4


Reaction Panel 2


PHYSICIAN PRIVATE PRACTICE

Isabel Hoverman, M.D.
Austin Internal Medicine Associates

Austin Internal Medicine Associates is a four-physician internal medicine practice. Its patient population, Hoverman said, is fairly heterogeneous—many are well educated, but there are also a number of disadvantaged patients, including a number of people with chronic psychiatric illness and mental retardation and a large number of Medicare patients. Most of the attributes described in the commissioned paper are doable, she said, although they are probably not doable in a small private practice, and more than 40 percent of physicians practice in small groups.

Organizational commitment is a very important attribute, she said, as are policies and procedures to support health literacy efforts. Health literacy is a team-based effort. For example, the first level of contact in her practice is the front desk. The practice has tried to simplify its registration forms so they can be understood at a very basic level, and patient information brochures have all been rewritten to remove as much jargon as possible.

Questions concerning what is covered in the many different health plans present particular challenges to the managers in the practice: What is the co-pay? Is the practice listed as a primary provider? Does the patient need a referral? Few patients know what their insurance covers or what their out-of-pocket expenses will be. Talking about a bill for



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4 Reaction Panel 2 PHYSICIAN PRIVATE PRACTICE Isabel Hoverman, M.D. Austin Internal Medicine Associates Austin Internal Medicine Associates is a four-physician internal medi- cine practice. Its patient population, Hoverman said, is fairly heteroge- neous—many are well educated, but there are also a number of disad- vantaged patients, including a number of people with chronic psychiatric illness and mental retardation and a large number of Medicare patients. Most of the attributes described in the commissioned paper are doable, she said, although they are probably not doable in a small private practice, and more than 40 percent of physicians practice in small groups. Organizational commitment is a very important attribute, she said, as are policies and procedures to support health literacy efforts. Health literacy is a team-based effort. For example, the first level of contact in her practice is the front desk. The practice has tried to simplify its registra - tion forms so they can be understood at a very basic level, and patient information brochures have all been rewritten to remove as much jargon as possible. Questions concerning what is covered in the many different health plans present particular challenges to the managers in the practice: What is the co-pay? Is the practice listed as a primary provider? Does the patient need a referral? Few patients know what their insurance cov- ers or what their out-of-pocket expenses will be. Talking about a bill for 31

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32 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS services involves a whole separate language: co-pays, deductibles, usual and allowable fees, covered and non-covered services. This is language that few other than those who use it every day in their work understand. Over the years the practice has struggled with employees who are frustrated by patients who did not understand their benefits or the terms of their health plans. “Making health care plans and insurance products more transparent and comprehensible”—one of the attributes mentioned in the paper—is a huge priority for the practice as it would save signifi- cant time and energy for both patients and the practice. Another important attribute is “Foster an augmented and prepared workforce to promote health literacy.” The health literacy of the staff can be a barrier to having a health literate practice. The practice started con - ducting interviews with staff members, asking simple questions. Discus - sions were held and then the staff was asked to write down what the mes- sage of the discussion was. One finding was that many of the staff could not triage a telephone call. Also, while many employees are sympathetic to patients’ needs, they may not have an understanding of what patients are asking. Therefore, the policy of this practice is that no front-desk office staff member can take messages with clinical content. The front office staff asks what the call is regarding, so that if there is an emergency or if the patient is ill and needs more than an appointment, a nurse or a doctor handles it right away. The practice has also looked at the health literacy of its medical assistants. Because the term “medical” is in the name of their position, patients often assume that they are able to perform at a higher level, but these are really entry level jobs with minimal training. It is important to make sure the medical assistants have the knowledge to function appropriately. Many patients are computer literate, but a large number do not feel comfortable with the Internet as a source of information or do not have easy access to the Internet. Many patients are unable to conduct reliable searches for disease information. Those who are slightly more computer literate tend to conduct a broad search and then have trouble separating information that is evidence-based from that which is not. The practice uses MedlinePlus.gov as well as specialty society websites and disease- specific sites run by related associations (e.g., the American Diabetes Association and the American Cancer Society) as information sources for patients. The practice could do a better job of providing patients with a broader list of useful Internet sites that provide reliable information. While being able to access one’s own health records via computer is attractive, it is difficult to imagine that this will occur widely in the near future, Hoverman said. Most electronic health records (EHRs) in the medical community are in a format to satisfy CPT coding guidelines and thus justify billing. Often important and useful information about why

