PatientsChartingCourse

Patients at Fargo Family Health Center decided they wanted to create a blog and listserv for patients living with diabetes. Instead of joining a public blog/support group for patients with diabetes, the patient advisors in the demonstration felt it was important that their providers know about their struggles and celebrations in living with diabetes. They also wanted to learn from other patients being treated at the health center. Patients registered for the site, and individual peer-to-peer phone calls were available for additional support. In the spirit of the phrase “all politics is local,” patients decided to create a geographic and condition-specific community of support for themselves that could be accessed by their clinical providers. Technical issues such as security and sharing of clinical information were challenges for this team. However, the opportunity to create a local community of patients who could offer each other support, provide information to their clinical partners, and impact the care provided at the local level helped the team decide to take on these issues and find effective ways of managing concerns about privacy and security for their participants (Miller, 2006).

eVisits: Saving Time and Money and Improving Satisfaction

Electronic provider visits hold the potential for enhancing patient–­ provider communication and enhancing the ability of primary care pro­ viders to offer care for nonurgent medical issues. The webVisit Study: Impact of Online Doctor-Patient Communication on Satisfaction and Cost of Care, conducted by researchers at Stanford and the University of ­California at Berkeley, evaluated whether using the eVisit platform offered by the company Relay Health was associated with satisfaction. Participating organizations included several health plans and large medical groups in California and Connecticut and 10 large self-insured employers. The intervention group included 282 physicians and 3,688 patients. Compared with controls, patients were 50 percent less likely to miss work; 45 percent were less likely to need a face-to-face visit with a physician, and 36 percent were less likely to telephone the physician’s office. Physicians reported that the system was easy to use (72 percent), satisfying (53 percent), and preferable to an office visit for nonurgent care (56 percent). Analysis of health claim costs for the intervention group showed a statistically significant lower cost for office-based claims (p <0.01) and total claims (p <0.05) (Zimmerman et al.).

a 2009 survey, 79 percent of whites, 67 percent of blacks, and 80 percent of Latinos said they used the Internet. Use of wireless handheld devices was actually greater for blacks and Latinos than for whites (Horrigan,­ 2009). In addition, Latinos with annual incomes below $30,000 had increased their use of the Internet by 17 points between 2006 and 2008 (Fox, 2009). Internet use is increasing across the board, and the differential use of web-enabled handheld devices may signal just-in-time health management opportunities for some patient populations.

The Penetration of Electronic Medical Records: Supply and Demand

In a 2007–2008 national survey of 2,758 physicians, only 17 percent of practices reported having EHR systems, with 26 percent indicating that they planned to buy such a system within the next 2 years (DesRoches et al., 2008). Physicians most likely to have EHR systems belonged to large practice groups, hospitals, or medical centers. Cost has been described as a barrier to purchasing such systems. The impact of the 2010 federal healthcare reform legislation supporting technical assistance for primary care providers in establishing EHR systems should be studied.

Reimbursement for Electronic Communication: Fact or Fiction

Many physicians continue to be concerned that they cannot bill thirdparty payers for Internet communications with patients. Although specific reimbursement policies vary from insurer to insurer, in 2008 the American Medical Association’s Current and Procedural Terminology was revised to allow for billing for online patient services. Online services have a designated code that can be used once per episode of care over a 7-day period and can include any follow-up issues, including prescriptions, laboratory services, and ordering of imaging studies (Porter, 2008).

Looking to the Future

Primary care delivery capacity, evolving HIT platforms, and demographic and market forces will shape the future use of the Internet as a vehicle for extending health care beyond the clinical practice setting. Recent studies show that the delivery and support of care through web-based platforms can increase patient and provider satisfaction while decreasing cost. As these web-based platforms continue to grow, developers should keep in mind the importance of the input of patients and their caregivers in the creation of these products.

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AHRQ (Agency for Healthcare Research and Quality). 2009. National healthcare disparities report. http://www.ahrq.gov/qual/nhqr09/nhqr09.pdf (accessed October 14, 2010).

DesRoches, C. M., E. G. Campbell, S. R. Rao, K. Donelan, T. G. Ferris, A. Jha, R. Kaushal, D. E. Levy, S. Rosenbaum, A. E. Shields, and D. Blumenthal. 2008. Electronic health records in ambulatory care—a national survey of physicians. New England Journal of Medicine 359(1):50-60.

