Participatory Medicine is a model of medical care in which patients are active in the management of their health. For a comprehensive article on Participatory Medicine in the AmedNews (January 2010) click here.
Archive for January, 2010
I like to get complaints from patients. The best situation is when I have the opportunity to meet face-to-face with the patient when they are in the office. No, I’m not a glutton for punishment. What I like about complaints is that I get to hear directly from the patient what is bothering them, and I have an opportunity to let a patient know what we’re trying to do in the practice. Here’s my guide to patient apologies.
Step One: I introduce myself and shake the patient’s hand and the hand of anyone else in the exam room.
Step Two: I sit down. There are two reasons for that. One is to send the message that they do not need to hurry - this conversation can take as long as they need it to. The second is to place myself physically below the patient. If they are sitting on the exam table, I will sit in the chair. If they are sitting in the chair, I will sit on the step to the exam table. The message I am sending is “I do not consider myself to be above you.” It sends a very strong message.
Step Three: I say “I understand we have not done a very good job with __________ (returning your calls, giving you an appointment, getting your test results back to you, etc.) Can you tell me about it?” I do not take notes as I want to focus on the patient, but I take good mental notes. The patient and/or anyone with them needs to be able to talk as long as they want. They might need to tell their story twice or many times to get to the point where they’ve gotten relief. The patient has to get the problem off their chest before the next part can happen.
Step Four: I apologize, saying “I’d like to apologize on behalf of the practice and the staff that this happened. I want you to know this is not the way we intend for _______ to work in the practice.” If anything unusual has been happening, a policy has changed, or new staff have been hired, I let them know by saying “So-and-so has just happened, but that’s not your problem. We know our service has slipped, but we’re hoping we are on the way to getting it fixed.”
Step Five: Answer any questions the patient has. How will you fix this for me? Why did the policy change? What’s the best way to get an appointment? Are you trying to drive patients away? Are you going to hire more doctors?
Step Six: I offer my name again and a way for them to contact me if they have further problems.
Step Seven: I follow-up on the information the patient has given me to find out where the system broke down or where a new system might need to be developed.
I had the opportunity to apologize twice last week. It helped me to keep a pulse on the practice, know what patients are struggling with, and of course, practice humility. All good stuff for a practice manager.
For an excellent article on how doctors can apologize to patients for medical mistakes (AmedNews, February 2010) click here.
SBAR stands for Situation, Background, Assessment and Recomendation and is pronounced “S – BAR.”
SBAR is a standard format initially utilized by nurses to bring a physician up to speed on a problem. At some point in time, it was realized that nurses and physicians communicate differently. Generalizing, nurses want to “tell the story” of a problem and physicians want “the headlines.”
The IHI (Institute for Healthcare Improvement) says:
The safety attitudes questionnaire administered at Kaiser Permanente identified that physician and nurse perceptions of teamwork were significantly different. Physicians tended to view the care environment as fairly collaborative, whereas nurses saw it as much less so. To address the issue, Kaiser Permanente developed a communication tool that was adapted from the US Navy, called SBAR.
SBAR is an easy-to-remember, concrete mechanism useful for framing any conversation, especially critical ones, requiring a clinician’s immediate attention and action. It allows for an easy and focused way to set expectations for what will be communicated and how between members of the team, which is essential for developing teamwork and fostering a culture of patient safety.
S=Situation (a concise statement of the problem)
B=Background (pertinent and brief information related to the situation)
A=Assessment (analysis and considerations of options ”” what you found/think)
R=Recommendation (action requested/recommended ”” what you want)
SOAP stands for Subjective, Objective, Assessment and Plan. It is a standard format for documenting a patient encounter and can be used both for face-to-face encounters as well as triage phone calls.
Subjective = what the patient reports as the problem, symptoms, location, duration, severity, etc.
Objective = the visual and physical examination of the patient (does not apply to phone triage)
Assessment = the diagnosis, or possible diagnosis of the problem
Plan = what the next step in treating the problem will be (medication, tests, referral, follow-up) or in the case of phone triage (work-in appointment vs. home instructions vs. ER)
Two acronyms that confused me early on in my career were “H & P” and “HNP” because they sound exactly the same and few people enunciate clearly enough to distinguish the difference. The context will tell you the difference, but for anyone new to healthcare the context might be just as confusing.
H & P – History and Physical
An H & P may be performed upon a patient’s admission to the hospital, prior to a surgery/procedure, or as part of a new patient visit. An H & P includes:
- History of Present Illness
- Past Medical History
- Family History
- Review of Systems
- Physical Examination
- Problem List
Herniated Nucleus Pulposus or Herniated Disk
A herniated (slipped) disk occurs when all or part of a spinal disk is forced through a weakened part of the disk. This places pressure on nearby nerves. Also referred to as Lumbar radiculopathy; Cervical radiculopathy; Herniated intervertebral disk; Prolapsed intervertebral disk; Slipped disk; Ruptured disk. (1-2010)
Prothrombin time (PT) evaluates the ability of blood to clot properly, it can be used to help diagnose bleeding. The PT may be ordered when a patient who is not taking anti-coagulant drugs has signs or symptoms of a bleeding disorder, which can range from nosebleeds, bleeding gums, bruising, heavy menstrual periods, blood in the stool and/or urine to arthritic-type symptoms (damage from bleeding into joints), loss of vision, and chronic anemia. Sometimes the PT may be ordered when a patient is to undergo an invasive medical procedure, such as surgery, to ensure normal clotting ability.
