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Danny

Feb 18 2018
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Imagine

By Clinician, ePatient

Clinician

Imagine sitting down with your patient and care partner to find them prepared to choose a treatment that works for them.

Imagine that they know their life priorities and their life challenges and can and will communicate them to you.

Imagine that you have a key to the Tower of Babel and can communicate with anyone.

Imagine that you have the latest research at your fingertips so you can have informed conversations with your patient.

Imagine that they understand that recommended treatments might work. It’s an experiment based on pretty good research, your clinical experience and training, and your sensitivity to them.

Imagine that you all accept the uncertainty of evidence and of life.

Imagine that they trust you.

Imagine that you have all the time you need together with no distractions for you or them.

Imagine that your practice runs so efficiently and effectively that most of your face time with patients is spent in relationship building, exam, and problem-solving.

Imagine that by spending a few minutes together, you can to input assessment and exam and their data seamlessly into their electronic medical record (EHR).

Imagine that they can and do submit corrections to the data in their records and that those corrections can be reviewed and entered quickly.

Imagine that it’s easy to track in the EHR how well the actions taken to treat actually worked over time using your entries and their entries.

Imagine that the recommendations chosen automatically populate a personal care plan for your patient along with all the other choices you made together about treatment and self-care.

Imagine that they will follow the plan, track progress, and let you know when they don’t and why.

Imagine that the up-to-date treatment plan and tracker is shareable in real time with anyone the patient chooses using any EHR or health app.

Patient and Care Partner

Imagine that you have all the information you need to make decisions about your medical treatment including the cost of those choices.

Imagine that the information can be shared with your family, friends, and advisors so you are prepared to advocate for yourself and make decisions with your doctor.

Imagine that you can talk about your life’s goals and challenges and that your doctor can hear you.

Imagine that all health professionals realize that they are guests in your life.

Imagine that you have time to talk and share with your doctor without distractions.

Imagine that your doctor trusts you to be the expert about you.

Imagine that your doctor helps you understand research and how it applies to you.

Imagine that you have a care partner who goes to doctor visits with you, listens and advocates for you.

Imagine that your health and wellness choices and plans can be found in your EHR.

Imagine that you can correct and update your health data and track your progress in your EHR.

Imagine you have one up-to-date EHR for all settings and providers and you control who has access to it.

Imagine that you have access to medical advice and can get questions answered when you need it, in a manner that you can digest.

Imagine that if you try something and it doesn’t work, you can adjust quickly with your health team to try something else.

 

Imagine

Photo by Bonnie Kittle on Unsplash

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Feb 11 2018
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People with Chronic Illness Get Sick Too

By Clinician, ePatient

When I watch the camera scan a crowd (sports event, political rally) or I’m on the T (subway) I pick someone out and wonder,  What’s their backstories? Where do they live? Do they like being where they are right now? What ailments do they suffer from? Are they chronically ill? I’m either curious or nosey, maybe both.

A common theme in chronic illness social media is the frequent invisibility of chronic illness. You don’t look sick! When I see someone with a visible disability, I wonder if they have a cold, a stomach ache, or recently stubbed their toe?  People with chronic illnesses get sick, too. As my Primary Care doc says, your specialists help you manage your multiple sclerosis, I help you manage the rest of you. You’re still a 65-year old white man with high cholesterol, a prostate, a heartburn. You can get sick just like anyone else. Read More

Feb 04 2018
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Health Hats: Reflecting on 2017

By Advocate, Caregiver, Clinician, Leader, Researcher

Since I stopped being an employee or a boss two years ago I’ve written annual reports for myself. I had written ones for my boss and staff for 25 years straight. I thought I’d keep it up now that I’m retired from that. Helps me be sure that my work serves my mission. With so much to do in this sick, sickness industry, it’s easy to feel disappointed and burned out. Fortunately, I’ve made a career of beating low expectations – starting with something truly disappointing and finding the small thing that can have an outsized impact by moving that something a lasting inch. I call them levers for best health. I’ve found that drinking water has the most outsized impact for best health. Anyway, the annual report helps me keep a pulse on the balance between impactful work and stoking my fires while managing my health and having fun. It’s an inspiring strange ride. Thanks for being on the ride with me. I couldn’t do it without the personal inspiration of my immediate family (Ann, Simon, Ruben, Jessica, Kate, Anica, Jacky, Leon, and Oscar) and my friends (Mary Sue, Sue, Michael, Kathy, Fatima, Regina, John, Geri, MaryAnne, and Pat). Read More