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treatment options (Holmboe et al., 2000). This is true even when the decision involves “effective care”—care that is supported by strong evidence and usually depends less on an individual’s personal values and preferences (O’Connor et al., 2007). When treatments are not supported by adequate evidence or when they involve trade-offs that could impact a patient’s ­quality of life, the traditional informed consent process is inadequate for helping patients make informed treatment decisions. In these situations, the process should more appropriately be framed as informed choice, incorporating a discussion of treatment alternatives, the evidence associated with them, and the patient’s personal values.

To achieve the IOM’s goals around patient-centered decision making, a framework is needed that will allow patients, families, and providers to engage in successful, mutual healthcare interactions, allowing patient and family values to guide all healthcare decisions. This paper presents elements of such a framework and describes tools used by the Dartmouth Hitchcock Medical Center to support it.

Categories of Care

Effective Care

John Wennberg is credited with defining three categories of care: effective, preference-sensitive, and supply-sensitive (Table 7-1). Effective care is that which is supported by high-quality evidence demonstrating that the benefits of a proposed treatment or intervention are large compared with the potential harms. Clinicians, and most patients, agree on the appropriate course of action for effective care. When care is deemed effective, the clinician typically makes a recommendation, and the goal is patient compliance or increased uptake by a population (Wennberg, 2002). Examples include the use of antibiotics for treatment of bacterial pneumonia, screening with pap smears, and preventive flu vaccinations for healthcare workers.

Preference-Sensitive Care

Because of conflicting, uncertain, or insufficient information as well as differing personal preferences, the quality of evidence often does not allow for a clear “right” choice. A quality decision for these “preference-­sensitive” medical decisions requires that the patient be knowledgeable about the options and that his or her personal values inform the choice (Sepucha et al., 2004). Examples include elective surgeries such as LASIK eye surgery; use of screening tests, such as prostate-specific antigen for prostate cancer; and prevention of cervical cancer with human papillomavirus vaccinations. An effective care recommendation may become a preference-sensitive deci-

demonstrated that supply-sensitive care varies widely across the United States. This variation may result in underuse of effective care and improper use of preference-sensitive care. The latter may occur when patients are not provided accurate information about their options and are not encouraged to incorporate their own values and preferences into care decisions.

Healthcare Variation

The Dartmouth Atlas has used Medicare data to map geographic variations in care for more than 20 years. The project reports on resource and medical care use among beneficiaries living in 3,436 hospital service areas— aggregated into 306 hospital referral regions—examining unwarranted variations in the above three categories of clinical care. It has revealed the presence of significant geographic variations in healthcare prices, practices, and providers; patient characteristics; and patient preferences. The project also has found that regions that spend more on health care and have higher rates of utilization do not experience better health outcomes compared with regions spending less on health and using healthcare services less frequently (Fisher et al., 2003).

Although higher rates of effective treatments are preferred, it is difficult to define the “right rate” for preference-sensitive treatments. The question raised by Wennberg and colleagues is, given the variation in the rates of procedures across the United States, which rate is right (Weinstein et al., 1998)? To illustrate the issue, Figure 7-1 shows the variations in spinal surgery across hospital referral regions in the United States. The number of spinal surgeries ranges from fewer than 2 to almost 11 per 1,000 Medicare enrollees. Even among high-performing academic medical centers such as Intermountain, Geisinger, Mayo Clinic, and Dartmouth-Hitchcock Medical Center, there is more than a twofold variation in the rates of spinal surgery. Why is this the case? In this area of preference-sensitive care, the indications for surgery are not universally agreed upon, and the evidence to support the decision-making process is imperfect for both the clinician and the patient. In these cases, it is impossible to know which rate is right, and ideally, well-informed patients should decide whether the intervention is right for them. Thus it is incumbent on the healthcare system to provide patients with accurate, balanced information and encourage them to participate in the decision.

Helping Patients Make Treatment Decisions

Decision Quality

When there is no clear answer as to which treatment is best, the patient should decide. High-quality decisions depend on adequate knowledge,