify, and perpetrators of violence could ask for amnesty. By and large, this commission worked and succeeded in creating a climate of trust to help make South Africa a workable democracy.

In America in the malpractice arena, a similar idea has surfaced in the form of a joint effort between Common Good, a charitable organization formed by Philip K. Howard and the Harvard School of Public Health. Backers of the Common Good concept advocate specialized health courts to hear alleged victims of malpractice and testimony of perceived malpractice perpetrators.

I became interested in how to resolve differences and create trust between litigants when I interviewed Leonard Marcus, PhD., in 1999 for Physician Executive Magazine, Marcus anticipated adverse impacts of managed care. When patients and doctors lose control of their medical care, he reasoned, conflicts would become more common. Marcus sought an alternative to litigation for people involved in such conflicts. Marcus believes conflict is not necessarily negative -- it can be used constructively to focus attention on how to effect system improvement. Unfortunately, as he stated in my interview , "...people can get so caught up in the conflict that they can't even see the costs of escalation and the potential benefits of resolution."

In a May 18, 2005 front page piece in the Wall Street Journal, Rachel Zimmerman reported on a new strategy of the malpractice industry – doctors owning up to mistakes and apologizing. The industry found that contrite apologies by doctors avoided costly settlements. The article “Malpractice Insurers Find Owning Up to Errors Soothes Patient Anger“ described how apologies sometimes worked better than the usual “defend and deny” approach.

Insurers and hospital lawyers have long discouraged doctors from apologizing to patients for fear that apologies might fuel lawsuits. But now, some hospitals are urging doctors to fully disclose errors to patients. Consultants are being hired to give seminars on how to deliver lawsuit-deflecting apologies. Medical schools are giving courses on how to apologize for errors. And two states, Oregon and Colorado, have passed laws saying doctors’ apologies can’t be used against them in court. This is not to say that a strategy of “To err is human, to forgive divine” works in all circumstances. It is still wise to consult a lawyer before offering an apology, particularly for grievous errors.

It is, however, a good policy for institutions and doctors to train employees to offer apologies for common complaints. In their book “I’m Sorry to Health to Hear That..” Real Life Responses to Patients’ 101 Most Common Complaints (rL-Solutions, 2006), Susan Keane Baker and Leslie Bank have turned apologizing into an art form. Ms. Baker works with health care organizations to improve service quality, and Ms. Bank is Director of Customer Service at Montefiore Medical Center in the Bronx, a large multi-hospital system. Baker and Bank recognize that when complaints and service failures are directly addressed, the result is less litigious, more satisfied, cooperative and supportive patients and families Here are a few examples of what they recommend.


Complaint: You lost my paperwork and as a result, you’re saying I can’t be seen today?

Response: I’m sorry that happened. Let me see how we can fix this right away. Who is your doctor?


Complaint: My room hasn’t been cleaned in days. No one has emptied my wastebasket, and no one has changed my linens. What kind of place is this?

Response: I’m sorry. Let’s start by changing your linens right away. Would you like me to get an extra wastebasket for you? Let’s make a checklist of the things needing attention so we can fix it all.

Service Quality

Complaint: It takes forever for anyone to answer my call bell.

Response: I’m sorry to hear that. I know that while you’re waiting, every minute seems like an hour. What can I do for you right now?

Quality of Care

Complaint: I’m in pain and nobody cares The doctor doesn’t believe me about my pain.

Response: I’m sorry you’re in a lot of pain. I’ll contact your doctor right away. First, please tell me on a scale of 1 to 10, 10 being the worst, how much pain are you feeling right now? OK, I’ll be back with an update for you within five minutes.


Complaint: I can’t read my discharge instructions. I can’t read what the doctor wrote.

Response. I’m sorry. Let me call the doctor and ask for a printed copy. It shouldn’t take long.


Complaint: This bill might as well be written in Greek. How the heck am I supposed to know what I owe?

Response; I’m sorry. I’ll be happy t help you. I can walk you through the entire statement, or just point out the “amount due now” section.

This discussion of reconciliation and apologies reminds me two rules Dr. Neil Baum, a urologist in New Orleans, imposes on himself and his staff in his practice.

Rule #1 . The patient is always right.

