Every month, we get a number of reports, huge collections of the names of those patients who are missing certain healthcare maintenance items and other monitored parameters.
We get a list of patients whose blood pressure is not well controlled, whose diabetes is not well controlled, who are still smoking, who are still obese. We get people who are missing their cervical cancer screening, breast cancer screening, and colon cancer screening. We get people who are missing their flu shot, their tetanus booster, their pneumonia vaccine, and their shingles vaccines.
From the looks of things, from the size of these lists, we seem to be doing a pretty terrible job. How could all these patients be missing all of these critically important items, when the systems we have should be perfectly set up to capture them, to make sure they get all the healthcare they need, when they’re clearly stopping in to see us at least once or twice a year? Are these reports helping, or can we do things a better way?
We also have what our electronic medical record calls “best practice alerts,” which are highlighted items flagged within the chart when we enter it during an office visit. They let us know that our patient is not up to date on one or more of these items. This gives us a nice opportunity to raise the issue, to discuss it with our patient, and then to go ahead and order it. Or mark it as declined. So are all these doctors, once they get these patients in the room, just saying, “Nah; why bother — this doesn’t seem that important”?
It’s Not Always Easy
Between the lists we get and the best practice alerts, we have two different ways of seeing how many patients aren’t completing these maintenance items. So I ask again: why aren’t we better at this?
There are clearly a lot of possible answers to this question. Often, the reasons why we aren’t getting all the things our patients need to be gotten to are beyond our control, and even sometimes beyond their control. Monthly reports on missing healthcare maintenance and other screening items land in our laps at an inopportune time, a moment when we don’t really have anything that we can do about much of this.
True, we can go through these huge lists of patients and sort them by provider, and divide them up, and email them off to the individuals whose patients are missing these items. But then they get them dumped into their in-baskets when the patient isn’t in the exam room with them, and the opportunity isn’t really there to do anything about it.
With the best practice alerts that pop up in the chart, so often these things only get noticed at the end of the visit, after we’ve already wrapped things up, after we’ve already squeezed five, 10, or 20 things into our very brief in-person office visits. So is there a way that we can take all this information about what our patients haven’t had done for them, and fine tune it so we are, in the end, filling in the gaps in their care?
Fixing the Issues with Colon Cancer Screening
Take, for instance, colon cancer screening, one thing that our patients in adult medicine will pretty much all need at some point or another. With the change in guidelines lowering the age to start screening in otherwise healthy individuals to 45 years old, we’ve recently expanded our pool of eligible patients. And those who have a strong family history of these malignancies also may need earlier screening.
Luckily, the system is set to trigger, based on age alone, that particular patients are due for colon cancer screening, and therefore if they haven’t had it done within our system, or we haven’t toggled the health maintenance item in the electronic medical record to show that it has already been done, they will show up on our long monthly list of overdue patients.
We are often dependent on the provider to change the settings when our patients tell us they already had a colonoscopy, a major source of missed opportunity. Also, there may be time, in the days before the visit, to send these patients noted as needing screening a bevy of educational materials, reminders, videos, patient testimonials, about the benefits of screening, hoping to touch on all their questions and concerns.
So, who should the list of overdue patients go to, and what should they do with it? Yes, dividing it up and sending it out to the individual providers makes sense, and this could probably best be done by an administrative support person. But more useful, perhaps, is looking at those patients who are on that list, who are scheduled for visits in our office this week, and maybe even on a particular day.
Someone could look through the charts of these patients and see if there was a record in previous notes or scanned medical records that the patient had had a colonoscopy done at an outside provider, and then set out to locate that report, and then from that point on satisfy the link in the system that shows they’ve had it done. If they can find no record in the chart of prior screening, and see nothing in the plan from a previous note about getting a colonoscopy or other colon cancer screening methods, then maybe it’s time to have somebody chat with the provider and let them know that a particular patient is coming in today, and this is one of the items that should be attended to.
Ideally, we’d love to be able to have that somebody also put in an order for the needed screening, and then let me, as the provider seeing them, decide to accept it or not. Or even present all the possible options electronically in a menu, including colonoscopy, virtual colonography, other testing such as Cologuard or FIT testing, hemoccult cards, flexible sigmoidoscopy, or even that the patient declines to get any colon cancer screening of any form done. Somehow, I think that if this happened at the time of the practice visit with our patient, we’d be more likely to close the loop and help our patient get on the right path to getting it done.
Making Sure to Follow Through
Then we have to help them actually get it done — we have to navigate the heck out of them. We need to make sure that the referral goes through to the gastroenterology department and that they successfully communicate and schedule with the patient, or that the Cologuard testing kit gets delivered to their home, and then returned.
We need to make sure they get lots of patient education materials about what is involved in prepping for a colonoscopy, as well as all of the risks, benefits, and alternatives of going through with screening. We need to have a counselor from GI speak with them about their concerns, helping them overcome any barriers they may have to getting it done, making sure they can take the prep okay and follow the pre-procedural steps necessary to successfully complete the procedure.
And we need someone to make sure they successfully navigate through the day of their procedure, that someone will come with them, that they know what time they need to arrive, that they have a ride home all set up. And resources to assist with all of these if something is just not right. And then we need to ensure that someone gives them their results, and sets them up for any follow-up testing or procedures they need, so they don’t fall through the cracks.
I think that by fixing the processes beforehand, in the weeks and days before an office visit, on the day of the office visit, and in the days afterwards, we’re more likely to succeed in getting our patients all the way to the finish line with the colon cancer screening they need.
And then we can move on to something else.
Source: MedicalNewsToday.com