Jan 21 2018
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A Fish Out of Water

By Advocate, Caregiver, Clinician, ePatient, Leader

When I went to an inner city Nursing School in 1975, I was a 19-year old hippie white boy from the suburbs in a class of 150 mostly mid-aged African American women (one other guy).  I felt like a fish out of water. When you’re admitted to the hospital you’re wearing a johnnie, pushing a button for help, and feeling like crap you’re surrounded by streams of people in uniforms who know each other and work together every day. A fish out of water. As a patient stakeholder/expert on a panel, I’m surrounded by scientists, physicians, administrators.  A fish out of water.

Interesting idiom, fish out of water. I picture a fish flapping, breathless, on the deck of a boat or in a pail, ready to die. But really that’s way too drastic. It’s more, oh crap, what am I doing here? I don’t belong. I feel so small. I’m an extrovert (or ENFP for you Myers Briggs folk), so I wriggle out of that fish out of water feeling pretty quickly. Ever since my hippie drug days, I learned to bring safety with me whenever I did anything risky. My intro to Participatory Medicine was Take this Book to the Hospital with You by Charles Inlander and Ed Weiner. Create your own pond in the middle of dry dock in the fish out of water idiom. In Nursing School I set up a study group and held them at my classmates’ homes.  I knew how to study and they knew how to cook. As a direct care nurse, I encouraged people to have a family member with them at all times. I build relationships with people on panels and soon I have a pond.

It’s harder when you’re not an extrovert.  It takes pre-thought, planning, and encouragement from others. When I watch introverts manage successfully they know who they are, have confidence, and are clear that it’s their needs that should be met. And they take someone to the hospital with them.

What do you do when you’re a fish out of water?

Post Image from Public Domain Pictures

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Jan 14 2018
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Eureka! Triggers and Signals

By Advocate, Caregiver, Clinician, ePatient

When Liz found herself unwilling to floss, she knew that major depression was soon to follow. She’s going to need help.  She tells someone who knows how to help her before she loses the will to take any action. When I start to get dizzy, I know my MS symptoms will soon get worse.  Drinking water almost always helps. Water! Sometimes I feel like I’m going to cry. No real reason. Normal life. It’s a signal that I’m overtired. Nap or meditation is next.  It always works. If John feels stressed and bloated, a flare-up of his Crohn’s is soon to follow. He avoids certain food, takes acetaminophen, and stays near a bathroom. When Tiffany gets a rash she needs to see her doctor within a couple of days. If she has joint pain as well, it can’t wait a couple of days.  Tiffany has lupus.

Liz, John, Tiffany, and I recognize signals that trouble is coming and action is needed. We learned the signals because we are wired to take the step back and watch ourselves from a distance. We are mindful and curious about patterns. It takes time until the Eureka/recognition minute hits. None of our doctors ever asked us if we knew our signals or asked us about our patterns.  We are all four fortunate to have a friend or care partner who listens to our ramblings.  It’s during these ramblings, complaining, wondering, pattern-seeking, and problem-solving that we learned first one signal, then more. Two of us have clinicians that helped us figure out what to do once we told them about our signals. The other two tried stuff they learned from our advocacy associations and social media networks. We are so relieved to be building this tool chest of actions to take when we recognize signals. We are eager to discover more patterns and signals. It’s like turning over a rock and finding a twinkling gem.

Once we recognize a pattern, a signal, and an action that works, we can start to look for triggers. Triggers are stressors we know will be likely to cause a signal. Managing triggers is prevention. Liz, John, Tiffany, and I have a common set of triggers: emotional stress, inactivity, smoke inhalation, insufficient rest. We also have unique triggers.  They are many and varied.