Rule #2. If you think the patient is wrong, re-read Rule #1.

Tuesday, December 19, 2006

clinical innovations, e-medicine, Twenty Clinical Innovations to Build Patient-Doctor Trust: Sixth in a Series

On E-Visits, E-messages, and E-Consultations

E-mail arguably has become the most common means of personal communication. It is replacing personal letters, faxes, long distance calls, and is supplementing wireless cell calls. It is cheap and fast. It is giving new meaning to the word instantaneity. Everybody is doing it – businesses, advertisers, friends, kids, family members, and yes, even patients and doctors.

If you doubt the gathering email flood and its impact on patient-doctor relationships, I invite you to review this list of media articles on the subject:

You've Got Mail? Not from the Doctor. Just a Quarter of Physicians Use E-Mail to Interact with Patients, though Some Say It Can Save Time and Money.
Los Angeles Times, October 2, 2006

Digital Rx: Take Two Aspirins and E-Mail Me Morning
New York Times, March 3, 2005

The Doctor Is Online: Secure Messaging Boosts the Use of Web Consultations
Wall Street Journal, September 2, 2004

Blue Cross Doctors to Treat Patients Online
Florida Times-Union, September 1, 2004
Rocky Mountain News, August 23, 2004

Email Consultations in Health Care
British Journal of Medicine, August 21, 2004

Physician To Be Reimbursed For Plan Member Web Visits
MCIC, August 10, 2004

RelayHealth Makes The Right Connections For Virtual House Calls
HealthLeaders, July 2004

Doctors Advice May Be Just a Click Away
Orlando Sentinel, June 7, 2004

E-Visits Begin to Pay Off for Physicians
Information Week, May 31, 2004

Colella Brings Medical Networking Online
East Bay Business Times, May 28, 2004

The Doctor Will E-You Now
The Boston Globe, May 24, 2004

Online Messaging Defied Expectations
Health Data Management, May 21, 2004

Payer to Reimburse Online Consults
Health Data Management, May 11, 2004

Should You Pay Providers for E-Visits?
Managed Care Report, April 30, 2004

Take Two Aspirins, E-Mail Me Tomorrow
The New York Times, April 27, 2004

Improving Doctor-Patient Relationships via E-Mail
National Public Radio, April 22, 2004

Cyber-Doctors: Medical Groups See Web as a Prescription
San Francisco Business Times, April 16, 2004

Tenn. Blues to Reimburse Physicians for Phone Calls, Online Visits
Managed Care Outlook, April 15, 2004

Physician Organizations Communicating With HMO Patients Online
Health Resources Publishing, April 2004

Online Communication with Patients: Making it Work
Family Practice Management, April 2004

Communicating with Your Patients Online
Family Practice Management, March 2004

Doctors Meet Patients in Cyberspace Office
Business First of Buffalo, January 30, 2004

Virtual Access
Modern Healthcare, January 26, 2004

Doctor-Patient E-Mail Getting Hotter
Internet Healthcare Strategies, December 30, 2003

Reimbursement Code Could Increase Online Consultations
iHealthBeat, December 22, 2003

Online Consultations With Patients Grow
iHealthBeat, November 18, 2003

Web Allows Doctor Access
Democrat and Chronicle, September 20, 2003

Company Gives Docs Online Treatment
East Bay Business Times, August 5, 2003

IT Part of Payers' New Game Plans
Health Data Management, June 2003

Connecting With Technology
Unique Opportunities/The Physician's Resource, May/June 2003

Please Get The Doctor Online Now
Wall Street Journal, May 22, 2003

Online Chats Heal Wounds, May 19, 2003

Reimbursement for E-ail Visits Urged By Group
Family Practice News, May 15, 2003

Some Doctors Use Patient E-Mail In Their Practices, But Most Aren't Ready To Log On
Washington Post, April 1, 2003

HIPAA Demands Encrypted E-Mail
Family Practice News, April 1, 2003

Connecting With Consumers: Hospitals See A Payoff In Linking Patients and Doctors Online
H&HN's Most Wired Magazine, Spring 2003

Will Doctors Get Online?
Los Angeles Times, March 31, 2003

MD-Patient Online Communications: Finding Money in Clinical Encounters
Jupiter Research, 2002

