Skip to main content
Category

Clinician

Professional, licensed caregiver, medical or not such as nurse, physician, technologist, therapist, etc.

Engage! Will patient engagement achieve “warp speed” this year?

By Advocate, Caregiver, Clinician, Consumer, ePatient, Leader

Engage! Will patient engagement achieve “warp speed” this year?

A fascinating HIMSS LinkedIn thread started by Brad Tritle (@BTritle) on January 9, 2013, with 100 posts through January 23, 2013 by 46 Individuals (31 single post, 15 multiple posts) – 18 pages. The full thread can be found here. I had great difficulty categorizing and summarizing. I started trying to use the National eHealth Collaborative, Patient Engagement Framework: Inform Me, Engage Me, Empower Me, Partner with Me, Support My e-Community. The exchange was more: Culture/lifestyle, Experience/literacy/diversity/education, Reimbursement/incentives/cost, Community/coordination, Clinician engagement, and Access/technology/interoperability/portals. The thread included 24 links. They are compiled here. The extract can be found below. Here are some pearls: Read More

Open Notes

By Advocate, Clinician, Consumer, ePatient
What information is there about me in my medical record? There’s certainly diagnosis, medications, procedures, allergies, treatment plans, referrals, diagnostic test reports (labs, radiology, EKG, pathology). I have more access to that information these days through visit summaries given at the end of the visit and on the different portals my providers have. But what about the notes they write? What is in those notes? How the plan /medications are working, my mood, concerns about my safety or my ability to think clearly, questions I ask with the answers given, calls the clinician makes about me, calls they receive about me, their thought process as they manage my care.  I can legally obtain these notes now by asking for a copy of my full medical record, but its cumbersome, complicated, costs money, and very, very seldom done. The movement to give us access to these clinician notes through a patient portal is called, Open Notes. (for more information click here) The VA and several hospital and physician clinic systems have committed to Open Notes. A study in the Annals of Internal Medicine (click here) was done that found  Patients accessed visit notes frequently, a large majority reported clinically relevant benefits and minimal concerns, and virtually all patients wanted the practice to continue. With doctors experiencing no more than a modest effect on their work lives, open notes seem worthy of widespread adoption.

I receive some of my care at one of the Open Notes pioneering institutions, but I see no notes on my Patient Portal. I will ask next week when I see the specialist. I completely support the Open Notes initiative. I want access to anything about me. I do have some thoughts and questions though:
  • As a clinician myself, having read tens of thousands of notes, it’s hard work finding relevant information in those notes. Clinicians don’t all write in an informative manner. Abbreviations abound. It will be interesting to see how note writing evolves as Open Notes proliferate.
  • Can I challenge an error? This is no different than errors in my medication lists or vaccinations. I have tried to correct something in my record with no affect. This will continue to be a challenge.
  • Will clinicians continue to write about concerns with my safety and state of mind? Read more about this here.
Have you experienced Open Notes? What do you think about access to Open Notes?

Magic levers of cultural change

By Advocate, Caregiver, Clinician, Consumer, ePatient, Leader
I’m traveling these days in many bands of committed people and groups striving to improve the health journey for themselves, their loved ones, and patients in general. These bands include advocates, novice and seasoned entrepreneurs, trade associations, providers of care across the continuum; and governmental and quasi-governmental entities. Each band slogs through terrain of incredulity, frustration, anger, hopelessness, and desperation with winds of dedication, confidence, hope, and possibility at their backs.

While traveling in these many bands, I periodically step aside to rest and contemplate change – process and cultural change. What do I expect, what do I want, am I using my limited energy wisely? Frankly, I don’t expect much. Cultural change in a complex system with nonsensical incentives, without clear leaders, with so much money, and seemingly stuck in cement is a bitch. I just aspire to a little better, some of the time. I want my family and fellow travelers to get the care they need, when and where they need it. I want to have fun while traveling. My personal energy is holding up – so far so good. But is my energy being used effectively? Do I make a difference

Helping

By Caregiver, Clinician, ePatient, Leader
As a nurse, caregiver, informaticist, and consultant, I help others. Intriguing concept – helping – much dynamic tension. Altruism, emotional gratification, self-satisfaction, egotism, persistence, profit, dependence. After nursing for several years I joked that nursing was an acceptable form of nosiness. I’m involved with people at intimate moments in their lives. I am gratified to participate. As an informaticist, helping clinicians and patients utilize electronic tools, the hardest work is listening to what help was needed and ensuring that the tools served the users rather than the other way around. It’s not about the tool, its about the patient, caregiver, and clinician. Caring for family members,  I’ve struggle with the tension of what I wanted to do to help and what help was wanted. Akin to parenting power dynamics. Occasionally, I’ve had to stop helping because we crossed a boundary of tension: My contribution wasn’t really helping, my feelings were hurt, I felt trapped, I was treated poorly, I wore out. As a consultant, I often found a misalignment between the help asked for and the help wanted. Confusing and disheartening. There’s a lot of helping in health care. How can helping be cleaner, regenerate, be powerful? Attending to personal, organizational, and system health of the helper – magic lever to best health. Fitness, rest, communication, leadership, fiscal soundness all help the helper. What challenges do you face as a helper or receiving help?

