Let’s clear the air right up front.  You do NOT have to use the infamous “.CHR…” dot-phrases if you don’t want to! No one is trying to turn you into a robot using the same cookie-cutter, boiler-plate lingo as everyone else.  Those dot-phrases were designed by your peers (docs, nurses, clinic staff) and were meant to be helpful (in fact many of your peers think they are).  You can customize them or ditch them as you see fit.  I don’t really care. As physicians we can use as much creativity as we like in our care plans.

But let’s think what our patients and their families want and need from us.  They want to know what medicines they are taking, in what doses, and for what reasons.  So we should all have the discipline to clean up our patients’ medication lists so that what gets printed in the After Visit Summary is accurate and makes sense to our patients.  Next, they want to know what some realistic goals and targets are for their main active problems.  They want to know what symptoms to look for, what to measure, and who to call if they have concerns.  They want to know their follow-up plan.  They want all this to be written in language that they can understand, and for it to be put in a standard place where they and their family to find the information.  And, by the way, they assume, quite reasonably, that if other doctors are seeing them for part of their care that we will all communicate well with each other so that everyone is working together to keep them healthy.  Now that’s a Collaborative Care Plan!

Let me tell you what I do as an endocrinologist seeing one of your patients who has diabetes among her various problems.  She might well have several other chronic problems she is dealing with.  Perhaps she sees Dr. Resnick for her mitral valve disease and Dr. Hsia for her ulcerative colitis.   Maybe you are Read more »

From the point of view of our patients what’s not to like about the Medical Home?  The phones get answered promptly, you can often talk directly to the doctor or nurse who know you best, you can get questions answered, order your medicines and check your lab results on line. 

The Medical Home is a delivery system designed to support a continuous healing relationship between you and your doctor.  But for many people, especially those who have one or more chronic conditions to deal with, the heart of the Medical Home is having the time to sit down with the doctor who know you best to develop a Care Plan that meets your needs; a plan that sets realistic goals and targets to keep you healthy. 

 It tells you what medicines you are taking and why.  It tells you what to look for, what to measure, and who to call if you have questions and concerns; sometimes it’s your own doctor, sometimes it’s a nurse or clinical phamacist or a specialist who works closely with your own doctor.  You have a printed copy of your care plan when you leave your appointment.  It is written in language that you and your family can understand, and if you lose it you can see it on-line.  I can’t think of any patient who wouldn’t like to have that degree of respectful collaborative support.  It is the heart of what “good medicine” is.

But this is precisely why the creation of a Collaborative Care Plan is the hardest aspect of the Medical Home work to roll out and standardize.  Most doctors feel that they have been developing Care Plans (or Medical Treatment Plans) with their patients for years.  They don’t need some damned bureaucrat from on-high forcing them to use clunky new one-size-fits-all dot-phrases and stifling their creativity!  “Look,” they say, “My patients are used to the way I do it.  I’ve always done it this way.  I get great Patient Evaluation Scores!  Leave me alone!”

As I travel from clinic to clinic to sit down with dozens of committed, caring, competent physicians of all ages I am struck by the variety of styles that they use to communicate the heart of their care to their patients.  Physicians vary in their skill and facility in using our EPIC Electronic Medical Record - and this is NOT  always related to age!  I have seen plenty of “old dogs” learning new tricks of using customized dot-phrases to “blow in” paragraphs of advice on all sorts of topics.  Others are speedy typists (or accomplished Dragon users!) who create punchy, sparse lists of instructions directly into the After Visit Summary. 

There are also philosophical differences in the approaches that I see.  Some people are “Lumpers” and like to have all the patient instructions for all their medical problems lumped together in one place in the chart.  Others are “Splitters” - they like to put the specific instructions for each problem on the Problem List typed under that specific problem.  A few physicians still like to write their patient instructions by hand; considering this to be a personal touch that their patients value dearly.  And maybe they do.  But maybe there is something that those patients would come to value even more…

For someone like me who has experienced a huge variety of health care organizations in four  different countries over a thirty year period I can tell you that I have never seen an organization with as big a heart as Group Health.  Nothing else even comes close.  We care about keeping our patients healthy, and we support each other and challenge each other to strive to give our patients better and better care every day. 

To transform healthcare irrevocably for the better  requires us to work together for the common good that will help all of our patient.  Developing Care Plans in a consistent and reproducible way is at the heart of this transformation.  In another post, “Myths and Realities of Meaningful Care Plans” I will give you my take on what makes a collaborative care plan great.  I’d love to hear your thoughts on the subject.