Patients Skip the Waiting Room for Virtual Visits to the Doctor
Wall Street Journal, December 26, 2002

New ROI Data: The Virtual Doctor's Visit Cuts Costs
Forrester Research Brief, October 24, 2002

Online Doctor Consultations Show Promise in Pilot Study
Wall Street Journal, October 24, 2002

Just Open Your E-Mail and Say 'AH'
San Francisco Chronicle, November 11, 2001

Take Two Aspirin and Hit the Send Key
Newsweek, June 25, 2001

Digital Diagnosis
San Francisco Chronicle, May 9, 2001

Employers Urge Doctors to Make 'Visits' by E-Mail
Wall Street Journal, March 23, 2001

Impressive as this list is, it overlooks one salient fact. Doctors remain reluctant to use email to communicate with patients. According to the study by The Center for Studying Health System Change, a Washington, D.C. think tank, only 25 percent of doctors talk to patients by email, up from 20 percent four years ago.

The reasons given for this reluctance vary: greater malpractice exposure, fear of invasion of privacy, lack of payment, reluctance to treat unseen patients, inability to read body language and truthfulness of patients, or just another task for overworked doctors. The last thing many doctors want is another way for patients to get hold of them.

These doubts are likely to give way to reality as consumers demand more doctor access and less costly and more convenient ways to gain information. It will also become clear that being paid $25 to $35 for a virtual visit is a more economical than handling patient problems via telephone calls, for which doctors are paid nothing.

Moreover, businesses, health plans, and health organizations, such as academic medical centers, physician groups, and professional organizations are encouraging their constituencies to use email. Medem, Inc, backed by the AMA and many medical specialty associations, actively promotes electronic consultations, and RelayHealth, Inc, an organization selling communication products to the nation’s health plans, characterizes its services as “a secure private way to communicate with your doctors and to take care of non-urgent health matters – quickly and easily.”

Call patient-doctor e-mails what you will – e-visits, virtual visits, online messaging, and online consultations. The trend appears inevitable. Email visits may serve as bridge to more widespread use of electronic and personal health records. Doctors who introduce these visits into their practices may also find they gain their patients’ trust.

Monday, December 18, 2006

clinical innovations, the Mayo approach, Twenty Clnical Innovations to Build Patient-Doctor Trust: Fifth in a Series

Innovation by Design, the Mayo Approach

No better example of innovation by design exists than that practiced at the Mayo Clinic.

Since its founding in 1889, Mayo has passionately believed in design innovation offering patients a superior clinical experience. In 2002, Len Berry, PhD, and Neeli Bendapudi, PhD, marketing business school professors, after five months of study, wrote of the trust Mayo generates in patents who go there for care (“Clueing in Customers, Harvard Business Review, February 1, 2003.)

Berry and Bendapudi attributed the trust and loyalty engendered by Mayo to:

• An integrated practice model with the fundamental principle being collaboration of specialists.
• Technologies - Integration of specialty care across Mayo’s multiple locations with computer-based and Web-enabled technologies.
• Staff quality – Recruiting and hiring only those who "reflect the values of Mayo brothers." The organization's values are published in the “ Mayo Model of Care," the centerpiece of the orientation for every new Mayo physician and employee.
• Exceptional facilities – Mayo recognizes the building environment provides "torrents of cues" about Mayo values to its patients, and reinforcing the Mayo image.
• Economies – Repeated surveys show Mayo care – focusing on teamwork, instant chart retrieval, cross-referrals, and ambulatory care – costs 20 to 22 percent less than comparable care in the outside world.
• Constant innovation to continually improve care through constant staff meetings.

The professors concluded a passion for innovation by design” is part and parcel of the Mayo experience.I believe this. Some 25 years ago, I was looking at a position at Mayo as part of their department of laboratory medicine. In the interview process, I was taken to the blood drawing area. There I was told how the area was designed – from types of chairs used and their placement, to the ideal waiting time, to the trek to and from the reception desk, to the view from the chair. Nothing was left to chance.

Mayo trains itself and its employees to design everything from buildings, to exam rooms, to dress codes, to demeanors, to give patients visual and experiential clues to tell the compelling Mayo story.