Traditional doctor visits seldom contain routine time to learn about and discover signals, triggers, responses, and prevention. The electronic medical records seldom keep track of this learning, action, and response. It makes sense (silly, but makes sense). It’s time-consuming and it’s not in the many medical professionals’ training and workflow.  It’s up to us and our personal health team. I find that people who blog about their illness and their life challenges caused or made worse by their illness, almost always write about signals, triggers, and actions. You can find many on The Chronic Illness Bloggers here on Facebook. Liz, John, Tiffany, and I also keep track as we learn about what worked – Spreadsheets, journals, or blogging.

Not everyone has a pattern-seeking brain. Even if they do have a pattern-seeking brain, they may feel so bad that there’s little space to use it.  So it’s up to our care partner, our friends, our social network, to help us.  It’s liberating. It’s diagnosis agnostic (true for any chronic illness). It’s so totally worth the effort. What have you learned?

Dandelion Trigger Photo by Dawid Zawiła on Unsplash

Pattern Photo by Amador Loureiro on Unsplash

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Jan 07 2018
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#WordsDoMatter for Action

By Advocate, Caregiver, ePatient

Language has a magical influence on the lives we lead, with an impact on our thoughts, emotions, and/or actions. The words we use are one of the most potent ingredients in the science of language. Words have the power to heal, guide and motivate. They can confuse, mislead, and even hurt us. The intent of a spoken word can often be misinterpreted leading to an unintended consequence. The majority of our words are a result of habit and convenience. If we follow the ripple effect of our words to understand the emotions and/or behaviors they might potentially trigger, would it force us to pause, think and perhaps communicate differently? See Sarah Krug’s post on the Society of Participatory Medicine blog, The Power of Words in Healthcare: A Patient-Friendly Lexicon. Top 10 List #WordsDoMatter Project.

Sarah offers 10 words she vows not to use with patients and their families in 2018!

  1. Patient Engagement
  2. Patient Journey
  3. Patient Centric
  4. Co-Create
  5. Compliance/Adherence
  6. Survivor
  7. Fight
  8. Caregiver
  9. Shared Decision-Making
  10. Negative

Language does have magical influence. I appreciate Sarah’s post. Let’s pause and break this down. Some of these ten words are names, labels, such as survivor and caregiver. While these aren’t slurs nor do they denote disrespect, they aren’t in and of themselves that descriptive without the story behind them. A person is always more than a label. Actually, I don’t like other people to label me. I’ve been labeled heterosexual, white, retired, disabled, male nurse, patient, caregiver, etc.  Some labels I own, some labels feel limiting to me.  When I’m with other people who share a label I may either feel solidarity or feel my uniqueness. Usually, I spend little time on the label. I’d rather hear stories, share experiences, what worked and what didn’t with the people with whom I’m sharing a label. When people write and use labels about me, I can’t help but think of exceptions. I am not the typical caregiver, male nurse, retired person.  I guess.

Compliance, adherence, patient-centric, and shared decision-making have a power component. Who’s up, who’s down? As a patient activist, I would rather use Informed Decision-making or Health Care Choices than Shared Decision-making. But depending on the setting and my goals in the interaction,  I may point out the implications of the word choices or I may not. In any communication, I can choose to focus on the words used and do some education. I could listen and try to understand what the person means by the words being used. If I feel the words are offensive, I could speak up, be silent, or leave the room. Up to me.

Words have history. Patient engagement was once a revolutionary new concept. Now it’s lost its meaning or it could mean so many different things. I’d rather engage in my care, negotiate engagement, or find a common meaning with the people I’m in the room with. I think there could be other words used. However, those new words will inevitably become diluted as well.  I use journey a lot. I get so frustrated with the episodic view of health care: the visit, the hospital stay, the diagnosis. I prefer the journey, the adventure, the extended time, people, settings and the idea of a destination or goal. But I don’t care what words other people use, as long as it’s not based on diagnosis and episode.  I’ll keep using journey.

