Strategy 6H: Tools To Help Patients Communicate Their Needs

Contents

6.H.1. The Problem
6.H.2. The Intervention
   6.H.2.a. Record Sharing
   6.H.2.b. Patient Question Lists (a.k.a. Doc Talk Cards)
   6.H.2.c. Feed Forward
   6.H.2.d. Coached Care
References

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Tools To Help Patients Communicate Their Needs
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6.H.1. The Problem

Communication is a two-way street. While the communication skills of physicians and other providers certainly play a large role in shaping the patient's experience, that patient’s ability to express herself clearly, process and interpret the information she receives, and act upon it (e.g., by changing behavior) also contributes to the experience of care.

One issue is that many, if not most, patients are just beginning to become comfortable with relationships with clinicians that are based on a partnership model rather than the traditional paternalistic model. This shift is especially difficult for older patients and people who do not speak English or who come from cultures where this kind of a relationship with a doctor is unheard of.

But even those who embrace the idea of working collaboratively with physicians may lack important communication skills, which can inadvertently undermine their interactions with the health care system. Beginning in childhood, people are socialized to restrain themselves with doctors, answering only what they have been asked. While this attitude is changing, it is still a big step for people to accept that their agenda is as important as the doctor's, and an even bigger one for them to learn how to satisfy that agenda while still respecting the clinician's constraints.

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6.H.2. The Intervention

Health plans, medical groups, and physician practices can help patients improve their ability to share information with providers by suggesting or even giving them one or more simple and inexpensive communication tools. Patients who can communicate effectively with their clinicians tend to be more satisfied with their care, less likely to sue in case of an error, and more likely to experience improved health outcomes.¹ Their clinicians are likely to be more satisfied with their caregiving experience as well.

There are several ways to implement this strategy, including the four tactics discussed below:

• Record Sharing.
• Patient Question Lists (a.k.a. Doc Talk Cards).
• Feed Forward.
• Coached Care.

6.H.2.a. Record Sharing

Record sharing involves using the patient's medical record as a way to facilitate information sharing and generate discussion in the context of primary care. It typically consists of giving patients a copy of their physicians' progress notes (on paper or electronically) together with a glossary of terms. Access to this information enables patients to:

• Better understand their condition and treatment plan.
• Feel more in control of their health.
• Identify and correct inaccurate information.

Two factors may drive record sharing to become more commonplace: the HIPAA regulation that requires health care organizations to allow patients to review and amend their medical records, and the emergence of electronic medical records, which make it easier to share legible (and therefore less confusing) information.

Proponents believe that this intervention has the potential to increase compliance, improve patient safety, and enhance quality of care. Controlled studies indicate that the sharing of medical records has a consistently positive impact on doctor-patient communications, as well as modest benefits in other areas; with the exception of psychiatric patients, it appears to have little downside.² It has been found especially effective for patients with repeated visits, such as those with chronic conditions³ and pregnant women.

6.H.2.b. Patient Question Lists (a.k.a. Doc Talk Cards)

Another tactic is to encourage patients to write down questions they wish to ask their doctor and bring the list to their visit; these lists are sometimes referred to as "Doc Talk" cards. Typically, patients are asked to generate two to five questions about their medical problems or their reason for the visit that they would like their physician to answer during the office visit. The cards are often designed to prompt patients for questions by listing topic areas such as symptoms and medications. These questions can be attached to the patient's chart for the physician's review. This intervention is simple, requires few resources, and is effective at generating communication and increasing patient satisfaction with their care.

One tactic is to provide a form on the Web that patients can print out prior to their visit. Some health plans and providers, for example, offer a form that suggests that patients write out answers to the following two questions and bring their response to the visit:

• What do I want to tell my doctor today?
• What do I want to ask my doctor today?

Patients can also use the form during the visit to write down what they and the doctor agreed the patient would do after the visit. Another approach is to maintain an ongoing record of health issues and concerns that the patient could share with his or her caregivers.

6.H.2.c. Feed Forward

The Feed Forward concept is part of a model developed by Eugene Nelson and John Wasson that aims to use information to improve the ability of the microsystem to deliver effective care that addresses the patient's needs. The basic idea is that, prior to a visit, each patient completes a questionnaire that asks about perceptions of the care received to date, functional health status, clinical health status, and health risk status. The clinical team can then use that information to design and deliver a treatment plan that is appropriate for that individual.

After the visit, the team collects similar information that can be used to redesign care for future patients (i.e., information for feedback). The model encompasses other steps as well, including a "prescription" that includes self-care assignments and tailored instructions.

6.H.2.d. Coached Care

Coached Care programs are designed to prepare patients to be more effective participants in their care by teaching them how to ask the right questions, how to interrupt, and how to get their needs met in the encounter. Coaching sessions may also address common misconceptions regarding a condition. Its goals include:

• Helping people become more assertive health care consumer.
• Improving the quality of interpersonal care.
• Increasing patient involvement in treatment decisions.

The design of Coached Care programs varies from the inexpensive, where patients receive brochures prior to their visits that contain a list of common questions and other prompts, to more expensive programs involving individual coaching sessions between patients and designated clinic staff. For example, just prior to a doctor visit, a nurse may interview the patient, review the chart together, and generate a list of questions the patient has for the doctor. These more involved coaching programs require larger resources for staff training in Coached Care techniques in addition to financial coverage of staff time. While coaching sessions are usually performed in an office setting, they may also take place through email or over the phone.

Coached care programs have been shown to improve both physiologic and functional outcomes.^4,5 In addition, anecdotal evidence suggests that Coached Care programs enhance physician-patient communication without requiring an increase in visit length.⁶

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References

1. Stewart MA. Effective physician-patient communication and health outcomes: A review. CMAJ 1995;152(9):1423-33..
2. Ross SE, Lin CT. The effects of promoting patient access to medical records: A review. J Am Med Inform Assoc 2003;10(2):129-38.
3. Maly RC, Bourque LB, Engelhardt RF. A randomized controlled trial of facilitating information giving to patients with chronic medical conditions: Effects on outcomes of care. J Fam Pract 1999;48(5):356-63.
4. Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med 1985;102(4):520-8.
5. Greenfield S, Kaplan SH, Ware JE Jr., et al. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3(5):448-57.
6. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989;27(3 Suppl):S110-27.

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