Primary care physicians know well that although the treatment they provide is important, changing patient behavior also is essential to ensure better health outcomes.
That's why physician practices in the Kaiser Permanente network utilize a patient portal designed to coordinate care and educate patients -- especially patients with diabetes -- not simply to collect data. The network has been widely recognized for its ability to build patient engagement into its technology and then use the platform to allow patients to co-manage their care.
William Wright, M.D., M.S.P.H., who completed a family medicine residency at St. Joseph Hospital in Denver, was the executive medical director of the Colorado Permanente Medical Group from 2007-2015. He often says in presentations that "patient engagement is the next blockbuster drug."
Wright recently spoke with AAFP News about how the network leveraged technology to assist primary care physicians and patients. The following Q&A is a summary of that conversation.
Q. Most insurers are focused on health statistics for an entire patient population, yet Kaiser now seems to focus on individual patient outcomes. What has changed?
A. I think two things have happened. During the last five to 10 years, patients have been making their own insurance decisions. The second is that Kaiser and other insurers have increased coinsurance and copays so patients are paying more out of pocket. Patients are acting more like consumers so you have to engage them at the individual level.
Q. A lot of tests can be ordered through an automated system in the patient portal. How does this save time?
A. It's best for patients who don't need to come in to the office. It's also good for patients with whom you already have an established relationship or if you have diagnosed their problem. Inside the portal, there is a personal action plan that alerts patients who need an A1c. It explains what they should do next and why the test is important. The patients learn to manage their disease by themselves without calls from the office.
For a typical primary care physician with a large patient panel, the system allows the doctor to bulk-order common tests used in preventive screening or disease management. Examples include A1c, immunizations, Pap smears and tools used to assist with tobacco cessation.
If the tests are handled this way, there is more room in the schedule for new consults so you can get more people into the care process. The real goal is to improve health and close the care gaps.
Q. How do you get patients to use the portal consistently?
William Wright, M.D., M.S.P.H.
A. Seniors, particularly females, are among the fastest adopters. Grandparents are using Facebook to look at photos of their grandkids and they do online banking. In the last decade we've seen a significant increase in seniors using the portal. When seniors go in for an office visit, you can tell them that the results will be on their electronic health record (EHR) within 24 hours and draw them in that way.
You can give them information about their prescriptions or provide reading material about diabetes. The records could include information on low back exercises in a prescriptive way rather than giving them a book. Once they access their EHR, they will look at this information including the doctor's notes, lab results and the after-visit summaries.
This also helps with self-triage. A patient with symptoms logs into the portal to schedule an appointment. The patient can select "e-visit," where he answers questions based on the primary symptom -- maybe it is a urinary tract infection or a cough. The answers are triaged to the appropriate medical team member, then medication is ordered or a diagnostic test is scheduled.
We've seen an increase in patient satisfaction after we opened up the records. There is some anxiety about that among physicians, but I think it will happen because it's the nature of the world we live in.
Q. Are there pitfalls to increasing communication through the patient portal?
A. Some doctors are worried that if they use the portal, patients will be contacting them about everything. Sure, there are some patients out there who when they get their lab results and see a number that is one tick above normal, they will want to know why. But the ability to access that information quickly and co-manage the condition with the patient outweighs any anxieties about patients pestering you every day.
Q. What advice do you have for primary care physicians trying to adapt to EHRs and other technology?
A. It requires a new set of skills. Physicians who are doing well figured out how to bring a laptop or a tablet into the exam room. Physicians can incorporate technology not as an intruder but as a facilitator.
The physicians who struggle the most with the transition are baby boomers. Why? Because they started practicing medicine under a different care model. Millennials are rolling with it because they grew up with technology.
Q. Is there support for physicians to make the adjustment?
A. We trained physicians on how to use technology in the exam room as a positive way to engage patients rather than just adding an extra task. If the physician and patient look at the screen together, you can do a cardio risk calculator in front of the patient. You can tell the patient, "If your cholesterol drops this much, then your risk improvement score will go up." The risk calculator can also be used for smoking cessation. Or you can show them an exercise to do on YouTube. Patients love it when physicians do that.
If you just throw a computer in the exam room and tell doctor to do more, it won't be effective. I know some physicians hired a scribe and use it well, but you have to respect a patient's privacy.
Q. How can the network's disease management program be replicated in smaller practices?
A. In the area outside the Denver metropolitan area, most primary care practices have fewer than 10 physicians, and often fewer than five. They are also participating with multiple insurers. We created a registry so the practice can identify all of their diabetic patients, and we pay to care for them. To start, we set a goal that all A1c screenings needed to be done at specified date.
Kaiser provided a nurse care coordinator who works in the physician's office. In smaller, rural practices, a nurse coordinator will work with them remotely to build registries. Geisinger (Health System) did it better than us in rural Pennsylvania. They put nurse care coordinators in small, rural physician offices. The nurses created registries of all the diabetic, congestive heart failure and chronic obstructive pulmonary disease (COPD) patients. You don't have to record that many reduced hospital visits to pay for that care coordinator.
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