Passion for Precision, Control, and Planning

A good example of the Mayo passion for control, planning, dress, design, and visual imagery is their new SPARC (for See, Plan, Act, Refine, and Communicate) innovation laboratory. This laboratory was developed to see how Mayo could best improve patient-doctor interaction by studying room architecture, furniture placement, body language, and behavior of both patients and doctors.
Mayo observers have concentrated on the “waiting experience.” They have compared patients sent to the registration versus those directed to a kiosk desk, like those at airline counter and have found kiosk waiting superior in all respects.

The idea is to observe how patients interact in waiting areas and exam rooms, and how doctors, nurses, and staff can best navigate the health care process. The Mayo team wants to create a basic template for facilitating service delivery innovation - a systematic process that includes how to brainstorm new ideas for using the space, rapidly prototype novel service delivery designs, and use customer observation and direct feedback to refine solutions.

The point of Mayo’s SPARC Innovation Program, according to the medical director of the program, Alan Duncan, MD, is to find ways to improve the patient experience. Says Duncan, “Everything we do is from the patient’s perspective.” He is quoted in The December 2006 issue of Minnesota Medicine as saying, “For a general internist, the relationship between the physician and patient is absolutely critical. I think it’s critical for any physician, but it’s really critical for the general internist, who often has a longitudinal relations with patients.”

Innovation, Above All Else

Innovation is in the Mayo organization’s DNA.

• When Doctor W.W, Mayo founded Mayo as an integrated health care group, built upon by his two doctor sons – still known at Dr. Charlie and Doctor Will; it was innovative.

• When the Mayo’s put multiple specialists in one building; it was innovative.

• When the Mayos hired Dr. Henry Plummer in the early 1900s to design their buildings, surgical and diagnostic instruments, examining room, record system, and pneumatic tube powered chart-delivery system; it was innovative.

• When Mayo developed a research division, culminating in two Mayo researchers, Dr. Edward Kendall and Dr. Philip Hench, sharing the 1950 Nobel Prize for their work on adrenal steroids; it was innovative.

• When Mayo founded Medical Innovations, Inc, in 1965; it has designed, patented, and marketed over 1000 medical devices; it was innovative.

• When Mayo took their diagnostic reference laboratories national in the 1970s; it was innovative.

• When Mayo collaborated with IBM to expand and refine its information technology system over the last 20 years, and then worked with IBM, GE, Siemens, and Phillips to build and market a better MRI machine in 8 months, rather than the usual 18 to 24 months, it was innovative.

• When Mayo developed their clinic trials service; it was innovative.

National Symposium on Health Care Reform

Now Mayo has undertaken its boldest reform innovation yet – to help design a national system based on Mayo thought and design.. On May 21 and May 23, 2006, Mayo hosted a national symposium on health reform. Before the symposium, Mayo CEO Denis Cortese, MD, and Mayo Administrative Director, Robert Smoldt, MBA, staked out the Mayo position on reform in the April issue of the Mayo Clinic Proceedings.

Cortese and Smoldt said, among other things, that the health system suffered from lack quality and safety, the uninsured, public unease, rising costs, misaligned payment incentives, and a looming baby boomer retirement.

Fixing the Problem

To fix the problem, Cortes and Smoldt argued, would require national learning organizations, led by physicians with shared visions, professionalism, information technology tools, and systems engineering management.

Cortes and Smoldt concluded,

“To achieve this vision of a new health system for America – one that functions as a vibrant, innovative learning organization – we propose a consumer-driven market-based model that delivers universal coverage to all Americans, a model similar to the Federal Employee Health Benefits Plan (FEHP) or the Universal Health Voucher Plan.”

To Mayo, systematic, organized and purposeful innovation has no limits --when it is designed from the patient’s point of view.

Sunday, December 17, 2006

clinical innovations, human vignette4s, Twenty Clinical Innovations to Build Patient-Doctor Trust: Fourth in a Series

On Technology and the Nature of Human Nature

Today's message is: Behind every health care innovation lies a human-technology vignette.

In my first three entries, I spoke about innovations and improving human interactions – how doctors can innovate through anticipating those magic moments of patient expectation and paying attention to nurses.

I did not speak of the technological nature of most health care innovations. But let’s face it. Most health care advances, no matter how small, occur through blending human need and a technology to fill that need.