Words are important.  Especially if they’re offensive or as dilute as water. But they are also opportunities for sharing, learning, advocacy. I feel very strongly that refining words used is only step one in activism. More important to me is best health and quality of life; equity; personal, spiritual, food, and financial safety; respect; and community. And what do these words even mean? We listen, talk, and do. Hopefully, communication leads to action – action that we desire. The patient-friendly lexicon will always be dynamic.  Participatory Medicine is part of today’s lexicon.  I’d welcome the day when it gets added to the list as outdated and dilute.

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Dec 31 2017
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Communication at Transitions

By Advocate, Caregiver, Clinician, ePatient, Leader

The Journal of Participatory Medicine recently published an article I authored, Communication at Transitions: One Audacious Bite at a Time. During my 40+ years as a nurse, 30+ years as a caregiver, and many years with a chronic illness, I can think of nothing more common than transitions: hand-offs between team members occur many times a day and moving between settings (e.g., home to clinic, hospital to home) occur many times a year for anyone who’s sick. How can it be that our health system is so bad at transitions? It’s as if Mass Transit couldn’t manage transfers from bus to subway, airlines couldn’t transfer bags from one airline to another, or banks couldn’t transfer money from my bank to a store or my employer to my bank. Without transfers mass transit, airlines, banks couldn’t exist. I wrote this article with incredulous frustration. Here’s an overview of the article. Please read the article and let me know your thoughts. How can solving this communication issue become essential for the healthcare community?

The Journey

To be audacious and take significant steps toward achieving the Quadruple Aim (improving the patient experience of care; improving the health of populations; reducing the per capita cost of health care; and improving the work life of clinicians and staff), we patients and caregivers need to better understand key features of our health journeys. When on that health journey, we are patients interacting with a series of care teams: our home team (social network), our community agency teams, our emergency care team, our hospital teams, and on and on. These care teams include ourselves, our caregivers, clinicians, other professionals, and direct care and support staff—people at the center of care. The actions taken by people at the center of care to improve, maintain, or adapt to our health or illness represents our health care. Actions can be diagnostic, taking medications, undergoing procedures, learning, living life and getting help living life. So, our health journey is teams of people at the center of care taking such actions to provide healthcare and service to us.

Transitions – What a Mess

During this journey, we transition from one setting to another, from one team to another, repeatedly. Communication knits this maze of actions, interactions, and transitions together. At its core communication is two or more people or parties sharing some information via some channel (voice, paper, digital, dramatic), one time or several times in a particular setting, hoping to accomplish something that moves us along in our health journey. One of the most persistent and ubiquitous frustrations in health care is that of poor communication. Poor communication at transitions is at the root of much overuse, underuse, and misuse of health resources, and results in the inability of patients to complete recommended treatment. For the patient and their family this means unnecessary delays in returning to health or worse. For those professionals on the care team the incidents of harm, burnout, stress, and frustration cause financial, emotional and career-ending consequences. Poor communication at transitions impacts each of the Quadruple Aims. Read More

Dec 24 2017
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Paying Patient Experts

By Advocate, Caregiver, Consumer, ePatient

You’ve heard the Chief xxx Officer saying, I don’t need to listen to patient experts, we’re all patients. Gee, what do you say to this inexperience? You’ve also heard the empathy and born-again drive of the Chief xxx Officer who has a chronic illness, was recently hospitalized, or is the caregiver of a family member with chronic illness. Nothing can replace the experience of spending a day in a hospital bed or navigating your neighborhood for a day in a wheelchair.

I attended the Society of Participatory Medicine’s first conference a couple of months ago. Some businesses making big money from patient data describing their volunteer patient advisory panels or providing gift cards to their patient experts. We’d like to pay more, but it’s what we can afford.

I’ve been a reviewer of funding requests since 2013 for Patient-Centered Outcomes Research Institute (PCORI). PCORI pays all stakeholder reviewers (patients, clinicians, scientists, administrators) the same stipend-a reasonable amount.

