Patient Satisfaction: Is It At Odds With Healthcare IT?

February 11, 2013
7 Comments

Recently, I participated in medical grand rounds at several hospitals. The primary topics of all these grand rounds were focused on delivering better care. One of these sessions was presented by Dr. Margaret Cary at Georgetown University Hospital on the topic of coaching, the role of active listening, and asking phenomenally good questions. These behaviors result in tremendous improvements in effectiveness for doctors, as well as improved satisfaction for everyone they deal with, patients, peers and staff alike! Dr Cary wrote a terrific essay on the value of presence here.  My previous blog on this subject is here.

 

During the course of one of the exercises, I shared in a private one-on-one discussion that my career involved helping use HIT to improve the quality of care. I pointed out that, prior to the establishment of "meaningful use," the rate at which healthcare encounters including adequate documentation of the patient's current medications and problems was very low. Clearly, not concordant with anyone's definition of quality. And, furthermore, how can a patient be satisfied with their providers if those providers don’t reliably know the patient’s story and concerns?

 

A very experienced, talented physician pushed back on my point. For him, the use of any form of IT in the exam room always decreased the extent to which the physician expressed care to the patient. The use of computers decreased or eliminated eye contact. Computers, according to the doc, took the physician's focus away from patients and their needs, and moved it to the needs of completing some sterile and defocusing form within the computer. I was reminded by him that “Everyone knows computers dramatically increase the documentation burden, with negligible value, if any, created for the physician doing the documenting.” His position was that to the extent information technology in the exam room had some positive impact, it was at most minor. And in any event, the net of HIT applications was negative for both patient and provider satisfaction.

 

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Patient Satisfaction vs Healthcare IT

Joe,
Based upon my experience as a consultant, not a physician, I think we all spend too much time dwelling on the docs who are resistant to evolving to the use of healthcare IT.

The fact is, the physicians who have come into the system over the past dozen or so years grew up using computers, and the vast majority received their medical training using them as a natural tool for clinicians. A high percentage of those who believed that the “old ways” were preferable have retired, and will soon be joined by the rest due to Father Time.

During the past two decades, I’ve consulted dozens upon dozens of providers, adding new clients each year. As I’ve talked with senior docs and performance improvement program execs, particularly in the past five years at least, I’ve seldom heard of any serious problems with physician cooperation as most of them are very enthusiastic.

Physicians are inherently competitive, savvy individuals. They need to be to survive professionally. For instance, when a doc sees that his or her quality measures slip below those their peers, that’s a call to action. And when physicians are properly informed of how directly their performance affects the financial viability of their provider organizations, the message becomes abundantly clear, they change or they are expendable.

A lament about “the way things were” is human nature at many levels in all walks of life. But that does not equate to a lack of acceptance when it comes to change, particularly when we take a step back and realize that everyone likes to complain a little from time-to-time. That, too, is human nature.

So to return to my initial premise, I do believe it’s time we change our stance to one that’s more proactive. That is, we deal with the occasional resistant doc as a relatively isolated instance as we move forward with the IT tasks at hand. I don’t think the majority of docs, and I am not a member of their fraternity, are receiving the credit they deserve for embracing and using, for instance, EHR technology in a positive manner.

Good post, what is your position and experience?

Jack

Re-Making The Superb Patient Expereince

Jack,
Thanks for your comment and sharing your experience. I agree with your observation, that physician resistance to use of HIT has largely passed, for the factors you have mentioned and others.

The challenge of how to create an effective and satisfying experience for patient and provider continues to be worthy of sensitivity.

When we move from transport by bicycle to automobile, the work for the driver requires new skills. The trip can and should be safer, faster, and better.

When a health care provider team greets and attends to the needs of patients and their families, the process disciplines become more important in the age of HIT than the age of paper. By analogy, when using a car, it's vital to have enough gas, release the parking brake, watch for other vehicles traveling at high speeds from greater distances, and consider the comfort of other passengers in that car. Those disciplines don't exist with bicycles and, by analogy, paper and paper-hybrid medical practice systems.

Just as on the flight deck of a modern aircraft (to extend our analogy), technology helps ensure that the passengers' safety and overall experience is managed with sensitivity, and the use of that technology does not negatively compete with or degrade the passengers' experience. That's not accidental. So, for example, when 200 passengers deplane at the end of a flight, the airline knows who is going to do what by when to get those passengers to their next flight or baggage claim. It's been relatively recently that our attention to discharge planning and execution has a comparable degree of sensitivity to follow up, discharge ePrescribing, patient instructions, and coordination with the receiving destinations. All necessary to achieving world-class patient experiences and satisfaction. And, all demanding the continuing care and attention of those creating and delivering that experience using HIT.

Technology makes the healthcare experience more intimate

Nine minute video interview with Dr Eric Topol on quality, cost and satisfaction improvements with mobile technologies including smartphones:

http://www.nbcnews.com/id/21134540/vp/50582822#50582822

Patient Satisfaction: Is It At Odds With Healthcare IT?

