Revolution in the Laboratory: Patients as Customers Wytze Oosterhuis - PowerPoint PPT Presentation

Revolution in the Laboratory: Patients as Customers Wytze Oosterhuis

1. Patients are troubled. 2. Patients have not chosen to buy the service, and would rather not be requiring the service. 3. Patients are not paying for the service. 4. Patients are not buying a product from which they can demand a positive outcome. 5. The patient is not always right. 6. Patient satisfaction does not always correlate with the quality of the product. http://www.kevinmd.com/blog/2015/02/patients-not-customers-6-reasons.html

changing patient-physician relationship Health Expectations, 2012; 16, 14 – 31.

Traditional physician-patient relationship: trust-based Hippocratic tradition High morality of physician Ethycal use of decision making power Paternalistic, hierarchic relationship Asymmetry of information No incentive for the physician to reveal his activities to patient

Problems with/reasons for change of old paradigm: Escalating health-care costs, efficiency-oriented physicians Physicians dual contradictory obligations: accountable both to health insurances and to patients Role of The Internet as source of information, erosion of trust Opportunity for physicians to act self-interestedly / patients susceptible to potential abuse

New model/new patient: distrust-based Patients as buyers-consumers Well-Informed, information empowerment Self-determination, exerting autonomy regarding treatment Active participants in management of their care

WHO

Definition of empowerment: “The discovery and development of one’s inherent capacity to be responsible for one’s own life.” People are empowered when they have - knowledge to make rational decisions - control and resources to implement their decisions - experience to evaluate the effectiveness of their decisions Empowerment: An Idea Whose Time Has Come in Diabetes Education .Funnel, Anderson ;The Diabetes Educator 1991;17:37-41

https://www.opennotes.org/

https://www.mychartweb.com/MyChart/default.asp

VIPP: project to speed up information- exchange between patient and professional

Department of Health and Human Services strengthens patients’ rights to access lab test reports As part of an ongoing effort to empower patients to be informed partners with their health care providers, the Department of Health and Human Services has taken action to give patients a means of direct access to the patient’s completed laboratory test reports . http://www.hhs.gov/news/press/2014pres/02/20140203a.html

- Survey amongst the member organizations of EFLM. - The aim of this study: laboratory professionals’ views to delivering laboratory results directly to patients and the current status of these issues in Europe.

Results: response 27 countries/67% - In 60% of cases, patients received their laboratory result from physicians only . - Patients can obtain results after asking for them, but this was not allowed for 16% or it was allowed only in special occasions (24%). - Of laboratory specialists 34% showed a negative attitude with the need to deliver laboratory results to patients. - Clinical interpretative comments added by a specialist in laboratory medicine to the report for physicians can be seen by the majority of patients. Unqualified access to unmodified comments were enabled in 49%, but not allowed in 24% of respondent countries

Health literacy skills are ‘the motivation and ability of individuals to access, understand, and use information in ways which promote and maintain good health. e379 British Journal of General Practice, June 2015

Health materials in England All items were nationally publicly available

Education reviewers assessed the level of skill required to understand and use the materials; separate analyses for literacy-only competency and for literacy + numeracy competency. - 5795 participants - 43% below the text-only competency threshold - 61% below the literacy + numeracy competency threshold.

Sending reports to patients Adding comments to reports... Can we do this? Should we do this?

Trial: - Sending test results to patients - Interpretative comments

Example reflective testing Male 53 year 7E230967 Test Result Unit Ref.value Potassium 4.2 mmol/L 3.5-5.0 Creatinine 95 umol/L 70-110 eGFR 72 ml/min/1.73m2 >90 Bilirubin total * 27.3 umol/L 0.0-17.0 % Direct bilirubin 11 % 0-40 Alkaline Phosphatase 74 U/L 0-140 Gamma GT 23 U/L 0-40 ALAT 19 U/L 0-40 LD 431 U/L 0-480 Haptoglobin 1.91 g/L 0.45-2.00 Report comments: • Unconjugated bilirubin high with normal liver enzymes • No signs of haemolysis • This can be Gilbert’s syndrome (hereditary conjugation disorder) • Clinically not relevant • Consider repeat bilirubin for confirmation

Aim of the trial: Send report with test results and personalized comments to patients. - Is it possible for the lab to make comments? - Do patients understand the comments? - Are the patients satisfied with the report?

Overview of trial - 4 GP’s /40 patients. - Structured interviews with GP’s /patients. - Results were blocked for reporting. - A comment was added and sent to GP by fax for agreement. - Report send to patient by mail.

Comments: - Explanation of the codes that were requested by GP , with naming of the requested tests. - Explanation of each test separately Ratio chol/HDL: - This is the ratio between total cholesterol and HDL cholesterol. - This ratio is used to determine your risk for vascular disease. - The risk for vascular disease can be estimated by your GP based on the following data: your age, if you are man or woman (men have a higher risk), your blood pressure, if you smoke or not, and the ratio between total and HDL cholesterol. - The GP can read in a (risk) table the risk that you will suffer from vascular disease (like a heart attaque) in the future. - If this risk is too high, it can be advisable to use a medicine. - A value lower than 4 is the most favorable (the risk table runs from 4 to 8). Your value is favorable (even very low).

Standardized comments

Questions (patients n=38) yes not +/- Was the report layout clear to you? 92% 0% 8% Clear which tests were ordered? 79% 5% 16% Content of explanation clear? 92% 0 8% Background information of any use? 9% 6% 0% n/a: 85% Sufficiently informed with information? 88% 0% 13% Anxious before the tests were done? 6% 64% 30%

yes not +/- Worried after report/ information? 0% 83% 17% Ok to be better informed (additional appointment with the doctor) 26% 0% 0% n/a 74% Like this procedure again in future? 97% 0% 3%

Remarks of the GP’s: - “ Inevitable ” - “ This is the direction we are going ” - “ This is the future ”

Best Practice for the implementation of Patient Focused Laboratory Medicine EFLM Working Group on Patient Focused Laboratory Medicine - best practice advice for anyone considering adopting a direct result and comment service to patients. 1. Ensure your employer is in agreement with initiating such a service. 2. Get the agreement in principle of the physicians responsible for the group of patients. 3. Ensure that any IT solution used is sufficiently encrypted to meet local laws and regulations 4. Agree the scope of comments to patients 5. Agree whether comments will go direct to patients with a copy to their physician or will be through their physician 6. If there is a patient group discuss the proposal with them and obtain their support

7. Explicitly agree the staff who can make comments and their adherence to the protocol. 8. The escalation procedure for a. If an unexpected finding is seen b. Patient initiated queries c. If something goes awry 9. Ensure a clear audit trail of all actions 10. Determine the length of record detention 11. Put Key Performance Indicators in place 12. Regularly review the service 13. Publish your experiences

Conclusions • Patients are in the position of consumers. • There is a need and challenge to inform patients about the meaning of the test resuts. • Automation of this process is crucial.

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