New post in The Empowered Patient on Informed Decision Making

See the latest "The Empowered Patient" column in the January issue of MPN Forum, an online magazine that features stories and news about myeloproliferative neoplasms. In my column, I share personal experiences with shared decision making and offer some background information about the process of informed medical decision making. The column can be found at: www.mpnforum.com/the-empowered-patient-january/. You can find a link to MPN Forum in my favorites on the right side of this page. I have added a link to the Foundation for Informed Medical Decision Making in my favorites as well. Check it out for excellent information and news.

Empathy and Reflective Statements in Primary Care Discussions About Weight

A recent study of discussions of weight concerns in primary care, published in the Journal of the American Board of Family Medicine (http://www.ncbi.nlm.nih.gov/pubmed/22086809), found that physician empathy (assessed by trained raters who coded audiotapes of primary care visits) was linked to improved patient satisfaction, while physician use of reflective statements was associated with patients'  perception that the physician suppported their autonomy. The study included 40 physicians and 320 of their overweight or obese patients. Of note, physician empathy was only rarely expressed in these encounters; only 18 of the 320 encounters were rated as demonstrating a physician empathy score of greater than 1 on a scale of 1-5! Of those encounters with empathy scores greater than 1, 27% of the patients rated their satisfaction as excellent, compared to 11% of the visits with empathy scores equal to 1. Reflections were rated as present in only 38% of the encounters. When reflections were present, 47% of patients reported high levels of autonomy support, a measure dervied from Self-Determination Theory (SDT). Previous studies suggest that increased autonomy support is associated with increased intrinsic motivation as well as improved patient follow-through. The authors conclude that strategies that increase physician empathy and number of reflective statements could improve patients’ adherence to recommendations. Limitations of this study include the small sample of physicians, high patient refusal rate and a rather well-educated patient population.

 

Two Great Links

I have added two new links that I highly recommend:

• Shared Health Data - a blog and more, written by my friend and colleague, Susan Woods, MD, MPH,  a primary care clinician, researcher and e-health advocate at the Portland, Oregon Veterans Adminstration Medical Center and Oregon Health Sciences University. I referred to Shared Health Data in my previous post about Personal Health Records. Sue describes her blog as follows, "This is a blog about better health and healthcare through exchange of health information, greater transparency and proactive engagement of consumers." It is all that and more. Check out her most recent column which celebrates Steve Jobs's contributions to the transformation of computing into consumer-friendly and empowering applications. She also imagines what Steve Jobs might have created if he worked in healthcare. Click on the link in my favorite sites list or go to http://www.sharedhealthdata.com/
• Mind the Gap - written by Stephen Wilkins, MPH, a former hospital executive and consumer health behavior researcher who became inspired to focus on patient empowerment as a caregiver for his wife during her successful, and traumatic, experience with cancer.  Mind the Gap offers, "evidence-based insights and best practices for improving patient engagement and the quality of communications between patients and their doctors". Stephen's latest post is entitled, "3 Reasons for Becoming More Patient-Centered". Check out the blog at: http://healthecommunications.wordpress.com/ . It is also on my favorites list.

Personal Health Records: Another Path to Empowerment

In my latest column in the October issue of MPN (Myeloproliferative Neoplasms) Forum, I share ways in which I have used a Personal Health Record (PHR) to track information about my condition. Using the tools available in PHRs, I can create graphs that show the relationship between treatments and key lab values. Sharing these graphs with my physicians not only helps us to make better decisions about my treatment, it also saves time and allows us to focus on what's important to me, including my feelings and concerns about my condition. My doctors have been very receptive to my use of these tools, and I have benefitted from the increased time they havefor empathy!

See link to the column in MPN Forum below:

http://mpnforum.com/a-oct-michael/

Note: the link is no longer working, so here is a version of the article:

The Empowered Patient – MPN Forum

October, 2011 – Draft 3

Personal Health Records: Another Path to Empowerment

 

Just this week, I prepared for my PV follow-up visit with my oncologist by printing out computer-generated graphs of my cbc results over the last 5 years. The graphs included labels indicating when I had started and stopped HU and made changes to my dose of interferon. See below for one of the graphs I brought with me to the visit.

 

 

 

Using this handy graphical representation of my response to treatment, both my oncologist and I were able to "see" where I was in my treatment. As a physician myself, I have an advantage, as I have more understanding than a typical patient about the meaning of blood tests and medical events. Also, my oncologist, who is on the Brown Medical School faculty, knew me as a colleague for many years before I became his patient. We respect each other’s expertise, and once I became a patient, we had long conversations about my PV and its likely course and prognosis. I bring him articles and share the latest findings from hematology/oncology meetings, which he appreciates. He once remarked that he should get continuing medical educational credits for my visits with him!

 

As a physician, it has always been important for me to feel prepared so I was making the most informed decisions with my patients. This need for preparation has carried over to how I approach the management of my own condition. Having reviewed the graphs the night before, I was prepared to remind my doctor that we had started Pegasys 2 years ago, and that we had made the last dose adjustment in May. We looked at the graphs together, which showed that my PV remission, initially achieved with high doses of Pegasys, has been maintained as I have gradually reduced my weekly dose. The time we saved by not having to search through my chart for the dates and data was devoted to discussing my symptoms, feelings and my preferences for treatment. We agreed to continue a slow taper of Pegasys and to recheck my JAK2 allele burden once i completed 6 months at my current dose. My oncologist marveled at my quite rudimentary spreadsheet, created from an online Personal Health Record (PHR) program. He asked me if he could make a copy of the graphs to scan into my chart, remarking, "I wish all my patients brought in graphs like these!" The good news is that we all can! And, there is evidence that if we monitor and track our own medical data, we can improve the quality and safety of our care.