In 2013 and 2014 funding applications I reviewed listed either no payment or $50 gift cards for patient stakeholders on their Research Advisory Boards. By 2016 many funding applications listed $500-$1000 stipends. In 2017 I saw an application that budgeted for the payment of respite care for caregiver experts’ carees. We’ve come a long way.

The US has a love-hate relationship with paying for value. It’s like the Golden Rule: easy to say, tough to do. Just look at the Trump-Ryan-McConnell tax bill. I digress… The healthcare industry values credentials as a proxy for knowledge- whether or not they know what the acronyms mean. Acronyms = expertise. Credentials usual mean deep expertise in a narrow subject. We willingly pay for deep and narrow with credentials. Patients can have deeper knowledge about a narrower subject than those credentialed. We don’t have a means to calculate that value nor a willingness to pay for it. Read More

Dec 17 2017
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A Vision of Paying for Value

By Caregiver, Clinician, ePatient, Family man, Researcher, Uncategorized

I’m the child, Custodian and Healthcare Proxy of my 89-year-old mother, Alice. I live in a different state. My mother has diabetes and is depressed. Her care team, beside herself and me, includes medical providers in various health settings, community support agencies, and a full-time caregiver that helps her schedule and get to health-related services. My problem is to understand what my mother wants for herself and to track who says they’re doing something for her (including my mother and me), what they’re doing, and when they’re doing it. I want to know what it takes to do it (Can she afford it? Can she get there? Does it agree with her? Who will be with her? etc.). I want to know if the actions have the effects we thought they would. I want to know what her risks are and how we plan to prevent or respond to them. I want to able to keep track of all this and keep it current. I want to share it or have it shared from day-to-day and from setting to setting even if I’m not present.

This scenario describes a vision of healthcare for a caregiver and his mother. The vision lives in a context of social circumstances, physical environment, individual behavior, genetics, and medical care – the determinants of health. In the best of circumstances, healthcare dollars pay for this vision of best health for people, their families, and communities.

The goals of any payment method should be to reward high-quality care and to permit the development of more effective ways of delivering care to improve the value obtained for the resources expended. These goals are relevant regardless of whether care is delivered in a predominantly competitive or regulated environment, and whether the ultimate purchaser is an employer or the patient/ consumer. Payment policies should not create barriers to improving the quality of care. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001. 8, Aligning Payment Policies with Quality Improvement. Available from: https://www.ncbi.nlm.nih.gov/books/NBK222279/

This means that payment systems for treatment and services recognize quality (best health), support improvement and reward stakeholders (patients, caregivers, clinicians, institutions, and insurers) for the process and outcomes of best health. Read More

Dec 10 2017
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CEO of My Health Team

By Advocate, Caregiver, Clinician, ePatient, Family man, Leader, Researcher

I am the CEO (Chief Executive Officer, the boss) of my health team with a ton of subcontractors: my primary care doc and her practice, my neurologist and his practice, the radiology department at my local hospital, the neighborhood pharmacy, the utility companies… You get the idea. They get paid through my employment benefits, your and my taxes, and out of my pocket. Right now I directly employ my massage therapist and acupuncturist – fee-for-service. I also have pro bono team members: my wife (my care partner), my family, friends, and advisors.

As CEO of my health team, I try to lead and manage. Leading is building and fostering relationships, finding service providers as needed, setting health goals, coming up with a plan to meet my goals, and learning from our mistakes (what doesn’t work).  As a leader I find ways to share information among the team, and, of course, I fundraise and cheerlead. Leading is also about succession planning.  Who will lead when I can’t? Managing, on the other hand, is negotiating service agreements (contracts), actually seeing that the tasks in the plan happen as desired, maintaining the team and it’s connections, and trying to fix what isn’t working. It’s a tough system to lead and manage. It’s exhausting. I have some of the skills I need, but nowhere near all. There’s very little training for Health Team CEOs- no certificate or degree. The pay stinks. There’s no vacation. I can’t resign. Read More