Building Something Better Than ‘Playing Catch Up’

It often feels like a big part of our annual visits with patients, when they come in for their physical and blood tests and to update us on their medical conditions, is spent seeing how their lives, especially as related to their health, have been progressing over the past year.

Or not progressing.

When I pre-chart on patients coming to see me for their Medicare annual wellness visits, or for their annual physical that’s covered by their commercial insurance or Medicaid, I look at the chores we decided at last year’s visit to accomplish together in the coming year. This is part of shared medical decision-making, and it’s usually all right there in my note in the assessment and plan.

Since their gastroenterologist had told them they wanted to repeat a colonoscopy in 3 to 5 years, and they were now at the 6-year mark, they had committed to calling their GI doctor and scheduling a follow-up procedure. They were going to get their shingles vaccine at the local pharmacy. They were going to fill their medications every month at the pharmacy and try to take them every day, and check their blood pressure at home, and send in readings via the portal.

They were finally going to start using that gym membership they were paying for. And maybe even start meditating, and schedule that sleep study so their bed partner would stop complaining about their snoring and possible sleep apnea.

Catching Up on the Past Year

So, much of that only once-a-year visit ends up being taken up with playing catch-up, finding out what they did or didn’t do, trying to help address their hesitancies and barriers to getting these things done, and then teeing up once again at the end of the visit those things that didn’t happen. “This year I’m really going to try and go to the gym a couple days a week, take my medications more regularly, schedule my mammogram, and call the nutritionist and follow their advice.” We hear this stuff a lot.

Recently we discovered that if you do not specifically place an expiration date on them when ordering, vaccines will sit in the nurse’s vaccine queue for years, potentially available to be given at a much later time, maybe when the patient does not want them or when they have suddenly become contraindicated. Imagine a patient is teed up for a vaccine, decides not to get it, and then returns several years later when things have changed, perhaps now pregnant or immunocompromised, and a well-meaning nurse picks up all the vaccine orders in their work list.

The Potential of Automated Reminders

But what if instead, after the patient left that visit years ago, the system noted that they hadn’t gotten their vaccine, and sent them a reminder? “Hey, we noticed that your doctor ordered a booster shot for you today that you didn’t get; would you like to do that at your pharmacy? Would you like to come back in, schedule a visit with our nurse to get it done here one morning? Or are you just not feeling the need or desire for it this year?” If they truly don’t want it, they can hit “delete”.

I envision a system where all the things we talk about and order for our patients get turned into a series of tasks and reminders and even possibly deadlines, opportunities for the system to reach out to the patient and say, “I noticed that Dr. Pelzman wanted you to get the shingles vaccine, and it has now been about 2 months. Would you like us to send a fresh order to your pharmacist? Can we help you schedule this? Do you have any questions or hesitancy that we can help address?”

And all the consults, imaging, and healthcare maintenance we order can turn into things that our own systems check for and make sure are done, and then make sure that we have the results brought into our system so that we can know they happened and know how to best move forward.

If they do their colonoscopy with an outside gastroenterologist, and that doctor sends us a copy of their consultation, then that result should be scanned into our system against our order for the colonoscopy, satisfy their colon cancer screening healthcare maintenance item, and toggle the time to when their next one is due based on their findings on the exam and the recommendations of the specialist.

If we learned that they’ve had the procedure done, either from a message from the patient, or that their insurance was billed for this procedure, and the doctor in question fails to send us a copy of their report, perhaps the system could be smart enough to reach out to their office and say, “By the way, that patient we sent to see you for a colonoscopy that you did the procedure on, please make sure you send us a copy of your report and findings so that we can coordinate their care and more efficiently help take care of them. And thank you so much for helping ensure they got this done.”

Lots of Opportunity

There are so many opportunities for the system to help us, whether it’s making sure patients get a vaccine, see a consultant, undergo a mammogram or a colonoscopy, or fill their prescriptions at the pharmacy and take them regularly. We could even potentially use data from their home monitoring of blood pressure, blood glucose, and exercise — through remote patient monitoring devices and wearable technology — to more effectively track their health during that long period between annual physical exams.

I know this has a little bit of a “Big Brother” feel to it, us monitoring and checking in on patients, making sure they are taking their pills every day and nagging and wagging our fingers at them when they don’t. Of course, when we build these systems out, we are going to need to get buy-in from patients and listen to them when they say, “Enough! Leave me alone; I’ll get to this when I get to it.”

But to keep things truly patient-centered, in those 364 days after they leave our office once they’ve completed their annual physical, a lot can happen. And a lot should.