Don’t take my word for it.

Five years ago, Victor Fuchs, PhD, Professor Emeritus at Stanford Business School, and Harold Sox, Jr,, MD, former chair of the Department of Medicine at Dartmouth and editor of Annals of Internal Medicine, wrote an article in Health Affairs reporting on the views of 225 general internists on the relative importance of 10 major medical innovations.

Physician Choices of Top Ten Innovations

Here are the internists’ rankings of the top 10 medical innovations, all of them technological in nature.

1. MRI and CT (magnetic resonance imaging and computed tomography).

2. ACE inhibitors –treatment of high blood pressure.

3. Balloon angioplasty – a procedure to open blocked blood vessels of the heart.

4. Statins – drugs used to improve lipid metabolism and reduce risk for coronary heart disease and other vascular diseases.

6.Coronary artery bypasses graft.

7. Proton pump inhibitors and H2 blockers – used to treat gastro-esophageal reflux disease.

8. SSRIs (selective serotonin re-uptake inhibitors) and new non-SSRI. Anti-depressants.

9. Cataract extraction and lens implant.

10. Hip and knee replacement.

Technology Not Management or Social Innovation

These are technology innovations, rather than social or organizational innovations. Most innovations (except for MRI and CT, originally developed in England), originate in the United States.

We are a nation of innovators. Over the last 30 years the United States has produced more medical Nobel Prize winners than all other nations combined; drug companies headquartered here have created eight of the ten selling drugs; and, in the 30 innovations listed by Fuchs and Sox, eight of ten came from the U.S.

These technological innovations’ downsides are high costs, and in some instances, unregulated entrepreneurialism (the operative words criticizing those who profit is “greed,” and for those favoring profit is “opportunities”) on the part of manufacturers and physicians users of these wonderful innovations. American patients are often willing accomplices to overuse, for they, like their doctors, have insatiable appetites for medical technologies as a “quick fix” for their ailments.
Consensus of Health Care Stakeholders

I recently polled 100 health care stakeholders – hospital executives, physicians, consultants, editors, and contributors to this book and to my previous books. I have asked them to rank the ten innovations in order of importance. Here is the consensus.

Top Ten Innovations – Consensus among 100 Health Care Stakeholders

1. Pay-for-Performance (P-4-P) programs

2. Introductions of electronic health records (EHRs) into medical practices.

3. Add-ons to EHRs – instant medical histories, coding devices, prescription-enabling modules, or websites that permit registration, virtual visits, prescription refills, open-access scheduling.

4. Software that facilitates office dispensing and prescription writing.

5. Self-care, self-service, and self-empowerment of consumers.

6. New practice business models ( concierge, cash, or other new types of innovative practices, such as retail clinics or home disease management )
7. High tech/high touch remote patient monitoring with patient interactive capacity.

8. Personal Health Records with and without EHRs.

9. Disease management programs.

9. The transparency movement as part of consumer-driven care movement.

Again most of these innovations are technological, but in this case, observe that the technology focuses on the digital revolution and how it can be used to blend and bind humans together.

An Example of Human-Technology Blending

In closing, let me offer an example of this blending and binding.

Fifteen years ago, Dr. Allen Wenner, a family physician in Columbia, South Carolina, was trying to figure out the clinical puzzle of an older woman with multiple complaints, including dry mouth and dry eyes. He referred her to a medical center, where a medical student spent hours with the patient, and with the help of the medical school faculty, diagnosed Sjogren’s syndrome, a chronic disease affecting many organs, and causing fatigue and marked by dry eyes and dry mouth.

Wenner remarked at the time, “If only I had time to listen to her entire story, I could have figured it out.” He reasoned that if she had told her story to a computer in a systematic and narrative way, guided by her chief complaints of dry eyes and dry mouth and by clinical logic, he would have quickly nailed the diagnosis. By telling her story to a computer, the time spent would have been her time, not his. Furthermore, she would not have minded telling her full story in the form of ‘yes” or “no” answers in response to a simple clinical algorhythim.

Wenner and associates set about developing hundreds of these algorhythims based on patients’ chief complaint, gender, and age. The result was a piece of software called the Instant Medical History, which most patients (more that 90 percent) can complete from their home computer or on a laptop in the reception room before seeing the doctors.