System Magic Levers of Best Health

By Caregiver, Clinician, Consumer, ePatient, Leader
I am an e-patient, a caregiver, a nurse, an informaticist, and a leader.  I live and work where the patient, the caregiver, the clinician, and technology intersect. Writing this blog for the past six months has helped me focus on magic levers of best health. The magic levers of best personal health include: Rest, diet, exercise, resilience, network, team, trust, mindfulness. The magic levers of best organizational health: leadership, purpose, alignment, trust, vulnerability, mindfulness, learning, execution. How about system magic levers of best health?  Here’s my first stab at that:
  1. Mutual goals and plans set by the health team (people, their caregivers and clinicians)
  2. Tools and relationships maximize the health team’s ability to follow the plans set to meet mutual goals
  3. Accessible evidence supports just-in-time health decision-making by people and their caregivers
  4. The entire health team works from the same goals and data set
  5. Transparent health care costs
  6. Healthy health care organizations
  7. Hardwired continual learning from evolving experience and evidence
  8. Financial and human incentive alignment
What would you add? More in future posts!

Magic levers in Medically Induced Trauma

By Advocate, Clinician, ePatient, Leader
You’re not alone, we can help. Sigh… such reassurance in those words.  Medically Induced Trauma Support Services (MITSS), Inc. is a non-profit organization founded To Support Healing and Restore Hope to patients, families, and clinicians who have been affected by an adverse medical event or unintended outcome.

Linda Kenney, the founder of MITSS says:  In November of 1999, I found myself at the sharp end of an adverse medical event that nearly took my life. There was no acknowledgement of the emotional impact that might follow, and I certainly wasn’t prepared.  This event made me extremely aware of the lack of emotional support in place for patients, families, and care providers following these incidences.  I knew that I was very lucky to have survived and felt a personal sense of responsibility to address this hole in the healthcare system.  I made it my mission to see that the healthcare community and public were made aware of the emotional impact that exists following adverse medical events regardless of the cause.  I also became aware that the medical community is not typically set up to provide the type of support needed following the hospital stay.
Three magic levers for best health reflected at MITSS:
  1. Unintended consequences – trauma – can lead to powerful, positive outcomes for individuals, organizations, and the community
  2. Continual learning depends on open and honest communication
  3. To benefit from the whole health team, the whole health team needs support

Health Hats off to Linda Kenney and the growing family of MITSS at the start of their second decade!

Advocacy – Health Partners

By Advocate, Caregiver, Clinician, Consumer, ePatient
I’ve participated in several lively discussions about patient advocacy in the past weeks –  at the Boston Healthca.mp #hcbos, on the Society for Participatory Medicine (#S4PM) list and with Kelley Connor of Real Women on Health fame. Advocacy has two overlapping worlds – individual advocacy and policy advocacy.  I will muse here about individual advocacy in acute care. An advocate is a guide, champion, companion – health partner. So challenging for the acutely ill person to be effective as their own advocate. One of my sons went to Africa as a development aide worker. When I invited to engage on health with his team as they prepared for their adventure, I suggested that they identify a health partner among their team. Several months into their experience, we hadn’t heard from him in some time. Then we received a letter, Hi, I’m your son’s health partner. He contracted malaria… OMG. Health partners are those who know the patient and can focus on logistics, relationships, communication/information, and patient comfort. Vigilance about the mundane important things comes first: a good team, hand washing, pain management, and mobility. Next its access to information and setting goals or milestones. What has to happen before the patient can be discharged? Pain management, activity level, self care in the hospital, a safe place to go upon discharge. If the acute care is elective, its scouting out the official communication routes: who’s the charge nurse, where’s the patient relations office, will you be communicating with a hospitalist, an attending, a resident, or a student?  Who’s in charge of the overall care for this episode? Charles Inlander’s book, Take This Book to the Hospital with You gave voice to my early nursing career observations that the health journey was a risky place.  I had realized that my role as a nurse to be a patient advocate was valuable and necessary, but insufficient. Acting as an advocate for a son when he had cancer, I didn’t know as much as I thought about what he wanted and how I could be of help and not get in his way. We had many discussions together and as an immediate family about death and dying, about treatment options, about communication with extended family. So challenging to integrate my perspectives, emotions, fears and put his first. Thankfully, it wasn’t just me in that role. We had an advocacy team – my wife, other sons and their partners, his girlfriend and her parents. We did pretty well. As a nurse I’ve been challenged by advocates. It’s been rare that the advocate was clearly identified. More often the tension between family members muddied the water. For end of life issues, advanced directives and durable power of attorney helps clarify, but most acute care episodes are not end of life.