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33 REACTION PANEL 2 the patient was seen, what the recommendations for treatment were, or what the patients were told is either missing or hidden in pages of text that summarize previous treatments or in family and social history that is documented but does not change from visit to visit. Addressing the issue of important attributes on which a small physi- cian practice might place priority, Hoverman said that medication safety and medication communication are paramount. Communicating with patients using such approaches as the “Ask Me Three” campaign is both possible and desirable. The practice uses checklists to a certain extent but could do a better job. Medical personnel try to use simple language by, for example, talking about the importance of “checking one’s sugar” rather than the importance of “glucose testing.” There are several major barriers medical practices face in implement - ing the attributes. The greatest barrier to addressing health literacy, for instance, is not recognizing that there is a problem. Another barrier is the limited time available to spend with patients. Some patients have low English proficiency or differing cultural or personal beliefs. Others have cognitive decline, hearing or visual impairment, or mental health prob - lems. These barriers make effective communication more difficult and time consuming. Ultimately, the focus needs to be on providing patient- centered care, and that means meeting the health literacy needs of the patients served, Hoverman concluded. PHARMACY PRACTICE Darren Townzen, R.Ph., M.B.A. Wal-Mart Stores, Inc. Wal-Mart Stores Inc. operates about 4,500 pharmacies across the United States, Townzen said, and within the health and wellness divi - sion there are also clinics and vision centers. These clinics are not owned by Walmart, but rather they are leased to partners in the local health care system. Each pharmacy and each clinic is required to have an electronic medical record and to transmit prescriptions electronically. Many of the attributes described in the commissioned paper did not seem to apply to a retail setting, Townzen said. However, four definitely did. These are 1. embedding health literacy practices into health information tech- nology (IT) to support providers and patients; 2. providing patient training and assistance around personal health records and health IT tools;

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34 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS 3. prioritizing medications safety and medication communication; and 4. recognizing and making accommodations for additional barriers to communication. Focusing on attributes related to health IT is a priority for Walmart because it allows use of new and existing technology to aid in the phar- macy mission. For example, one of the things Walmart pharmacies do is to text-message a customer when his or her prescription is ready. The company is also developing more meaningful messages, such as letting patients know when they are late on chronic medications—something that is good for the patient and provides a positive return on investment to the pharmacy. The pharmacies gave customers the option of receiving either a text message or a telephone call. Most people wanted to receive a call, and the hypothesis is that people believed they would have to pay to receive the text message but would not for the call. Such a perception is a barrier to the use of technology. Providing patient training and assistance around personal health records and health IT tools is another attribute that is important to Walmart. Patients can access their prescriptions through Walmart’s web - site, but this technology is not being used. And Walmart employees rarely use their own personal health records, even though all were provided with them. Trying to motivate a customer, patient, or employee to use this technology is difficult, but such use, if it could become standard, could be extremely beneficial. Another high-priority attribute is medication safety and medication communication. Pharmacists view this as a social responsibility, Townzen said. One approach to improving medication safety and communication would be to develop a more health literate prescription label. Another would be to work with physicians so that they do not view the pharma- cist as a mere dispenser of medication but rather as an active partner in providing high-quality care to patients. An adequately trained workforce is also key. Pharmacy staff members should reflect the community so that they can better communicate with those who use the pharmacy. Interpreters are needed to aid in increasing patient understanding and comprehension. Certainly the written informa- tion provided with prescriptions is unlikely to be read or used by patients. A much more strategic approach to providing information is needed. Internally, Walmart is developing communication systems for patients with limited English proficiency and addressing how to counsel a patient. One challenge to becoming a health literate organization is competing priorities. Some projects are compliance-driven because of regulations.

