We do better when we have meaningful conversations with our clinicians about our health care. Growing recognition of the importance of our participation has resulted in proposals to require that such conversations take place at strategic points – before initiating some treatments and when leaving the hospital, for example. Frequently, a new requirement to act to improve the quality of care is accompanied by a requirement to document that the action has taken place.
Such initiatives have much to learn from previous attempts to document that specific clinician-patient conversations have taken place and the various attempts by clinicians (aided by administrators) to ‘game’ the requirements of regulators and payers.
Here’s a cautionary tale:
Last week my doctor prescribed an inhaler to relieve some upper respiratory symptoms. When I went to the pharmacy to pick it up, the clerk asked me to sign in the credit card screen.
The little screen was all black except for one small red field. In that field was the word “decline.”
Decline what? As it happens, I know what I am being asked to decline. In the early ‘90s, pharmacists lobbied hard for a bill requiring that every patient be offered counseling when receiving a prescription medication. That bill passed, and today we sign a screen or a paper log indicating if we want counseling prior to receiving our prescriptions. Note that I hadn’t been offered counseling, just the opportunity to decline something.
But I needed counseling. Despite all my years as a patient, I have never used an inhaler. I read that it is possible to use an inhaler incorrectly and get no benefit from it. And I was desperate for the symptom relief the inhaler promised. And so I was determined to talk to the pharmacist.
“I don’t want to decline counseling so I’m not going to sign this. May I please speak to the pharmacist?”
“Of course,” the polite 17-year-old clerk told me. “You still have to sign that you decline counseling.”
“But I haven’t declined it. Why should I sign it?”
“You can’t get your medication unless you sign it. But you can always get counseling from the pharmacist.” What, I’m going to debate store policy with a 17-year-old clerk? I signed it.
The pharmacist gave me a through demonstration of how to use the inhaler. And he confirmed what the clerk had said: “I’m always available to talk with you, but our system requires that you have to indicate that you have declined counseling to get your medication.”
Well that’s revealing: The system designed to measure this pharmacy’s compliance with the law is set up so that it can’t record anything but a default option, efficient for passing off those little white bags of medications but missing the opportunity to record real encounters. Can you imagine an electronic health record with only a “decline” box to document that each patient had been offered access to his or her medical records?
First: Promoting access to high quality counseling for pharmacy patients has been transformed into a requirement that really only documents that the pharmacy offered to do so. The original intent – to improve our safe and effective use of prescription medications – has been overshadowed by the immediate demands to demonstrate compliance with the grossest aspect of that intent: that the service was offered. Who is accountable for monitoring – and correcting – the rates of counseling offered by this pharmacy: The store chain? The State pharmacy association? Is this approach OK with them?
Second: This system could have been set up to provide a record for pharmacists to help them track our ongoing problems and encourage them to check in with us at the next visit – you know, to build a trusting relationship in which over time we come to count on their expertise to help us make the best possible use of our medications. But it does nothing of the sort. My complaint echoes those lodged by many clinicians about current electronic health records: The software is designed to track isolated events and justify payment but doesn’t support or encumbers opportunities for meaningful individualized care.
Patient-centered care advocates are (successfully) proposing policies to mandate the provision of personalized conversations about some treatments (shared decision making for preference-sensitive treatments) and how to take care of ourselves after a hospital stay (part of readmissions prevention programs). Simultaneously, measures are being developed that indicate whether clinicians are in fact routinely having those conversations.
But it is devilishly difficult to develop a meaningful indicator of whether counseling has taken place between a clinician and patient. What threshold must be crossed for a clinician to check the box that shared decision making has taken place: The provision of the Web-address of a decision support tool? Asking the question, “What’s your preference?” A fifteen-minute time-block devoted to an unspecified conversation?
Similarly, what counts as an adequate hospital discharge discussion? Reading the discharge orders to the patient and handing them the paper? An in-depth planning meeting about self care? Who is the judge of whether the specified interaction actually took place: the patient or the clinician or both?
And who is accountable for reviewing the documentation of those conversations and either lauding or administering corrective action: Health system managers? Outside quality certifiers such as NCQA? Clinicians themselves? Some personal injury lawyer?
Argh! This is too much detail and too many variables to track. I can see why I had only a forced choice to check the box to decline counseling at my corner pharmacy.
And I can all too easily see how this default approach will be replicated as competing interests in quality improvement, payment, and treatment battle for valuable real estate to indicate whether these conversations took place on each electronic health record systems across the country.
I am disheartened by the crude-but-crafty “decline” option I experienced at the pharmacy last week. And I lack the imagination to see how similarly disruptive and amorphous interventions like shared decision making conversations and counseling prior to hospital discharge – critical as they are – can be more effectively integrated into care and then accurately documented. But I realize that both are necessary in order for us to experience a real transformation toward greater patient-centeredness.
Got any bright ideas?