I’ve embraced and learned about health partners as a patient, caregiver, nurse, and leader. I’ve had cyclical conversations with any family I might serve as a health partner, especially my mother and my wife. With my mother it took 15 years to arrive at comfort with the discussion. My sister-in-law, a nurse, was the best I’ve ever seen identifying and supporting health partners with her patients. She brazenly and tenderly included it as part of her routine first assessment of every patient she cared for and then included them in the routine care.
Then there’s private, professional advocates – almost 350 of them members of AdvoConnection.  What are your thoughts about health partners?

Thresholds

By Caregiver, Clinician, Consumer, ePatient
We continuously cross thresholds in our journey to best health. A threshold is a beginning, a change – before you weren’t, now you are. You cross a threshold when entering a building, a room, a relationship, an experience. Cross a threshold as you park your car, enter a clinic, go for an MRI. Cross a threshold when your doctor or nurse enters the room or responds to your email, when you call your insurance company, when someone asks, How are you? Cross a threshold as you feel a lump, hear a diagnosis, throw up, panic, feel pain, fall. Before you didn’t, now you do.These thresholds upset our sense of balance, our inertia. The manifestation of imbalance can be spiritual, mental, and/or physical. Why me? Hopelessness, annoyance,frustration, fatigue The sense of imbalance when crossing a threshold can require or suck energy, depending on the moment and perspective.

A pivotal moment for me as a nurse was discovering the opportunities I had to experience some of these threshold crossings, moments of imbalance, with others. Having a companion or a guide at these moments is huge. A smile, a touch, information can change the trajectory of that crossing, speed the regaining of balance, add energy, provide relief, increase hope. My mission became: to increase the sense of balance patients, caregivers, and clinicians feel as they work together towards best health.

Threshold crossings occur around us constantly. Sometimes we notice them. How can we increase our personal and organizational capacity to be a guide or companion?

Magic Lever – Adherence to Health Plan

By Caregiver, Clinician, Consumer, ePatient, Leader
Unfortunately some providers call adherence to a health plan – compliance. This unhelpful label implies singular focus on the patient, as in “they aren’t compliant with taking their meds”.

The ability to develop and adhere to a health plan is probably the most complex magic lever of best health. Developing and adhering to a health plan involves studying population health; evidence-based best practice; collaborative relationships, behaviors, language, and alignment of the health team; standardized work flows with on-the-spot improvisation; electronic and non-electronic tools; leadership; and management of cultural and social habits and challenges. Setting up systems to make adherence more likely is challenging and labor intensive. The effort has to be worth the outcome.


Population health analytics – studies to predict those groups of people for whom adherence planning would yield the greatest benefit to health, experience, and cost. Evidence-based practice – adherence planning should be based on evidence – knowing it’s likely to do what the health team expects. Collaborative relationships, behaviors, language, and alignment of the health team – the intricate choreography with stars and cast who can speak to, understand each other, and work together for a common purpose. Standardized work flows with on-the-spot improvisation – adherence planning is largely production work repeated across groups of people. Yet each of us is slightly different and unique. Teams respond as people and circumstances change. Electronic and non-electronic tools – Adherence is not a point in time, but occurs and adjusts over time. Well meaning and determined people need help. Leadership – Creating and maintaining adherence friendly systems needs inspired leaders. Dance without a director is just a rave. Management of cultural and social habits and challenges – A person who doesn’t get a lunch break can’t take a mid day medication with food. A single parent with several children depending on public transportation can find it difficult to make a physical therapy appointment three times a week. Sensitivity to such challenges and public policy advocacy can increase the likelihood of adherence.
In short, adherence is serious work for everyone. It is not compliance.

Errors in Electronic Medical Records

By Clinician, Consumer, ePatient, Leader
I’m concerned about errors in electronic medical records. I love my technology, I’m an early adopter. I participate in several national initiatives bridging the consumer and health technology – HIMSS (Health Information Management Systems Society)  eConnecting with Consumers Committee, Society for Participatory Medicine, the federal Automated Blue Button InitiativeTIGER (Technology Informatics Guiding Education Reform), Patient Adherence Workgroup. I have a PHR (Patient Health Record) through Microsoft Health Vault and have enrolled in patient portals for all my physicians who have one. What worries me is the quality of the data in those systems. As a nurse, quality improvement expert, informaticist, leader, and  consumer, I know the opportunities for errors in data. Databases and electronic information are only as good as the information in them.  We all have our stories about frustration with erroneous data in our credit reports and how difficult it is to fix it. Health care data is the same only there’s more of it. Clinicians are challenged to correct mistakes in electronic data. Here is an article about clinicians correcting electronic data mistakes. As consumers expect and receive more and more access to their electronic health data, they will question the quality of some of that data. How will they be able to correct it? Correcting electronic data is complex and labor intensive. Here is an article about consumers correcting their records. Do any of you have experience with errors in your medical record, electronic or paper? Please share.