The International Normalized Ratio (INR) is used to monitor the effectiveness of blood thinning drugs such as warfarin (Coumadin). These anti-coagulant drugs help inhibit the formation of blood clots. They are prescribed on a long-term basis to patients who have experienced recurrent inappropriate blood clotting. This includes those who have had heart attacks, strokes, and deep vein thrombosis (DVT). Anti-coagulant therapy may also be given as a preventative measure in patients who have artificial heart valves and on a short-term basis to patients who have had surgeries, such as knee replacements. The anti-coagulant drugs must be carefully monitored to maintain a balance between preventing clots and causing excessive bleeding.
Information provided by the American Association of Clinical Chemistry site here (1-2010).
Considered by many to be the most useful and realistic management theory ever, MBWA is the concept that you need to be present in the area you are managing to be an effective manager. MBWA includes:
- making rounds in every area several times daily
- touching base with each employee to see how they are, if they are having any issues and if there is anything they need help with
- modeling appropriate behavior and customer service by greeting patients, picking up the phone if there is no one else to do it, picking up paper off the floor, etc.
- checking to make sure machines are operating properly, staff are following protocols, there are no bottlenecks anywhere, and there are no signs of trouble brewing.
A manager who manages from their personal office is ineffective and out of touch with the people and area s/he is managing.
Accounts Receivable, abbreviated and called “A.R.” and written as “A/R” is the money due to a healthcare organization for services provided. For most cash-based non-hospital practices, the A/R works as follows:
- When a service is provided to a patient, the charges are added to the A/R.
- For most charges that are added to the A/R, it is assumed that a portion will be paid by an insurance company, a portion will be paid by the patient, and a portion will be written off.
- Very few, if any healthcare organizations will actually collect the entire A/R as most provide whopping amounts of charity care, negotiated payment care, government-subsidized care and care that is never compensated and is written off to bad debt as uncollectable.
- When payments are made, the amount due is reduced and therefore, the A/R is reduced.
- An aged A/R will divide the money owed into aging buckets of Current (less than 30 days old), 30, 60, 90, 120, and 150+ days old.
- The older or more “aged” the charges in the A/R become, the harder it is to collect and the less value it has.
- I think the appropriate way to age charges is from the date of service, but some groups age their A/R from the date the insurance pays and the remaining balance is due from the patient. This is called “re-aging” the account.
When a claim is adjudicated, the payer (or possibly the Third Party Administrator) applies a series of payment rules such as:
- the subscriber or beneficiary’s eligibility to receive benefits
- whether the services provided are covered under the subscriber’s plan
- the allowable charge per the contract between the care provider and the payer
- the percentage of the allowable charge paid according to the contract
- the application of the terms of the subscriber’s plan insofar as deductibles, co-insurance, co-pays
Once these rules have been applied and a benefit or denial, or combination of the two, has been determined, the claim has been adjudicated.
Some payers currently provide electronic time-of-service adjudication which allows a care provider to collect the patient’s portion of the payment during the check-out process.
Social media is media designed to be distributed through social interaction using Internet and web-based technologies. Social media use is said to be the defining factor in the idea that the current period in time will be defined as the “Attention Age.”
Wikipedia lists the following information and examples of social media:
Social media can take many different forms, including Internet forums, weblogs, social blogs, wikis, podcasts, pictures, video, rating and bookmarking. Technologies include: blogs, picture-sharing, vlogs, wall-postings, email, instant messaging, music-sharing, crowdsourcing, and voice over IP, to name a few. Many of these social media services can be integrated via social network aggregation platforms like Mybloglog and Plaxo.
- Blogs: Blogger, LiveJournal, Open Diary, TypePad, WordPress, Vox, ExpressionEngine, Xanga
- Micro-blogging / Presence applications: FMyLife, Jaiku, Plurk, Twitter, Tumblr, Posterous, Yammer
- Social networking: Bebo, Elgg, Facebook, Geni.com, Hi5, LinkedIn, MySpace, Ning, Orkut, Skyrock
- Social network aggregation: NutshellMail, FriendFeed
- Events: Upcoming, Eventful, Meetup.com
- Wikis: Wikipedia, PBworks, Wetpaint
- Social bookmarking (or social tagging): Delicious, StumbleUpon, Google Reader, CiteULike
- Social news: Digg, Mixx, Reddit, NowPublic
- Opinion sites: epinions, Yelp
- Photography and art sharing: deviantArt, Flickr, Photobucket, Picasa, SmugMug, Zooomr
- Video sharing: YouTube, Viddler, Vimeo, sevenload
- Livecasting: Ustream.tv, Justin.tv, Stickam, Skype
- Music and audio sharing: imeem, The Hype Machine, Last.fm, ccMixter, ShareTheMusic
- Reviews and opinions
- Product reviews: epinions.com, MouthShut.com
- Business reviews: Customer Lobby, yelp.com
- Community Q&A: Yahoo! Answers, WikiAnswers, Askville, Google Answers
- Media and entertainment platforms: Cisco Eos
- Virtual worlds: Second Life, The Sims Online, Forterra
- Game sharing: Miniclip, Kongregate