Getting to a Better Patient Handoff

There's a need for training in how to communicate better

Mar 06, 2012 - Production Blog Author


Editor’s Note: Vineet Arora, MD, MPP, is an Associate Program
Director for the Internal Medicine Residency and Assistant Dean of
Scholarship & Discovery at University of Chicago’s Pritzker School of
Medicine
. She blogs about medical education at FutureDocs.

My work studying handoffs began back in 2003, after I was chief resident at the
University of Chicago. Through our research, we found that even in optimal
situations (dedicated room, dedicated time, attending supervision, etc.), 60
percent of the time, the handoff receiver was not able to name the top issue
for the patient as determined by the sender–despite having access to the
written record. Part of the problem may be information overload; people simply
cannot decipher the importance of various items when faced with so much
information. Therefore, there’s a need for training in how to communicate
better.

Imagine you’re writing a shopping list for somebody. If you’re putting it
together for a stranger, chances are you’ll be much more detailed in your
instructions than you would be with your spouse, who implicitly knows whether
“buy milk” means 2% or skim, thanks to your rich history of shared experiences.

What may be going on in hospital handoffs is that people are assuming that
they’re seeing the same things–so there’s that illusion of shared
experiences–but since those experiences are in reality happening successively,
there’s no opportunity to create a shared mental model of them. As a result,
directions may be vague and not precise enough for someone who does not
know a patient sufficiently to understand what to do.

In addition to verbal communication issues, there are also problems with the
written records. Eighty percent of handoff notes, for instance, contain a
medication omission of some kind. Electronic health records that integrate with
medications can certainly solve this problem. However, there are downsides to
integrating with EHRs. The ease of the copy-paste function means that handoff
notes are getting longer and longer. What you see is text that looks more like
a wiki than it does a synthesized problem list.

The best handoffs, both verbal and written, are concise and strike the right
balance between pertinent and thorough. They’re composed of a one-liner
diagnosis, followed by clear and specific anticipatory guidance that include
enough rationale so the recipient doesn’t have to guess at what the sender was
thinking.

Along with in-hospital shift handoffs, effective handoff communication is also
the cornerstone for continuity between a hospital-based physician and a primary
care physician. Mobile HIPAA-secure messaging, such as what’s used on
Doximity, has the potential to promote real time physician communication
during these care transitions, such as keeping primary care physicians
up-to-date during a patient’s hospitalization, or to alert them that their
input is needed on a specific question. Some of our other work has shown that
hospital-based physicians spend a lot of time looking up contact information
for primary care physicians–so certainly there is also potential to tighten up
that side of the process and facilitate timely communication. So, whether
it’s in-hospital or out of the hospital, it’s important to remember to handle
the handoff with care.

5 Health Technology Trends to Watch in 2012

Dr. Felasfa Wodajo, an orthopedic oncologist in metro Washington, DC and mHealth editor at iMedicalApps, shares his predictions for the new year.

Jan 05, 2012 - Production Blog Author


One of the most personally rewarding sides of my role at iMedicalApps is consistent and early exposure to the many ways technology is influencing and in some cases changing the way we physicians think about healthcare.

In particular, the proliferation of medical apps has opened doors we just a few years ago wouldn’t have thought possible. Some represent huge opportunities, others are as yet more vague. I’d argue that much of that gray is due to the fact that doctors and medical societies are only just beginning to engage with the task of evaluating what’s feasible and what isn’t in this relatively new landscape.

Given our exposure to what’s needed in the field, I think the conversations we doctors initiate and participate in play a critical role in this process. To that end, I’m devoting this post to a cribsheet of the health tech trends that have proven robust in the past year.


1. Patient education programs

You interact with patients for a brief amount of time, but their questions keep going. We’re starting to see a few good apps, as exemplified by the Orca MD series, that are trying to offer the kind of credible answers that might be tough for patients to find on google or through their social networks.


2. Phones as medical devices

The image is especially appealing–physicians and patients walking around with these incredibly powerful computers right in their pockets. Radio-frequency identification and bluetooth will be a huge component of how this technology develops, enabling doctors to do things such as use a phone as a pressure sensor to find out if a cast is too tight. Another application: Instead of having an ICU where patients are monitored, scannable monitors could be used on their bodies.


3. Networking services for information sharing

HIPAA-compliant networks such as Doximity are benefiting from the two obvious features already on smartphones–cameras and location services. Both are making it easier to discuss cases and make referrals.


4. Apps as prescriptions for behavioral change

On iMedicalApps we’re getting ready to publish some interesting early research on centers that are harnessing existing technology to develop behavior change programs. These apps can track behavior patterns through location services, text prompts asking users to evaluate state-of-mind, and even offer facetime counseling. This is place for great opportunity as mobile phones, as truly personal devices, could help modify behavior at the time and place where it counts the most.


5. Data flow for health records

Health data is shifting toward becoming less and less human-centered. Imagine a patient having his or her weight taken, with that measurement flowing into the medical record passively and immediately from the scale. The implications for data aggregation are profound.

Online physician reviews: 6 essential actions

Word-of-mouth is the number one referral-driver among patients, and that’s no less true online, where testimonials really can reward you for a job well done

Dec 29, 2011 - Production Blog Author


Editor’s Note: Howard Luks, MD, is Chief of Sports Medicine and
Arthroscopy at University Orthopaedics, PC and Westchester Medical
Center
, and blogs at howardluksmd.com.

Digital content has profoundly changed the way we think of patient feedback and
referrals; what used to be private has now become very public, thanks to the
proliferation of review sites like Yelp and Angie’s list. This is
largely positive. Word-of-mouth is the number one referral-driver among
patients, and that’s no less true online, where testimonials really can reward
you for a job well done.