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35 REACTION PANEL 2 Others are business-dictated projects. It will be of major importance to determine the best way to distribute available resources so as to make sure that pharmacies are delivering good value rather than just satisfying a rule or regulation, Townzen concluded. DISCUSSION Roundtable member Paul Schyve said he was stuck by Townzen’s comment that implementation will depend on competing priorities and on expense. The roundtable is focused on how important health literacy is, but in practice settings people are faced with many important things that must be done, many of which are not currently being done. How do organizations, whether private-practice medical offices, Wal-Mart Stores, or a health plan and delivery system, make decisions about priorities and about where to put resources? Townzen responded that the Walmart system is attempting to develop a more robust informatics strategy. Health benefits are achieved when patients stay in compliance with their therapy and they are getting their prescriptions filled on time. Hoverman said that change in her practice required a change in cul - ture at all levels. It is not a question of, Can we spend X dollars? Change must come from the leadership, which means that the leadership must understand the problem. But changing culture is very difficult. One advantage of having taken care of many of the patients for a very long time is that the staff members know the patients, their families, and their problems and are more sympathetic, which is a big plus in facilitating needed change. Isham said that for his health plan, decisions must fit into a chain of logic and rationale that allows taking advantage of the resources that already exist for the purpose of meeting the identified needs. Choices need to facilitate superior patient experiences as well as having a value proposition for the health plans, both medical and dental. It is not a mat - ter of whether one has more or less in these challenging times, but rather it is a matter of how to redeploy existing resources to meet these very important needs. What the commissioned paper does is point the way, very specifically and tangibly, to how one can make the arguments for redeployment. Cynthia Baur from the U.S. Centers for Disease Control and Preven- tion asked what innovative strategies Wal-Mart Stores is pursuing to achieve the attributes of health literacy. Townzen responded that mak- ing the attributes a priority within the organization would motivate the creation of innovative strategies. This requires getting the right people to focus on the issue. The practice management system is designed around

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36 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS pulling people from the field—those on the front line—in order to come up with solutions. Isham said his impression is that organizations like Walmart are focused on meeting the needs of the customers or patients at an afford- able cost. There is tremendous potential for such organizations to address the issues of health literacy. Such organizations can challenge those in the more conventional health care system to be more creative. Roundtable member Benard Dreyer asked whether the personal health records kept by Walmart contain the kinds of information that patients are likely to want to know or whether they are records of only a small portion of the patient’s health. If the latter, perhaps that is why the records are not accessed. Another possible reason for lack of use might be the way in which the information is presented. Is it presented in a format that a patient can understand and use? Electronic medical records are being promulgated across the United States, but they may well be in a format or use language that is not understandable and usable by the patient. That seems to be what the attribute concerning electronic health records is trying to convey. Townzen replied that the personal health record contains a record of all prescriptions filled within one of Walmart’s facilities. It also contains all of the information needed for medical billing and processing. Users are also allowed to enter information themselves, including over-the-counter medications used and other information they think is important. And notifications are sent when something has been updated in the record. In terms of usability, it may be that the company to which the system has been outsourced needs to conduct some focus groups or other investiga - tions into the record’s usability. Roundtable member Sharon Barrett asked if Townzen could describe more fully what Wal-Mart Stores is doing for its employees in terms of its health insurance packages. Is there some kind of training to help them become more health literate or knowledgeable about what an appropriate packages for them might be? Townzen said that there is an internal website that is very easy to navigate that provides all kinds of information for employees. It is still a work in progress, but Walmart hopes it will become a very useful tool. Roundtable member Cindy Brach asked both Townzen and Hoverman what their overall reactions were to the attributes presented in the com- missioned paper. Did the paper make you reflect on your own organiza - tion and ask yourself how it is doing and whether it is a health literate organization? Did it inspire you to think about new ways in which you might stretch yourselves to take on something new, to address some attribute that you are not currently addressing? Did it provide you with any guidance on how you might do this? And, finally, do you have any

