Strategies to help tackle poor health care communication
From the May ACP Observer, copyright © 2004 by the American College of Physicians.
By Deborah Gesensway
At a conference held last fall by the ACP Foundation and the Institute of Medicine (IOM), leaders of America's medical community discussed the daunting challenge of how to improve communication between health care providers and their patients.
Experts at the conference presented startling statistics from the National Adult Literacy Survey, which found that half of all Americans may not have the literacy skills they need to understand and use health information. Those findings were confimed last month in a report issued by the IOM.
Because physicians' effectiveness in treating patients ultimately rests on their ability to communicate, experts at the conference said that patients suffer when they are not able to hear, comprehend or accept what clinicians are trying to tell them.
Conference presenters were optimistic, however, that new strategies can improve the situation. Several described solutions that use state-of-the-art technology, while others described approaches that rely more on training and education.
The conference was part of the ACP Foundation's 10-year project to improve health outcomes by improving health communication. (Summaries of all conference presentations are online.)
Here is a look at three of the projects presented at the conference.
Better management through telemedicine
Steven Shea, MD, professor of medicine and epidemiology at New York's Columbia University, is principal investigator for the Informatics for Diabetes and Education Telemedicine (IDEATel) Project. The project is testing ways to use telemedicine to better control hemoglobin A1c, blood pressure and cholesterol levels among low-income patients with diabetes.
The program is a joint project of Columbia University, New York-Presbyterian Hospital, SUNY Upstate Medical University, and the Centers for Medicare and Medicaid Services (CMS). Several hospitals and health care organizations throughout New York state are also participating.
The project targeted a random sample of diabetic Medicare beneficiaries living in areas the federal government has designated as medically underserved. Patients in the intervention group each received a two-way video-voice conferencing computer device in their home that allows them to talk with a nurse at a diabetes center.
Each device is equipped with what Dr. Shea called a "launch pad" with buttons labeled in both English and Spanish. He explained that researchers decided to avoid using a more traditional computer keypad because patients with low computer skills find such devices too hard to use.
Each device also has a glucose monitor and blood pressure cuff, making it possible to upload data across standard phone lines.
The technology allows patients and nurses to discuss health status and medical care in real time. Nurses then communicate results to patients' primary care physician.
It is important to 'bridge the digital divide' between people who have access to computers and those who are intimidated by them because of their age, lack of education or language skills, culture or rural isolation.
One explicit goal of the project, Dr. Shea told conference attendees, was "bridging the digital divide" that exists between people who have access to and are familiar with computers, and those who are intimidated by electronic advances because of their age, lack of education or language skills, culture or rural isolation.
While project data are still being analyzed, Dr. Shea said that interim results already show "statistically significant" improvements among patients in the intervention group in terms of blood sugar, blood pressure and cholesterol control. He also pointed out that the CMS, which funded the project, currently does not reimburse providers for most telemedicine services.
Proponents hope that projects such as this one, which suggest ways to reduce the prevalence of stroke and heart disease among Medicare beneficiaries with diabetes, may convince the agency to explore reimbursement for telemedicine programs.
While many researchers focus on communication problems between physicians and patients, physicians often have difficulty communicating with each other, said Brent E. Wallace, MD, a family physician at Intermountain Health Care (IHC), the giant integrated health care system in Utah.
According to Dr. Wallace, IHC is trying to improve provider communications by using a computerized medical records system and encouraging physicians to use electronic clinical workstations. The organization's "clinician desktop," as it is called, can now work with more than 40 different clinical systems within the IHC network.
"With this system, we find data for clinical research and quality assurance, and we have been able to establish that we have cost savings and significantly better service," Dr. Wallace said.
More and more of the network's physicians are taking advantage of the computerized system. More than 4,000 providers use it, Dr. Wallace said, up from 800 in 2000.
Several of the system features have convinced physicians that computerization can improve their efficiency. One valuable feature is an electronic "message log" that allows physicians to electronically respond to text messages from phone calls from patients and other physicians. "I can use buttons to respond or forward [requests] on to staff to take care of or fulfill prescriptions," Dr. Wallace said, demonstrating the system's features.
Physicians can also access patients' records across the entire health care system, including physician notes from hospital wards, emergency departments and intensive care units, as well as results of lab and microbiology tests, X-rays (including, in most cases, the actual image), ECGs, charts of vital signs over time and medication lists.
That capacity, Dr. Wallace said, goes a long way toward reducing the confusion that can result when patients move between inpatient and outpatient settings. It has also improved patient care.
"Patients' hemoglobin A1cs are better with our physicians who are using the system than those who are not," he explained. "The average control of their patients is better."
Dr. Wallace admitted that for many patients, the clinical workstations take some getting used to in the exam room. "It is a real challenge to use it as a tool that the patient likes and doesn't hate," he said. But his patients have been sold on the ease with which they can find instructions they received during an emergency room visit, for instance, or chart their progress with a chronic condition.
IHC has now launched two pilot projects to give patients access to the system. Participating patients can log on and see their own health records and test results, request refills and schedule appointments, and send e-mail to their physician.
The system is removing not only many of the communication barriers between physicians, but those between clinicians and patients as well. "We see it as a vision for the future," Dr. Wallace said, "to help us meet many of the challenges we have within the medical system."
Coping with language differences
There is an urgent need for groups to find affordable solutions to language differences in health care settings, said Yolanda Partida, DPA, the national program director of Hablamos Juntos, an $18.5 million initiative funded by the Robert Wood Johnson Foundation.
According to Dr. Partida, physicians across the country—not just in California, Texas and New York—are struggling to cope with dramatic demographic changes. Today, she said, one in nine patients is Latino. In areas like Birmingham, Ala., and Greenville, S.C., the Latino patient population has grown more than 400% over the last decade.
Physicians are using various strategies to try to overcome that language barrier. Some, for example, are learning Spanish themselves or hiring bilingual staff.
Most doctors, however, still communicate with non-English-speaking patients by "relying on patients to bring in interpreters, usually family and friends and children," she explained. That can be a poor solution, she pointed out, given the sensitivity and complexity of health care communication.
Hablamos Juntos is spending $1 million in 10 different communities to test strategies to help reduce those language barriers. The grants have been given to a variety of health care entities, including hospitals, academic health centers, HMOs and community-based health care organizations.
Finding ways to improve interpreter skills is one goal of the program. Some of the organizations that have received grants are testing assessment tools to measure competency in Spanish language proficiency and health interpreting skills. Others are replicating college-level training programs for health interpreters. And some are testing new models for pooling interpreter resources or using videoconferencing technology to increase the availability of interpreter services.
But "hiring interpreters is not the only solution," Dr. Partida said. "It might not even be your first solution." Some programs that have received Hablamos Juntos grants, she explained, will support the development of a symbol-based signage system to help patients with limited English or low literacy skills find their way around health care facilities. The project will also explore ways in which symbols can be used to help patients comprehend different medical instructions.
And other grantees are testing ways to use technology to bridge language differences particularly with staff at health care access points, such as telephone operators or receptionists. Solutions now being explored include PDA programs with voice recognition, computer-based programs and audiotaped health care instructions.
Deborah Gesensway is a freelance health care writer living in Glenside, Pa.
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