Nevertheless, like it or not, negative feedback is also part of this landscape.
No matter how hard you try, you’re never going to please absolutely everyone.
For example, you may have someone in your office with whom on a normal day
you’d get along extremely well, and you’re just running late. That person may
well go online and share that.

Patients have a right to freedom of speech, and you can’t practice as if each
case is a potential bad review. You can, however, take this newer, more public
feedback loop as an opportunity to assess how strong your communication lines
are–not just in the context of the broad social media universe, but also among
your existing patient base. Here, six factors to consider:

Make sure you’ve educated your staff on how to treat patients properly: A
well-managed practice is the easiest way to keep patients from being
disgruntled. Do a careful assessment of the experience in your office, thinking
about how well you and your staff handle common bottlenecks such as intake and
wait times.

Designate an on-site point-person to deal with patient dissatisfaction as it
happens:
In our office, we have a point person who has actually gone through
HR training for patient complaints. We’ve designated a comfortable room off of
the examining area, and if someone is unhappy, we bring him or her there to air
grievances.

Give patients a way to reach someone directly after the fact: All of my
patients leave with an email address at which they can reach me. I make it
clear to them that I check it often, and if there’s a complaint, I’ll address
it directly.

Show who you are, online: Think about what your message is, how you’re
going to portray to yourself and select your site and topics carefully. I’m a
big believer in generating meaningful content, and giving other people a chance
to share it. One obvious benefit is that your online presence will drive down
any negative reviews, but more importantly, this kind of communication offers
patients additional ways to get to know you.

Remember that one bad comment won’t kill you: No matter how hard you try,
you’re inevitably going to annoy a patient or two. But you know what? It’s okay
to have a bad review. The world will hardly stop spinning. In fact, given that
75 to 85 percent of people never go past the second page of a search, it will
most likely not change course at all.

Let patients know you welcome positive reviews: The real message: Rather
than worrying about bad content, it’s much easier (and more rewarding) to focus
on generating the good. There’s absolutely no harm in being proactive about
engaging happy patients in supporting your public reputation, so be it through
your website or your office, be sure to invite them to post reviews on sites
like Yelp, or even a Testimonials page directly on your own site.

We've passed our 30,000 user milestone!

We’re excited about how far we’ve already come, and are looking forward to rolling out some new features in the next few months

Dec 03, 2011 - Production Blog Author


In April, when we first launched Doximity, we set a goal to reach 30,000
members before the end of the year. There are 600,000 physicians currently
practicing in the U.S., so 30,000 would represent 5% of our market. For
companies that rely on registered users, this is typically the point where
growth shifts well beyond early adopters.

This past week–just eight months later–we hit that mark. (You can read more
about it in the context of other healthcare companies in this TechCrunch blog
post
, and for even more nitty gritty, on our press page.) We’re also
wrapping up the year having become the largest medical professional network in
the U.S. To give you a sense of size, LinkedIn, which is the biggest
professional network overall and the only other such medical network requiring
real name users, currently has 15,000 physician members nationally.

We’re excited about how far we’ve already come, and are looking forward to
rolling out some new features in the next few months. Please continue to reach
out to us here, on the site, and through Facebook and Twitter.
We’re committed to addressing the unique needs of doctors and, as such, we take
your feedback very seriously.

Sincerely,
The Doximity Team

Debate: Is Kaiser good for medicine? (Part 2)

When it comes to issues of choice, namely the freedom to pursue an untried or very tailored treatment plan, there are significant compromises

Nov 25, 2011 - Doximity Blog


Editor’s Note: Marc Lawrence, MD, is a member of Doximity’s Advisory
Board.

Last month, advisory board member Peter Alperin wrote an essay outlining
the strengths and advantages
of Kaiser and other integrated delivery
systems. Like Peter, I have worked for Kaiser, and I, too, have found it to
be a good place for doctors. While the pay isn’t overwhelmingly high, the
employee benefit program is excellent, and physicians certainly face a smaller
risk of litigation there than they would in independent practices. Patient
follow-up is exemplary, and standard procedures and courses of treatment are
carefully developed and researched. However, when it comes to issues of choice,
namely the freedom to pursue an untried or very tailored treatment plan, there
are significant compromises.

Kaiser has a certain way of delivering care, and the bottom line is that you
can’t just see any specialist you choose when you want to get a second opinion.
You first have to go through Kaiser’s own system. If you’re a patient with an
oddball disease–a rare cancer, for example–Kaiser is therefore a tough sell.
The bureaucracy can be frustrating, and the kind of deeply targeted care you
would get somewhere like MD Anderson or the Cleveland Clinic, while not
impossible, will be more challenging to pull off. It’s reasonable that
patients, empowered as they are with information resources, will resist having
to march through all the steps and go through all the Kaiser ropes when the end
result will be exactly what they already know–that they need to get care
elsewhere.

Looking at this same issue from a physician’s perspective, one could argue that
Kaiser is getting considerable press for being the “right” system, but an
environment where there’s only one style of care is a limited one. Just as some
patients may not fit the Kaiser model, there are most certainly brilliant
doctors who don’t thrive in the kind of ultra-integrated environment.
Individuals whose personalities make them impatient to innovate, for instance,
will undoubtedly find the pace too slow. Because Kaiser is committed to proven
approaches, change does not come right away. In certain cases, there may be
other, more cutting-edge ways of delivering care that just haven’t yet made it
into the pipeline.

There are countless arguments for why Kaiser and other integrated care systems
are well-run and effective models, and I agree with the vast majority of them.
But as we continue to develop new approaches in healthcare, I want to make a
case for remembering to look outside of the box of what’s already working on a
broad scale, and continuing to make room for the small-scale and even the
untried.