Tuesday, December 14, 2010

Should Physicians and Nurses Chase "No-Show" Patients?

December 14, 2010 7:40PM
Needham Heights, MA, USA
Bernard P. Wess, Jr.
link: http://www.bbc.co.uk/news/health-11641929

Physicians are beginning to take note of the new opportunities to encourage patients to comply with diagnostic and treatment processes, particularly for high-risk or expensive patients. Expect more technology for compliance and coordination to be developed as software and telecommunications improve in speed and telecommunications devices pervade society.

In an article in the BBC website on patient compliance Dr. Jacqui Philips, legal adviser to physicians in the British Medical Defence Union urged British physicians to "try to chase patients to improve patient care and reduce their professional liability risk."1

Patient healthcare process compliance is more than a public service issue for many patients who need coercion to encourage them to apply: some may have serious conditions that require follow-up.

No physician or case manager intentionally fails to follow-up with a patient, but physicians will tell you in private that they do not have the resources (time and money) to "chase patients" and to manage the organizational and scheduling needs of patients who are in need of personal help in managing there own care. Physicians almost universally depend on the patient to initiate contact for an office visit or follow-up, particularly if a visit is missed or re-scheduled. Recently, HarvardPilgrim in Massachusetts has started nurse care manager initiated home phone calls to facilitate compliance by patients at risk.

On a grand scale in the U.S. or British health systems, missing appointments for care costs hundreds of millions in the British case and billions in the U.S. Moreover, the "failure to diagnose" and/or the "failure to treat" are much more serious since these failures subject the provider of care to legal action and these torts are leading causes of successful professional liability cases in both countries.

From a cost perspective, patient compliance is a severe issue for government programs, not just commercial insurance. Governments pay for failure of compliance and associated adverse events, bad outcomes or mis-diagnoses in disability programs, Medicare and particularly Medicaid insurance programs. "Chasing patients" in the British healthcare system could result in a £600 million savings and in the U.S., billions of dollars.

A Systems Solution
New integrated care information systems are redefining the standards of care for patient episodes, not just for office visits. If a patient is added to a "surveillance" group for follow-up, they can be tracked and monitored by an integrated care system. The physician asks a nurse to enroll a patient using the telecommunication information on the patient and the software "follows" the patient through a set of pre-defined rules for a diagnostic or treatment episode.

The source of the claim liability, whether personal or group health, disability, Medicaid, Medicare or worker's compensation should not influence the follow-up and monitoring process. For worker's compensation and group health, this coordination may be complex, since the patient may not select the care providers, facility or physicians, in a worker's compensation case. This should not matter to the integrated care system. The system should follow and "nudge" the patient forward in the care management process.

Using personal clinical rules, integrated care information systems can communicate through inexpensive telecommunications: text messages, calls, email and letters to intervene in the patient's life effectively and as often as necessary to achieve compliance.

Bills collectors seem to have raised this process to an annoying and extremely high-art but surely the healthcare system can provide a process that is tolerable and effective. Moreover, the audit process protects the provider of care in the unfortunate condition where the patient does not comply and the outcome is untoward and litigation ensues.

Product Architecture
The Life Sciences Universe product is enabled to design, build and operate simple or complex insurance, clinical and financial rules for all lines of business and risk and to create and monitor patient "watch" or "surveillance" groups by diagnose or treatment category.

Patients can use cell phones, smartphones, home computers and receive PDF documents created by personalized follow-up rules. These are not time consuming to create and they can be quickly designed and attached to a patient by a care or case manager.

To enable enterprise-scale systems implementation, the entire product is written in Oracle and supports Oracle cluster processing, 64-bit architecture and full, secure Internet processing using Oracle Sun Web Services.  advanced transaction processing, audit and control is implemented using Oracle Advanced Queues for clinical, administrative and financial transaction processing that guarantees delivery of web transactions to secure queues for immediate processing. 

Numerous tools are provided to balance real-time, clinical and analytical processing of patient rules. Full audit trails are created for all patient communications both sent and received.

1 Dr Jacqui Phillips, BBC, Doctors warned to check no-shows, 19 November 2010, http://www.bbc.co.uk/news/health-11641929

keywords: clinical rule engine, integrated care, medical home, no shows, clinical rule engines, life sciences universe, medicare, medicaid, patient compliance