Patients, as it turns out, like telling their complete story (even if to a computer), and doctors like reading the narrative. It tells the patient’s story, helps them immediately zero in on the chief complaint, documents the story logically, and makes for a completely documented story of the clinical encounter, which the patient can take home upon leaving the office.

More than anything else, the Instant Medical Record saves 5 to 8 minutes of time for each patient encounter. Waste of time – in waiting for an appointment, in the reception room, and the exam room – is the bane of modern medicine, of busy patients, and harassed doctors.

As Peter F. Drucker, father of modern management, observed:

“Time is a unique resource. One cannot rent, hire, buy, or otherwise obtain more time. The supply of time is totally inelastic. No matter how high the demand, the supply will not go up. Three is no price for it and no marginal utility for it. Moreover, time is tally perishable and cannot be stored. Yesterday’s time is fore forever and will never cameo back. Time, is therefore, always in exceedingly short supply. Time is totally irreplaceable”

And as Sir William Osler, father of modern medicine, noted:

“Listen to the patient, and they will tell you the diagnosis.”

Time permitting, of course.

Thursday, December 14, 2006

clinical innovations, asking rurses for help -Twenty Clinical Innovations to Build Patient-Doctor Trust: Third of aA Series

On Physicians Asking Nurses for Help in Building Patient Trust

Today’s blog is elemental. My message is this:

Busy doctors should rely more on observant nurses to help increase productivity, save time, and build patient trust.

In The Successful Physician: A Productivity Handbook for Physicians (Aspen Publications, 1998), Dr. Marshall O. Zaslove, a Napa Valley psychiatrist nationally known for his productivity seminars for overburdened doctors, says practitioners would be happier and more productive and have more trusting relationships with patients if they would simply listen to office nurses, follow their advice, and respect their judgments. Nurses, he believes, are potent messengers of patient trust.

Doctors, according to Zaslove, don’t give nurses opportunities during a busy day to help because they don’t consult the nurses. Doctors don’t listen to nurses, he says. This lack of attention frustrates nurses. That is why nurses are heard to say. “He just doesn’t listen!” “He doesn’t know how to work as a team.” “He doesn’t respect us.” “He’s not working safe.” “He refuses to accept our help.” When nurses voice these feelings, they are indicating doctors may be too arrogant, myopic, money-hungry, or afflicted with tunnel vision to listen.

Doctors, maintains Zaslove, should step back, listen, and ask nurses: “How could I do this better?” Can you help me do it better?” “Should you be doing this rather than me?” “Am I missing something here?” “Am I being arrogant?” ”Am I scheduling too many patients?” “How do you think we can better address his patient’s problems? “How we better build this patient’s trust?”

Zaslove advocates teamwork to build trust. In From Chaos to Care (Perseus Publishing, 2002), David Lawrence, MD. Chairman emeritus, Kaiser Permanente, refers to the “promise of team-based medicine” to achieve competence and trust. Teamwork can be applied to small practices as well as large ones. Building trust requires clear communication by doctors with patients -- and with nurses. Zaslove advises doctors to step back, stop, look, listen carefully to nurses, trust them.. Nurses are on their side and the side of patients. We –doctors, nurses, and patients – are all of us in this together, and it will take all of our talents, knowledge, and trust to make it work.

Patients trust nurses. Patients find nurses approachable, easy to talk to, and nurturing. Patients share with nurses intimate details they don’t share with doctors. Patient trust of nurses is a simple, irrefutable, unarguable, universal fact.

The power of nurse trust by patients has not been lost on health care organizations. Nurse trust is why hospitals have had such great success with “Ask a Nurse” programs.; why American Healthways, other chronic disease firms, health plans, hospitals, and health systems vigorously recruit nurses and why nurses are more in demand than any other job category in America..

There are not enough nurses to go around. There may never be. Nurses have medical knowledge, speak the medical language, understand disease, and are emphatic listeners and caregivers. They are an indespensible and irreplaceable asset and resource.

My wife, a nurse, says the foregoing should be accepted with absolute certitude as a self-evident truth.

