The workshop’s third panel was also structured with one presentation and several reactions to that presentation. In the main presentation, John Byrne, associate chief of staff for education and chief health informatics officer at the VA Loma Linda Healthcare System and associate professor of medicine at the Loma Linda University School of Medicine, discussed the after-visit summary tool that he and his colleagues have developed. Reactions to this presentation came from Rachel Solotaroff, medical director at Central City Concern, and Alice Horowitz, research assistant professor at the University of Maryland School of Public Health.
The Veterans Health Administration (VHA) has more than 8 million enrollees who made some 85 million outpatient visits in 2012, said John Byrne, and it possesses one of the most robust and well-regarded EHR systems (Edsall and Adler, 2011). The EHR system consists of the VHA’s EHR, VistA, and its graphical user interface, the Computerized Patient Record System (CPRS). What the VHA does not have, however, is a means of using VistA or the CPRS to generate an after-visit summary, forcing VHA physicians to create their own workarounds, including those using pen and
1This section is based on the presentation by John Byrne, associate professor of medicine, Loma Linda University School of Medicine, and the statements are not endorsed or verified by the IOM.
paper. It was this situation that spurred Byrne to develop an after-visit summary that was as good as the one he received from his own family physician as far back as 2006.
The goal of this effort, he explained, was to provide patients with a patient-centered clinical summary of their outpatient visits while minimizing the burden on providers by automatically populating the summary with data from VistA but leaving room for customization. After pilot testing the resulting after-visit summary in 2012 and 2013, the VHA has now deployed the summary at six of its sites, including the VA Loma Linda Healthcare System. The development and evaluation process, said Byrne, solicited input and feedback from patients as well as the VHA Medication Reconciliation and the Meaningful Use groups to first create a prototype after-visit summary and then improve the summary through an iterative cycle of field testing and reprogramming. He noted that one challenge that arises from including so much input in the development process is that it can lead to what he called “scope creep.” “You end up going beyond the requirements that you had planned for,” explained Byrne.
From an operational viewpoint, the after-visit summary is generated by a system that resides outside of the CPRS, which allows it to leverage the data in the VistA EHR and enables it to reach out to other sources on the Internet to expand data and information that is drawn into the summary. A physician, however, creates the summary from the CPRS, using a dropdown menu, and the summary changes in response to items selected for inclusion by the physician. Once the physician opens the summary, it appears in a browser and looks like a PDF document that is going to be printed for the patient. The browser auto-refreshes as the provider enters orders or information into the EHR, minimizing the data entry burden on the health care provider.
The format of the after-visit summary is designed to meet Stage 2 meaningful use criteria and comprises several distinct sections. The patient information section, for example, contains the patient’s name, demographic information, smoking status, and language preference. The “Today’s Visit” section includes the provider’s name and office contact information, the reason for the visit and current problem list, vital signs, a list of diagnostic tests pending, future scheduled tests, immunizations of medications administered during the visit, and referrals to other providers. The “Important Notes” section lists clinical instructions, future appointments, recommended patient decision aids, and remote appointments that account for the fact that many VHA patients spend winters and summers in different parts of the country. Byrne noted that this section also describes the care plan and will eventually include the patient’s goals, though it is still unclear how to incorporate those goals into the after-visit summary. “This is more an issue of cultural change rather than a technical issue,” Byrne explained.
The “My Ongoing Care” section lists the patient’s medications, including those prescribed by physicians outside of the VHA system and those at other VHA locations. This section also includes the names of all the members of the patient’s primary care team. Byrne noted that his team is trying to translate the after-visit summary into Spanish and enabling it to be printed out in a larger font size for visually impaired patients. The physician can also include charts for trending clinical data, a feature that patients particularly like, and can call up education sheets based on the ICD-9 codes entered into the CPRS during the patient’s visit. This educational material can be incorporated into the after-visit summary, either entirely or in pieces that are copied into specific section of the summary. It can also be printed separately, in which case a note is inserted automatically into the instructions section of the summary informing the patient to read the attached materials. There is also a technical translator built into the system that converts jargon from VistA into patient-friendly language.
Going forward, Byrne and his colleagues plan to conduct an evaluation trial of their after-visit summary. They are also working on a pre-visit summary to provide patients with the list of their medications to facilitate medication reconciliation and an opportunity to write down their concerns for the day. In addition, efforts are under way to make both the pre-visit and after-visit summaries available on patient kiosks that are part of the VA Veteran Portal System.
Central City Concern, the organization that Rachel Solotaroff works for, is a broad-based social service agency whose mission is to provide comprehensive solutions to ending homelessness and achieving self-sufficiency. As Solotaroff explained, Central City Concern is not a health care organization per se, but there is a high degree of substance abuse and mental illness in the population that it serves, so medical care is an important component of its mission. The population served is 60 to 80 percent homeless, using a fairly broad definition of “homelessness,” from chronic homelessness on the streets all the way to transitional housing. Almost all the patients are at 100 percent of the federal poverty level or below, she said.
“Our core product isn’t to produce visits, or to reduce hospitalizations,” Solotaroff said. “Our core products are to produce hope and to produce safety, in the hope of ultimately influencing the choices that people
2This section is based on the presentation by Rachel Solotaroff, medical director, Central City Concern, and the statements are not endorsed or verified by the IOM.
make.” Given the patient population that she and her coworkers treat and the general messiness and ambiguity, as she put it, associated with providing health care for this population, an after-visit summary serves as less of a summary of a visit or as an instructional tool and more of a snapshot in time of where a given individual is, what that individual is hoping for, how the physician can help, and where things might move to over time.