Dr. Joe,
2 reactions to your blog. First, another insightful installment. Your references to HCAHPS scores and institutions competing on scores is great in its own right, but I wonder if it might also go a bit deeper. On one level, CMS and ONC policy through Meaningful Use is moving us all in the direction of one of the primary ARRA/HITECH/MU tenets: patient engagement. We’ll see more of that in ACOs, bundled payments and risk-sharing. Federal policy commitment to patient engagement has been constant across multiple National Coordinators and Administrations. Your thinking points to how national policy promotes the use of IT and how IT can assist achieving patient centeredness in ways that traditional encounters and paper systems never did. On a second and more important level, perhaps, is whether this patient-centeredness and satisfaction scoring will actually achieve values over and above competitive advantage in the hospital marketplace. Might it lead to demonstrably higher quality outcomes and wellness levels? I recall a study from a Colorado hospital in the days before the Internet (by which I mean I cannot find a copy of the study) which purportedly demonstrated that patients who opted in to a faith-based in-patient visitation program achieved better outcomes than a severity-adjusted cohort who opted out. The parallel is whether active participation via IT will improve outcomes.

My second reaction is to ask what became of your interaction with the “experienced, talented physician” who pushed back against IT in his exam room? I noticed that when the HIPAA privacy rules were first imposed, I spent half of the time in my personal health encounters listening to my physicians condemning the regulations and proclaiming them totally useless. Now those Notices of Privacy Practices are routine and nobody gets riled anymore. At that time, there were no computers in the exam room. For the last 4 years I’ve watched my physicians go through a similar opposition/resistance to acceptance/integration journey as each of them acquired EHR systems. So did your case example physician stay steadfast in his opposition, or did he, like National Coordinator David Blumenthal, eventually adapt his patient relationships to accommodate the initially unwelcome new IT tools and change his viewpoint?

Engaged Patients Do Better - HIT can promote engagement

HITmaven,

Thanks for your kind words and observations.

Your reminder is important: Since the inception of the ONC, the tenet of patient engagement has been explicitly a constant. It was one of the four cornerstone's in the Brailer-era (2004-2006) strategic blueprint for the ONC and the country.

You clarified several important linkages:

1. Will patient-centeredness and satisfaction scoring actually achieve values over and above competitive advantage in the hospital marketplace, i.e. true higher Quality and Wellness Levels?

2. You introduced the concept of an Active Participation Determinate: In some prior studies, those who opt-in (to more engagement) do better than those who opt-out. Is that an association or truly causal?

3. On the issue of physician opposition to HIT-- Melting vs Warming: Thanks for reminding us about Dr Blumenthal's shared experience, evolving his orientation to technology which warmed over time.

The physician I wrote about had adapted to EHRs over time, possibly ahead of his peers. His deep lament was about an apparent, concurrent reduction in expressed caring by physicians to patients, occurring with greater use of EHRs. Although not caused by EHR use, the associated trend was a chilly, cold trend he experienced. He thinks it's worth calling out and addressing. I think he's right.

two parallel tracks

Joe,
As always, you've posted an extremely thoughtful blog, one that, clearly, based on the comments from readers, is stimulating excellent dialogue. Reading your initial blogpost, my mind was drawn to the idea that we're discussing at least a couple of different phenomena, linked together here topically. One is the broader policy agenda, which, driven by the public and private purchasers of healthcare, is mandating action on the part of physicians, hospitals, and all providers, really, to document improvements in patient safety, care quality, cost reduction and cost-effectiveness, and patient and family satisfaction, all at the same time. The other phenomenon is the evolution of the physician-patient interaction, in the context of the typical office visit. Of course, I under that in the initial stages of a first go-live of an EMR/EHR, individual physicians find it cumbersome to interact both with the patient and with the technology at the same time. But as others have noted, this is the way the world is going anyway, and younger physicians, like all younger people, are far more accustomed to interacting with IT to begin with. The role of healthcare IT leaders, including CIOs, CMIOs, and everyone else involved in EMR/EHR implementation and optimization, is to help physicians strike a balance, so that they accomplish the tasks that purchasers are demanding that they must accomplish, while remaining fully engaged with the patient, in the moment. Is some of this challenging? Absolutely! But I believe that a lot of solutions are emerging that will be able to create a good balance. In some cases, it will mean working with mobile technology such as tablets, or even moving towards better basic ergonomics in office furniture. But it can be done. And ultimately, it must be done. Thank you once again for an exceptionally thoughtful blog!

Parallel Tracks - transcending the time and place of encounters

Mark,
Thanks for your kind words and helping with the framing. You observed several levels:

"1. The broader policy agenda, 
• driven by the public and private purchasers of healthcare, 
• mandating action on the part of physicians, hospitals, and all providers, really, 
• to document improvements in patient safety, care quality, cost reduction and cost-effectiveness, and patient and family satisfaction, all at the same time. 

2 The other phenomenon is the evolution of the physician-patient interaction, in the context of the typical office visit."

I think you're right. Patient satisfaction and, more broadly, the patient/consumer's experience with the health care system is far more than active listening skills and great eye contact, during "the typical office visit."

Patient satisfaction includes knowing the patient's needs to the greatest extent possible and practical, before they show up. It varies by patient generation, gender, prior experience with providers, and what's going on clinically. Ensuring that the patient meets with the right empathetic nurse may be far more critical than re-engineering their physician interaction.

We also need to think more broadly about the patient's interaction with the health system beyond encounter. So, for example, a timely and satisfying response to an email may improve the patient's experience far more than trying to improve the nurse and physician interactions (which may already be close to ideal.)

Thanks Again, Mark