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The Challenge of Patient-Provider Communication in Ambulatory Care

The 20-45 minute ambulatory care patient-provider encounter has critical value and potential benefits perhaps not fully realized in the VA today. Beyond primary care, these crucial encounters also occur thousands of times a day in VHA Specialty Clinics. For that reason, I invite the VA research community to describe or develop evidence-based best practices for patient-provider encounters. Such research will be particularly important as we transform to the medical home model.

My interest in such research is based on four factors. First, the daily mission that drives us at VA Central California, a Level 2 facility accomplishing 300,000 annual visits, is achieving "clinical excellence in a clean and safe environment." I firmly believe a positive patient experience, while secondary to an accurate diagnosis and effective treatment, is an extremely important aspect of clinical excellence. Our goal for every patient is to improve well being and achieve the best health outcomes. The patient-provider encounter is critical to this fundamental goal.

Second, as the single most important determinant of outpatient satisfaction, "the physician (or provider) is the focus of the patient experience."¹ Of secondary importance are efficiency of support staff and length of time in the waiting room.

Third, VHA is committed to Secretary Shinseki's Transformation 21 core principle of "People Centric" care. Overlaying that is the current major investment in the primary-care "medical home" model, which promises far reaching change in the delivery of VA ambulatory care. In this program "home" means health care that is friendly, supportive, and fully coordinated around each patient's needs. Some have described this model as a fundamental transition from provider-centeredness (emphasis on provider expertise and patient passivity) to patient-centeredness (information sharing, shared decision-making, and emotional support).²

Finally, since 1996, VHA has aggressively surveyed, widely reported on, and made outpatient satisfaction a core "mission critical" measure among the Executive Career Field (ECF) Performance Measures. Today the overall "passing" standard on how patients rate their care is a score of "9" or "10" on a scale of "0" to "10." Informally this is known to directors as the "WOW!" rating. Embedded in the SHEP survey are several important questions that cover, for example, whether or not providers: explained things in a way that was easy to understand; listened carefully to you; showed respect for what you had to say; spent enough time with you; and talked about the pros and cons of treatment options. Outpatient Veterans are also asked to score their provider or specialist on the rating scale of "0"—representing worst possible to "10"—representing best possible.

Ideally much can be achieved in the ambulatory care patient-provider encounter: positive rapport building; emotional support; shared decision-making; building trust and confidence in the provider; an open dialogue; high likelihood of adherence with instructions and therapy; and, of course, arriving at the right diagnosis and treatment. For patients, the encounter should provide the answer to their most basic concerns; "What, if anything, is wrong with me, and what are we going to do about it?"

The challenges in ambulatory care are considerable: limited space; time pressure; potential language barriers; patient anxiety; high emotion; required computer use by the provider in the exam room; accomplishing an ever-increasing number of clinical reminders; patients ranging widely in age from an 18-year-old Operation Iraqi Freedom Veteran to a 92-year-old World War II Veteran; availability of telehealth (and its limitations); and, in some cases, provider fatigue and burnout. And then there are the numerous patient-provider "connection" and approach choices, such as: handshake or not, white coat or not, to touch or not, standing or sitting, how best to engage a patient with the computer, how to prepare for visit then execute the optimal visit entry, interview and exam, and visit exit.

My challenge to VA researchers is to determine what evidence-based practices VA leaders can draw from ambulatory care patient-provider encounter research. What have proven to be best practices at leaders like The Mayo Clinic, or Geisinger Health? How do we achieve both the desired clinical outcome and a positive patient experience? Timing answers to these questions with the implementation of the "medical home" primary-care model throughout VHA will be of great value to center directors, and, hopefully, will also help VA achieve the best health care possible.

References

1. K. Otani, R. Kurz, L. Harrit, Managing Primary Care Using Patient Satisfaction Measures, Red Orbit News, August 7, 2009.
2. J. Cvengos, C. Christenson (CRIISP VA HSR&D) C. Cunningham (CRIISP VA HSRD), Patient Preference for and Reports of Provide Behavior: Impact of Symmetry on Patient Outcomes, Health Psychology 2009; vol 28 No 6: 600-67.