Sunday, February 18, 2007

Doctor patient relati0nships - High Touch-High Tech Innovations at the Patient-Doctor Interface: A Baker’s Dozen + A Website

Today I spoke to Susan Keane Baker, a national expert on managing patient expectations at the patient-physician interface.

Until recently, this interaction interested only physicians, who considered the patient relationship a private matter. But times are changing, sometimes dramatically, with struggles of health plans to retain members, competition between hospitals and doctors for the high-cost procedure market , emergence of Internet-savvy cost-conscious consumers seeking to rate doctors , the Joint Commission’s concern with health literacy of consumers, and a current campaign of Medicare and AHRQ (Agency of Healthcare Research and Quality) to measure patient satisfaction and to tie that satisfaction to pay for hospitals and doctors.

Linking Pay to Patient Satisfaction

Linking hospital and doctor pay to patient satisfaction has caught the health industry’s attention. CMS and AHRQ have initiated a federal program called CAHPS (Consumer Assessment of Health Providers and Systems), CAHPS develops and distributes surveys to evaluate patient-doctor relationships. Surveys probe care aspects for which patients are the only source of information, as well as aspects consumers and patients identify as important.

Annual Surveys of Patient Satisfaction

CMS is also conducting annual surveys of recipients enrolled in Medicare Advantage plans and the original Medicare plans concerning their experiences and their evaluation of the care they receive in these health plans.

Patient surveys ask about:

• Getting care quickly
• Getting needed care
• How well providers communicate
• Health promotion and education
• Shared decision making
• Provider knowledge of patient medical histories
• How well office staffs communicate

This survey information may eventually be tied to:

• Quality improvement programs
• Continuing certification
• Public reporting
• Accreditation
• Pay for performance
• Accountability

Ostensibly this information will.

• Help Medicare beneficiaries and the public make more informed choices among health plans.
• Help identify problems and improve quality.
• Enhance CMS' ability to monitor Medicare plans’ quality and performance.

Big Brother, in other words, will be watching hospitals and doctors and basing reimbursement on consumers’ answers to questions about satisfaction and quality. Consumers’ answers will be categorized as: always (5), usually (4), sometimes (3), rarely(2), never (1). If hospitals or doctors’ average numeric score is high, they will presumably be rewarded, if low, they may suffer from yet to be named consequences. One consequence is likely to be public reporting of high and low performers, or perhaps I should say “satisfiers.”

CAHPS surveys raise issues and eyebrows. How reliable are patient satisfaction surveys? Do patient satisfaction surveys correlate with care quality? Does patient satisfaction have anything to do with physicians’ technical competence? Is intrusion into patient-physician relationships a proper role for government, long considered to be sacrosanct by the medical establishment? And what innovative steps can hospitals and doctors take to cope?

Susan Keane Baker, MHA, is a good person to whom to talk to about patient-physician interactions. Trained as a hospital administrator, Susan is author of Managing Patient Expectations: The Art of Finding & Keeping Loyal Patients (Jossey-Bass, 1998, San Francisco.) Her book has been ranked #3 on’s list of 100 top sellers in the general medicine category.

More recently, she and Leslie Bank, Director of Customer Service at Montefiore Medical Center in the Bronx, co-authored, “I’m Sorry to Health That…”: Real Life Responses to Patients’ 101 Most Common Complaints about Health Care (rL Solutions, 2006, Toronto). Susan is currently working on the 2nd edition of Managing Patient Expectations.

Susan has seventeen years experience as vice president at New York and Connecticut hospitals. She has also directed the quality initiatives program for a national PPO with 19 million members. Since starting her own company in 1994, Susan has spoken in 45 states. She gives 100 presentations a year, mostly to hospital groups.
For her communications work, Susan has been awarded the General Electric Circle Award and a Life Communicators Award of Excellence. She is a Certified Speaking Professional, the highest earned designation of the speaking profession. Susan is a Fellow of the American Society for Healthcare Risk Management and a Commissioner of the Connecticut State Commission on Medicolegal Investigations.

Thirteen Moments of Truth, A Baker’s Dozen

Susan basically preaches this gospel to hospitals and doctors: pay attention to human details: recognize the power of word of mouth, create a strong first impression, listen closely, elicit patient feedback, educate patients, and use best practice techniques. Above all, anticipate the following 13 human moments of truth where patients form their opinions:

1. calling your organization,
2. making an appointment,
3. receiving directions,
4. meeting the receptionist,
5. waiting in reception or exam room,
6. meeting the clinician,
7. giving a history,
8. having an examination,
9. having an invasive procedure,
10. giving a lab specimen,
11. receiving discharge instructions and leaving the organization,
12. obtaining test results,
13. receiving a bill.

Train yourself and your staff to meet patient expectations at these critical 13 moments of truth. Any of these 13 moments can be a turn-off or a turn-on. The trouble for doctors and their staff is, of course, is that these moments are hard to keep in mind all at once.

Physician Websites and E-Mail Communication

If there are any two innovations physicians can undertake to satisfy patients, particularly the demanding up-and-coming and aging baby boomers, it may be creating a practice website telling patients what to expect and using e-mail to communicate with patients about minor problems not requiring patients’ physical presence.

There are a number of companies out there to help doctors develop these websites and to facilitate email communication , including Medem, Inc. and Revolution Health, Inc. You can find other companies by googling “physician websites.” Use of email lends itself to e-visits, sometimes called virtual visits.

As patients visit the Internet more, physicians are using the Web to build and maintain loyal patients. An effective website facilitates scheduling appointments, refilling prescriptions, getting directions to the office, giving doctor credentials, educating patients, and even offering advice for treating minor illnesses through E-mail communications. Patient and doctor email exchange is still not widespread.. Although now only used by abut 25% of patients, patient-physician e-mail is growing in popularity and is destined to become an effective practice marketing tool for doctors.

E-mail communication is cost-effective, convenient, and time-saving for patients. And many health plans are now paying for virtual visits. E-mail saves physician time on the phone. Here e-mail is a plus since some physicians may spend up to three hours a day responding to phone calls, which also interrupt the flow of their work. Physicians are rarely paid for phone calls. Physicians can answer emails at their convenience. They do this by setting aside a convenient time at day’s end to answer all e-mails. Physicians are overcoming their reluctance to use email , and are finding their initial concerns – malpractice exposure, privacy concerns, overwhelming numbers of emails, and the impersonal nature of email - are largely unfounded.

I have a foreboding, unrelated to the exemplary work of Susan Keane Baker. Big Brother may be watching caregivers, but we in the health system are also watching Big Brother. My main concern is that CAPHS (Consumer Assessment of Physicians and Health Systems), begun with the best of intentions and still small, may grow into a vast intrusive federal bureaucracy with unforeseen, unintended, and undesirable consequences. By spreading its tentacles into private relationships, it may limit freedom and choice. Sometimes we need protection against our protectors. Most consumers, aka, patients, are intelligent and resourceful, and will, on their own, without federal assistance, figure out who are the good doctors and good hospitals.

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