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37 REACTION PANEL 2 suggestions on what might be missing from the paper or what should be changed? Hoverman replied that, as she had stated in her presentation, she was inspired by the report. She had never heard about some of the tools mentioned, such as the Ask Me Three campaign, but she was excited about integrating into her practice. However, she said, there are two very different kinds of audiences for this paper—the audience composed of large organizations, such as the New York City Health and Hospital Corporation and Wal-Mart Stores, and the audience that is composed of small groups, such as the physician group practice or the independent pharmacy. Certainly there are some attributes that all of these entities should pay attention to, such as the issue of medications and the issue of how to best communicate with patients. But instituting other attributes requires resources that may be beyond the reach of the small groups. No one has discussed how to reach out and educate physicians about becoming more health literate, Hoverman said. What is the plan for this? Might one work with medical societies and associations? Furthermore, she added, the pharmacy aspect is incredibly challenging, particularly when patients use mail order to get their prescriptions. How does one have a conversation about medications when they just appear in a patient’s mail box? Another thing that seems to be missing is how to measure the out - comes of one’s efforts to become more health literate. Isham suggested several mechanisms might be used to transmit ideas and to give physicians and others incentives to pursue activities to become more health literate. These mechanisms include quality-improvement organizations,1 regional quality-improvement collaboratives, require- ments instituted by the Centers for Medicare and Medicaid Services (CMS), medical societies, and certifying organizations. Townzen said that the paper had inspired him. He was happy to see that the changes that Wal-Mart Stores are making, such as reconstructing the counseling queue, fit well with the goal of becoming more health liter- ate. The new system under development will not only provide access to a patient’s information at the point of sale or at the register, but it also will provide the right questions to ask the customer to make sure he or she understands. Having the attributes in hand will assist in the development phase. Townzen said that he would like to see some kind of quality check emerge from the paper and the discussion. Are the innovations being 1 “A Quality Improvement Organization (QIO) consists of groups of doctors and health care experts to check on and improve the care given to people with Medicare.” Many QIOs also contract with private companies to conduct reviews of care. https:// questions.medicare.gov/app/answers/detail/a_id/1943/~/what-is-a-medicare-quality- improvement-organization-(qio)%3F (accessed January 25, 2012).

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38 MORE HEALTH LITERATE HEALTH CARE ORGANIZATIONS developed as good as they think they are? How can the quality of these innovations be measured? Roundtable member Yolanda Partida asked whether there are oppor- tunities to raise awareness about better choices among one’s patients—for example, about a good diet for individuals with diabetes. Townzen said, yes, absolutely. Walmart is, for example, working with different manufacturers to identify in the stores certain food groups that are better for a diabetic customer, perhaps by installing appropriate sig - nage. And perhaps the pharmacy could direct a patient picking up a prescription for diabetes treatment to the area with those healthful foods. Hoverman said that in terms of community involvement there are limits to what a small group can do, but larger groups have tremendous opportunities. For example, Walmart has introduced organic foods in its stores and has been able to support some businesses that probably would have gone out of existence without that support. That is a powerful thing for promoting health. Roundtable member Will Ross noted that both speakers had men - tioned financial limitations to implementing the attributes and asked Hoverman to address the issue of return on investment. Hoverman responded that if patients understand their health problems and disease processes, they have a better chance of understanding why they need to take their medications and adhere to a treatment regimen. Therefore they are less likely to be ill, and a visit to the physician’s office takes less time. This may take time initially, and there may be many return visits before one begins to see change, but, ultimately, patients have better health. That is a good return on investment. Schillinger said that return on investment can also be calculated in terms of provider satisfaction, provider retention, and prevention of burn- out. The cost of training, recruiting, and hiring needs to be quantified and included in the assessment of a health literate health care organization. Myra Kline, an audience member from Tulane University, said that she practices in the clinical setting of what used to be a charity hospital in New Orleans. There are major health literacy issues in post-Katrina New Orleans, many of which are due to the large influx of undocumented immigrants. Walmart is where many patients go because it is affordable. How, she asked, does Walmart provide information to patients who have limited English proficiency? And in the university clinical setting, she added, patients are inundated with a barrage of information from their health plans which requires much time to interpret. How does a private practice handle such issues? she asked Hoverman. Hoverman said that the practice tries to assist its patients in under- standing their health insurance plan. For example, many of the patients in her practice are retirees on Medicare who are now being encouraged by

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39 REACTION PANEL 2 mail and telephone to enter a Medicare health maintenance organization. When patients receive these numerous letters, they do not understand what the letters are saying. The patients bring the information to the practice, which tries to help them understand what their choices might be. This is a definite burden on the practice in terms of time and effort, but it is necessary to assist the patients. Concerning patients with limited English proficiency, Townzen said that printed monographs can be provided only in English, Spanish, and Canadian French. The software does not exist to provide the prescrip- tion label in all the languages needed. And certain laws require English to remain on the label so that it can be easily read in case of emergency, such as the patient being taken to an emergency room. There is just not enough space on a label to include everything in English and in another language as well. Furthermore, one cannot simply convert the English text to another language. There are cultural issues and issues of syntax that need to be addressed. Suggestions for new and better ways to address this issue would be welcome, Townzen said.

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