The after-visit summary that she has developed starts with an off-the-shelf product that the health care provider fills in as the visit proceeds. It is a very informal process, so much so that, in Solotaroff’s case, she uses a marker to circle the important parts on the printout. She characterized this type of after-visit summary as representing the low-technology end of the spectrum, but one that is highly patient-centric. She starts the process by asking, “What is important to you today, and how can I help?” The patient lists a number of things, and together they try to identify goals to accomplish. Next, Solotaroff spends time checking her understanding of what has been agreed to and then tells the patient that she, too, has some goals, things that she needs to make sure the patient knows about or that they need to address together. Solotaroff said she may ask additional questions, conduct an exam, and look at the discharge summary if the patient has just gotten out of the hospital.
Then, collaboratively, they develop a plan. That is as far as the after-visit summary goes, that teach-back moment when patients describe what they heard and understand. Solotaroff said she is typing as they have that discussion. For example, when she hears what they say they need to do about swelling ankles, she will write, “for your swelling of your ankles” do such and such. “Or if they have gotten it wrong,” she said, “or if they have a misunderstanding, we will reframe it in a way that they can understand it. I type that in as the plan in their own words as we go.” She says she tries always to end the summary with a personal sentiment, which may be as simple as “I am thinking about you. Take each day as it comes, and I am amazed at your strength.”
Alice Horowitz described a feasibility study she and her colleagues conducted to determine the user friendliness of community-based dental clinics in Maryland. This project consisted of a health literacy environmental scan of 26 community-based dental clinics using methods developed by Rima Rudd and Jennie Anderson (Rudd and Anderson, 2006) and by
3This section is based on the presentation by Alice Horowitz, research associate professor at the University of Maryland School of Public Health, and the statements are not endorsed or verified by the IOM.
AHRQ (DeWalt et al., 2010). As part of the health literacy environmental scan, Horowitz and her colleagues also conducted a technology assessment of websites and use of EHRs. In addition, they assessed print materials (consent forms, postoperative instructions, and educational materials) that were available in the 26 participating clinics. They also conducted patient interviews and did a mail survey of providers to identify the communication techniques they were using.
This study, said Horowitz, confirmed the feasibility of conducting a health literacy environmental scan in community-based dental clinics and provided guidance for extending the guidelines developed by Rudd and Anderson and by AHRQ into the dental environment. “[The scan could be used] maybe not only just in community-based clinics, but also probably in private practice,” said Horowitz. Their survey found that 18 of the 26 clinics used EHRs, though only three of these clinics—all operating under the umbrella of a federally qualified health center—integrated their dental EHR with the patient’s medical EHR. “The lack of integration causes terrible barriers, both for the patient and for all kinds of providers,” she said, particularly when it comes to decreasing early childhood caries because accomplishing that goal requires the entire health care team (medical and dental) to counsel patients about how to prevent dental caries and how to provide their infants with fluoride varnish treatments. Integration is also important for patients with diabetes, she explained, because controlling periodontal disease has a huge impact on controlling diabetes.
The printed forms, assessed using the SMOG (Simple Measure of Gobbledygook) readability formula,4 were rated between the 9th and 16th grade level, a long way from the recommended 8th grade level or below. The printed forms tended to use complex dental and legal terminology. These forms, said Horowitz, “were used more to protect the facility or providers than to help the patient understand what was going on.” One of the more disturbing findings from this study was that none of the 26 clinics provided after-visit summaries to their patients, though she noted that her personal dentist did not provide after-visit summaries either. “I think we have a long way to go in dental health,” said Horowitz. “Despite the availability of guidance for developing after-visit summaries from CMS, dentistry has not exhibited much interest in this potential activity that could make dental facilities and patients more health literate.” Horowitz concluded her presentation by saying that the use of after-visit summaries in dental clinics is an exciting new area to explore, develop, and evaluate. Such summaries, if properly prepared, can help dental facilities become
4The SMOG formula estimates the level of education a person would need to be able to read and understand a piece of text. See http://www.readabilityformulas.com/smog-readabilityformula.php (accessed July 16, 2014).
more health literate, and they can provide an opportunity for patients to ask questions and providers to remind patients of important information about their appointment and what they need to do next.
Laurie Francis pointed out that patient-centeredness is critical to effective discharge planning, yet there are no data in the EHR on patient centeredness. Solotaroff responded that behavioral health is several decades ahead of primary care in terms of understanding patient-centered goals. When her organization was designing its system, it looked at seven domains of an individual’s life that lead to self-sufficiency: physical health, substance use, mental health, housing, legal involvement, employment or income, and worldview (a way of getting at the issue of hope). Goals were then developed for each of the domains. When interacting with individuals, if the only thing a person is interested in is housing, then the other domains are set aside. As her organization redesigns its primary care EHR, Solotaroff continued, it will use these domains. The process will be more codified in terms of questions about self-efficacy than the free-form process described earlier in her presentation. There will be questions such as “How confident are you that you will be able to meet this goal?” and “What do you anticipate are barriers to this goal, and what can you use to overcome these barriers?”
John Byrne said that one of his colleagues suggested that the VA system needed a section on goals. It is a great idea, he said, but actually making it work in the EHR and changing the culture to have physicians address patient goals are big obstacles.
Rima Rudd said a common theme is attention to perspective—to the clinician’s perspective but also to the patient’s perspective. “The idea of dialogue, of truly asking and listening, and engaging those perspectives seems to be the key to successful work,” she said.