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.

The Intervention

Health plans and medical groups 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 and less likely to sue in case of an error. 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

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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, to feel more in control of their health, and to 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 will make it easier to share legible (and therefore less confusing) information. Some health plans are already taking advantage of this capability: Geisinger Health Plan in Danville, PA, for example, offers members access to portions of their electronic medical record through the Internet. (Visit https://mygeisinger.geisinger.org/.)

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.[1] It has been found especially effective for patients with repeated visits, such as those with chronic conditions[2] and pregnant women.

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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, for example, offers members a form that suggests they 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.

Review a “Shared Care Plan” developed by PeaceHealth, a health system in the Pacific Northwest: Accessed June 2, 2008.

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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. (Learn about the microsystem concept.) 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.

For more information, see

  • Nelson EC, Batalden PB, Homa K, et al. Microsystems in Health Care: Part 2. Creating a Rich Information Environment. Jt Comm J Qual Improv 2003 Jan;29(1): 5-15.
  • Wasson JH, Stukel TA, Weiss JE, et al. A Randomized Trial of the Use of Patient Self-Assessment Data to Improve Community Practices. Eff Clin Pract 1999 Jan-Feb;2(1): 1-10.

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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 consumers, improving the quality of interpersonal care, and 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 e-mail or over the phone.

Coached care programs have been shown to improve both physiologic and functional outcomes.[3],[4] A 1995 literature review of 21 studies found a definite correlation between effective physician-patient communication and improved patient health outcomes.[5] In addition, anecdotal evidence suggests that Coached Care programs enhance physician-patient communication without requiring an increase in visit length.[6]

Find citations about the impact of coached care on breast cancer decision making.

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Some Examples

The PREPARE Program: The Institute for Healthcare Communication offers a communication improvement model for patients called the PREPARE Program. The PREPARE to be Partners in Your Health Care: Six Steps to Help You Get More Out of Your Doctor’s Visit program consists of a self-administered audio tape and a guidebook that can be used to prepare patients for medical visits. It is designed to be used in a brief time period such as while waiting to see the doctor. The program takes approximately 20 minutes to complete and is most effective when used immediately before the doctor’s visit and when the guidebook is taken into the visit as a reminder and place to write.

 

The Six Steps of Prepare

 
Step One: PlanThink about what you want to tell your doctor or learn from your doctor today. Once you have a list, number the most important things.
Step Two: ReportWhen you see the doctor, tell your doctor what you want to talk about during your visit today.
Step Three: Exchange InformationMake sure you tell the doctor and ask the doctor what is wrong with you.
Step Four: ParticipateDiscuss with your doctor the different ways of handling your health problems. Make sure you understand the good things and bad things about each choice.
Step Five: AgreeBe sure you and your doctor agree on a treatment plan you can live with.
Step Six: RepeatTell your doctor what you think you will need to do to take care the problem.

 

For more information on the PREPARE kits, visit the Institute for Healthcare Communication Web site at http://www.healthcarecomm.org/index_noflash.php?sec=courses&sub=special&course=1&noflash. For more information about how to implement this program in a clinic, hospital, or managed care organization, please contact the Institute at 1-800-800-5907 or by e-mail at info@healthcarecomm.org.

Consumer Tips on Patient Safety: Health plans and medical practices can help patients understand what they can do to get safer care by taking advantage of a communications program launched by several Federal agencies, including the Agency for Healthcare Research and Quality, the Centers for Medicare & Medicaid Services, the Office of Personnel Management, and the Department of Labor. Conducted in partnership with the American Hospital Association (AHA) and the American Medical Association (AMA), this campaign aims to distribute information about improving patient safety to health care providers and patients across the country.

Posters and fact sheets describe “5 Steps to Safer Health Care,” which are evidence-based, practical tips on the role that patients can play to help improve the safety of the care that they receive. These materials, which are available in English and Spanish, emphasize that good communication between health care providers and patients can often reduce a potential source of problems in today’s increasingly complex health care system. The tips are also included in CMS’s Medicare & You handbook, which is mailed to about 39 million Medicare households each year.

The AHA and AMA are encouraging hospital leaders and physicians to hang the posters in their waiting rooms and exam rooms to help encourage dialogue between patients and providers about health care safety. The groups also are distributing the posters through mailings and meetings.

Copies of “5 Steps to Safer Health Care” are available on the Web in English at http://www.ahrq.gov/consumer/5steps.htm or in Spanish at http://www.ahrq.gov/consumer/cincorec.htm.

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Key Resources 

[1] Ross SE and Lin CT. The effects of promoting patient access to medical records: a review. J Am Med Inform Assoc 2003;10(2): 129-38.
[2] 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.
[3] Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med 1985;102(4): 520-8.
[4] 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.
[5] Stewart MA. Effective physician-patient communication and health outcomes: a review. Cmaj 1995;152(9): 1423-33.
[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.