Wednesday, December 13, 2006

clinical innovations, what to expect -Twenty Clinical Innovations to Build Patient-Doctor Trust: Second in a Series

Deepening Patient Understanding of What to Expect from Surgery, Procedures, Disease, and Health Care Interactions

Give the matter any thought at all, and you will realize much of what is wrong with the health system can be traced to this simple reality:

Patients don’t understand what to expect from invasive procedures, complications of disease, benefits of complying with medical instructions, an gaps in countless health care interactions.

Nobody’s Fault in Particular

This lack of patient understanding is nobody’s fault in particular. Medicine is a complicated, highly specialized profession. People often visit multiple specialists, each with a slightly different take on their problems. Business dealings of health organizations may be Byzantine, secretive, mysterious, and unfathomable. Disease strikes when you least expect it. Furthermore, with each new health interaction, you may be experiencing something highly personal, health-robbing, and even life-threatening for the first time.

As a patient, you may have asked: Why didn’t someone explain this problem to me and my family clearly in simple language and with graphic drawings or illustrations what to expect? Why wasn’t I more informed of hazards and benefits of my encounter with my doctor and the health system?

Lack of Understanding

Answers to these questions may come down to a lack of understanding. Here is how a company called Emmi Solutions puts it:

“There's a health literacy crisis in this country that, according to the Institute of Medicine, costs as much as $58 billion a year. An estimated 90 million Americans don't understand or act on health information, don't fully understand the consent forms they read, and don't understand or remember what they hear in a clinical setting. Poorly informed patients are more likely to be noncompliant, more apt to suffer complications from medication errors, and are at higher risk for hospitalization."

“Add the stress of the clinical encounter and health worries to the mix, and it's easy to understand the urgent need for a simple, reliable, and powerful healthcare communication solution that manages expectations and calls patients to action.”
Founding of Emmi Solutions (

Doctor David Sobel, a Chicago urologist, and his wife, Michelle, founded Rightfield Solutions, the forerunner if Emmi Solutions in 2001. Emma stands for Expectation Medical Management Information. The basic mission and vision of the company is to educate patients, communicate with them clearly, and manage patient expectations
Sobel shared with Michelle his concerns about limitations of informed consent forms in telling patients what to expect from surgical procedures. As a solution, Michelle suggested an online interactive pictorial voice-guided video “prescribed “ to patients before surgery as an effective means of deepening understanding of patients’ and their families.

Emmi solutions’ video voice explains “This will be pretty simple,” as indeed it is, being expressed in language at the 6th grade level with supporting pictorials.

Everybody “Gets It”

To make a long story short, the idea of simple-to-understand interactive videos has caught on fast. It is a win-win-win-win-win Physicians like the videos because they save time in explaining what to expect – simply, consistently, and comprehensively. Patients and their families like the videos because they understand what’s about to take place. Hospitals and health plans like the videos because they reduce misunderstanding and win patient loyalty. Malpractice carriers like the videos because they document what was explained. Everybody involved likes the videos because they educate patients in a consistent, relevant, and timely fashion that helps compliance with medical instructions. Everybody, in short, “gets it.”

Patient Education at Point of Care Not New, But Timing Is

Patient education using interactive technologies at the point of care is not a new idea. Weinberg and associates at Dartmouth, Bachman at Mayo, and others have pioneered and explored the use of multimedia interactions to educate patients about prostate cancer, chronic diseases, colonoscopies, and other procedures.
What is new are three major developments: 1) the growing ubiquity of the Internet and broad band access in multiple settings – doctors’ offices, hospitals, health plans, consumer websites, Internet cafes, information kiosks, public libraries, 2) increasing ease, simplicity, and functionality of Web use; 3) emphasis of major organizations, such as the Institute of Medicine, on what patients should expect from the system.

Ten Simple Rules for Meeting Patient Expectations

The Institute of Medicine has issued these 10 “simple rules” for meeting patient expectations:

1) Care should be based on continuous relationships.
2) Care should be customized for patient needs and values.
3) Patients should be the source of control.
4) Knowledge should be shared and information should flow freely.
5) Decisions should be based on evidence.
6) Safety should be a given.
7) Transparency is necessary.
8) Patient needs and understanding should be anticipated.
9) Waste and duplications should be continuously decreased.
10) Cooperation among clinicians is a priority.