 

In previous columns, I have focused on strategies that we, as patients, can use to help us get the most out of our visits with our doctors and other members of our health care team.  Preparing for clinic visits, asking questions, sharing concerns, and being assertive about our needs are strategies that can help us to take a more active role in decisions about our care, and can help us to learn to cope with and manage our conditions. This is one path to empowerment, one that takes advantage of interactions with members of our health care team. Yet, many of us see our doctors only a few times a year, and there may be only a few minutes available for us to use these strategies, even if our doctor obliges. Thankfully, PHRs are available to help us take a more active role in our care.

 

PHRs are health records that are designed to be used by patients, in contrast to medical records created by doctors, hospitals or clinics to keep track of and document our health history and care. I'm sure most of you have seen at least snippets of your doctor's chart notes or an oncologist's consultation note, or perhaps a lab or x-ray report. These medical records are full of highly technical language and obscure abbreviations that only a health care professional can fully understand. Before the advent of electronic health records (EHRs), many were illegible, too!  Because these "clinician-facing" records are not understandable to most of us, they have limited utility for helping us to manage our conditions. As an example, I recently got a copy of my eye exam after developing some new visual symptoms. Despite being a doctor and also the son of an eye doctor, I couldn’t understand all the notations and abbreviations used to document the findings from my exam! And, unless you currently get your care in a very forward thinking health care organization, these medical records usually don't provide graphs like the one I created myself. They are even less likely to include the information that may be most meaningful to you, like the names and contact information of key people in your lives, your use of non-traditional forms of healing, or your health care preferences. And they are even less likely to mention your life goals and values (e.g., what's really, really, important to you) or your ideas for optimizing your health (e.g., engaging in more physical activity; spending time with grandkids).  PHRs, because they are designed for you, often include this information, and more!

Typically, PHRs help you to keep track of key health information, including data about your:

•   allergies and adverse drug reactions;

•   chronic conditions (including your MPN);

•   family history;

•   illnesses and hospitalizations;

•   laboratory test results, imaging reports (e.g. x-ray), pathology reports (e.g., bone marrow biopsy results);

•   immunization records and records of preventive screening tests (e.g., mammography results);

•   medications and dosing, including over the counter medications and herbal remedies; and

•   surgeries and other procedures.

 

Having all of this information available to share with new providers, or in emergencies, is invaluable and can reduce medical errors that result from depending on our memory at a time when we are ill or stressed. Simply have this historical data in an easily accessible form can be empowering, both to us and our health care team.

 

Some PHRs, particularly electronic versions, go a lot further than just storing key health information and data. These advanced PHRs are interactive and provide electronic links to relevant health information, offer tools and resources for self-management, warn you about potential drug-drug interactions, remind you to obtain medication refills and obtain needed tests, and allow you to make appointments with your providers. Some even provide you with access to your providers through secure electronic messaging, a form of email that protects your privacy, allowing you to ask questions of your health care team or report concerns directly to them. Being able to communicate with your health care team between face-to-face visits and outside of the limitations of telephone calls is freeing and, in systems that embrace this approach to communication, increases the chances that you can get the information you need in a timely way. Now that's empowering!

 

A colleague and friend, Susan Woods, MD, works in the area of Medical Informatics, en emerging new field that focuses on using information technology to enhance the quality of medical care. Sue has a blog called Shared Health Data http://www.sharedhealthdata.com/ that I highly recommend as a source of news and developments in this rapidly growing field. Several columns on her blog focus on PHRs and other "patient-facing" medical informatics tools.

For an example of a PHR that you can complete online and download, see  http://howsyourhealth.com/. This site, which was developed by health care professionals at Dartmouth Medical School, uses questions and assessments to gather data about your history, symptoms and function and then provides you with feedback and links to resources. Some health care plans and communities allow you to share your howsyourhealth record with your providers. Other online PHRs and related tools are available through Microsoft HealthVault at http://www.microsoft.com/en-us/healthvault/.

 

I am curious to know how members of our MPN community are utilizing PHRs and related tools. Please share your experiences, ideas and comments here.

New Posting of The Empowered Patient on MPN Forum

The September issue of MPN Forum, an online forum for patients with myeloprolifeative neoplasms. included a column entitled, "Can Clinicians Empower Patients?" and is based on a previous post here.

Enjoy and please comment either here on on the Forum. The link to the column is: http://mpnforum.com/2011/10/12/the-empowered-patient-the-clinicians-role/



Michael

New Monograph on Communicating Risks and Benefits

For your interest, the Risk Communication Advisory Committee of the FDA recently published a monograph, entitled "Communicating Risks and Benefits: An Evidence-Based User's Guide". This is a valuable resource that provides readers, clinicians and public health folks with guidance about how to understand, interpret and communicate about risk. It is relevant to our discussion about the risk information provided by 23andMe and other genomic profiling services. I was fortunate to have the opportunity to serve on this committee, learn about this important topic and contribute to this effort.

Click on the title of this post or paste the link below into your browser to peruse or download the monograph:

http://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Reports/UCM268069.pdf

New Column in MPN Forum

I have published a revised version of my "Being Heard" blog post in the August issue of MPN Forum. Click on the title to get to the column and the newsletter.

Michael