This interview with Douglas Kamerow is the third in a series of brief chats between CFAH president and founder, Jessie Gruman, and health care experts'among them our CFAH Board of Trustees'who have devoted their careers to helping people find good health care and make the most of it.
Douglas Kamerow, immediate past CFAH Board Chair, is a chief scientist at the non-partisan research institute RTI International and Professor of Clinical Family Medicine at Georgetown University. His new book is Dissecting American Health Care.
Time, Tools and Temperament- Requirements for Engagement
Gruman: As a practicing family physician, what do you see as the challenges to people's active engagement in their health and health care?
Douglas Kamerow: Three of the things that optimal patient engagement depends on are TIME, TOOLS and TEMPERAMENT. Clinicians and patients experience each of these differently, but they are central to us working together to get the best possible outcomes.
Gruman: OK. Start with TIME. What do you mean? Whose time? Time for what?
Douglas Kamerow: For clinicians, time equals money. Clinicians need to be paid in such a way that we are encouraged -- not penalized -- for spending time discussing what an individual might do to prevent and manage disease. Similarly, patients need to devote the time necessary to becoming and staying actively engaged.
Gruman: What specifically do you think we need time to discuss?
Douglas Kamerow: If clinicians are in a fee-for-service setting, we don't have enough time to talk with our patients about all the preventive tests and behaviors they should be doing, in addition to working with them to solve the problem that brought them to the clinic.
Over and above that, however, I think we (and our team members, if we have them) need time to talk with our patients about what they need to do to get the most from their health care.' We clinicians just assume that everyone knows what we know about getting good care ' how to keep track of lab tests, what results mean, what step comes next, and so on ' and we forget that patients don't know.'
Who gives lessons in being an engaged patient? It's pretty clear that most people aren't going to go to 'patient college' to learn this. Though they can find lots of disease-related information online, that really doesn't address what an individual must do to make the best possible use of services and drugs and information and technology to address his or her unique needs.
This kind of personalized collaborative planning ' something that is most effectively done with a primary care clinician (or team member) and a patient (sometimes with a family member or caregiver) -- is critical to people engaging in their care.' And there is often no time for this. No one will pay clinicians to do it.
Patients also have to see this as sufficiently important to be willing to devote time to explore with their clinician how to best participate in their care and then commit to spending the time necessary to do it.' There are different incentives for patients to engage, with better outcomes primary among them.
Gruman: Your second requirement is TOOLS. What do you mean?
Douglas Kamerow: By tools, I am referring specifically to electronic record-keeping approaches that allow patients and clinicians to keep track of an individual's health care history.' A tremendous amount of attention and money is currently aimed at getting electronic health records (EHRs) up and running. There are two aspects to this: patient access to the EHRs and true inclusiveness in the EHRs.
Eventually, many of these systems will provide a patient portal for people to view parts of their medical record.' Right now, however, unless you are in a system like the VA or are a member of Kaiser Permanente or Group Health Cooperative, you probably have little access to your health records: when did you get your last tetanus shot? When did you stop taking that beta-blocker?' Most people are out of luck: they either keep records themselves on paper or are at the mercy of a paper record and a medical assistant willing to plow through it.
As for inclusiveness, closed health care systems like Kaiser and the VA have a huge stake in decreasing duplication and errors. They already work hard to make sure that every specialist note, every x-ray result, and every lab test is included in their EHRs. No such incentives or systems exist for most clinicians, who are paid by the services provided.' So while there is slow movement toward an interoperable, transportable EHR that contains meaningful information for both patients and clinicians, it is not going to be a reality for most people any time soon.' In the meantime, responsibility for keeping track of which information can be found in which clinician's chart falls to the patient.
Gruman: And the third requirement: TEMPERAMENT?
Douglas Kamerow: By temperament, I'm referring to attitude and interest in an individual's engagement in his or her care on the part of both the patient and the clinician.' Both have to view this as important: patients have to know that they can't be passive and get good outcomes; they need to know what's going on and why, how to keep track and assert themselves and what they have to do to get better. And clinicians have to understand that they just can't write orders, that their role is to describe, explain, explore and advise, recognizing that people vary in their interest in participating in their care, based on education, language, culture, and health status.'
The mutual commitment to figuring out what's wrong and solving it is critical. Clinicians need a predisposition to work with their patients to help them understand what they think is needed.' Say a patient has hypertension. The patient needs to know what's in it for them in the long and short-term in lowering their blood pressure.' The clinician needs communication skills and interest so the patient will find the discussion both useful and motivating. Clinicians have the power to put the tools of medicine ' drugs, devices, knowledge, procedures ' in the service of what needs to be done, but they need to be clear about their reasoning ''because it can help you.' We clinicians can't just give directives, i.e., 'Lose weight!' 'Take these pills!' We have to connect cause to effect and make sure our patients understand their role in increasing the likelihood of the best possible outcome.
Gruman: These three requirements seem to be closely related.
Douglas Kamerow: You're right.' They are.' None of them will take place without specific incentives for both patients and clinicians to change the way they interact.' For clinicians, the incentives are two-fold: payment for their time to work with their patients to understand their role and make plans, and the realization that their interventions are more effective when patients participate actively in their care.' And the patients' incentive is the knowledge that they are doing everything possible to get better or stay healthy.
Each has a role to play in the service of an individual's health.' One way to improve and maintain health is trying to make sure that the patient is engaged. It doesn't work unless both sides play their roles ' learn, teach, facilitate, and DO.
We need time, tools and temperament to do this.