To these ten points, I would add: For a truly “patient-centered system,” understandable and timely patient education and communication at every point of health care interaction is fundamental if we are to build enduring patient-physician trust.

Tuesday, December 12, 2006

Clinical Innovation, Building Trust, Twenty Clinical Innovations to Build Patient-Doctor Trust; First of a Series

This is the first of 20 blogs on building physician- patient trust. I shall describe these innovations one blog at a time.

The general proposition behind these blogs is that clinicians can always innovate to better control their destiny, satisfy patients, win trust, and improve care. I define innovation as doing things better, differently, more humanely, and more cost-effectively. Today’s patients are seeking greater compassion, convenience, choices, comfort, and cost-effectiveness.

These attributes are within most clinicians’ grasp, are commonsensical, and do not necessarily require outside help. There are, of course, many approaches to innovation at the grass roots – large and small; no tech. low tech, and high tech; or simply changes in how one views the practice. Dr. Randall Oates, a family physician in Arkansas, for example, decided he would only see complex patients requiring a physician’s professional knowledge; he would delegate to staff all other patients being seen for other reasons. His decision made better use of his time and increased coding revenues.

Over the years, I have been collecting innovations that clinicians and others tell me have been useful in their practices. I shall share them with you now, one at a time.

One - Identifying and Paying Rapt Attention to “ Moments of Truth”

In her book, Managing Patient Expectations: The Art of Finding and Keeping Patient Expectations, Susan Keane Baker, a health care speaker, educator, and consultant, said patients experience 15 "moments of truth" when dealing with a physician’s practice (A moment of truth is when patients form an impression of your practice – good, mad, exceptional.).

Calling your organization
Making an appointment
Receiving directions
Meeting the receptionist
Waiting in reception room
Waiting in exam room
Meeting the clinician
Giving a history
Having an examination
Having an invasive procedure
Giving a lab specimen
Receiving discharge instructions
Leaving the organization
Obtaining test results
Receiving a bill

These moments of truth can win or lose a patient’s loyalty. These moments distinguish one practice from another. Engage your staff in analyzing, recognizing, and practicing these moments. Improve your techniques for greeting patients, exiting your presence, using their names appropriately, sharing their personal histories. I once knew an ophthalmologist who had a card for each patient on which he would jot down some personal information. He would ask, for instance, “How is your son doing at Stanford.”

One final note. Learn to handle complaints. They are inevitable in today’s fast-paced complicated world. For this purpose, you might consider buying Susan Keane Baker’s latest book (with Leslie Bank), “I ’m Sorry to Hear That…” Real Live Responses to Patients’ 101 Most Common Complaints about Health Care (rL Solutions, 888-737-7444,

Monday, December 11, 2006

beginning - In the beginning

December 11, 2006 -- To begin, I don't believe the U.S. health system is "broken," or that it will let people die in the streets, or that it will drive millions into medical bankruptcy, or that it will bring down the entire U.S. economy.

Instead, I believe the health system will adjust, it will innovate, and its current major players will "do the right thing." The talents, intelligence, and abilitiies of two of those major players, unfortunately, to take responsibility for their health and medical conditions have been sorely neglected.

I am referring to practicing physicians and their patients. You. Yes, You. You practicing physicians and you patients who go to them for care in the clinical trenches.

This is for you. I have thought for a long time that medical care is directed too much from the "top down" --government, employers, health plans, hospitals, large physician advocacy groups. It is not that these organizations are bad. They are simply so big, bureaucratic, and political that they make innovation at the grass roots practice level difficult.

Also they tend to confine physicians through regulations, evidence based guidelines, advice on what to do and not to do, how to reorganize their practices, and what electronic and personal health records to install. Again there is nothing wrong with this heart-felt and well-intended advice as far as it goes.

But constraints and rules from above by those who have never spent a day in a busy medical practice have produced uninticipated side effects --demoralization among physicians , dissatisfaction among patients, and a feeling of helplessness to control or improve what is taking place on the ground.

In these series of blogs, I shall describe clinical innovations that facilitate the patient-doctor relationship, ease the cost of care, deepen understanding of disease, help patients understand and comply with medical instructions, and clearly document what takes place in the office, and what to expect from medical treatments, procedures, and disease.