Is It Time to Retire the Phrase Physician Order?

The inspiration for this blog was my Twitter post on Friday, October 14, 2011 12:53pm where I professed “@Cascadia #ITrans n that case its time 2 retire the term DOC order. Order does not exist in a world of participatory medicine. Recommendations do. “ As much as I love Twitter though I felt additional context was needed to substantiate my claim that the phrase physician order needs to go.

Decades ago, patients were admitted to the hospital for days on end, the physician was a male leading the care team, who was a paternalistic, authoritative and directive figure. There was the nurse and the patient in that hierarchy of order and the physician issued orders. Physician orders encompassed every aspect of the patient’s personal health and lifestyle choices including nutrition, exercise, medications, treatments and diagnostic tests. Physician orders were not to be questioned but followed precisely to ensure the care and recovery of the patient. If the patient did not agree to take the medication or participate in the treatment then they were labeled with a term “noncompliant”. In frustration, many patients would choose to leave the facility, against medical advice, as we affectionately refer to as AMA. Inevitably those patients were also the very people that would frequent the emergency room and hospital beds for lengthy stays. These patients were labeled as “frequent flyers” and considered noncompliant trouble makers.

But times are changing and there is a shift in the healthcare paradigm. Not only has there been a balance in the gender makeup of physicians, physicians are also welcoming a new type of healthcare model. Patients and other healthcare professionals such as nurses and therapists are demanding for an open access system eliminating the need for physician orders. In addition payers and government entities are demanding access to patient data and information to help with clinical decision support, population health and care transitions and to educate their beneficiaries/constituents to become empowered and engaged patients with the ability to make decisions about their personal health and wellbeing.

As patients become engaged, empowered and a part of the healthcare team, they are moving the medical profession into the world of participatory medicine. In participatory medicine, the patient is a partner to the physician, and works in a collaborative manner to find the best healthcare options to support their personal values and beliefs. In participatory medicine the physician is offering the patient a host of options to select from utilizing a comparative effectiveness approach. Comparative effectiveness is when care options and treatments are evaluated against one another to find out which is the best based on efficacy and cost. In participatory medicine the physician works with the patient in a consultative manner offering recommendations about care as opposed to issuing orders. It is up to the patient to select the best treatment options based on their lifestyle choices, beliefs and home economics. Therefore in the world of participatory medicine, the physician order is a paradoxical phrase and cannot exist.

As Todd Park (@Todd_Park) was quoted at Putting the IT in Care Transitions (#ITrans) conference on Friday “let’s punch a hole in the wall of disbelief” …it is time to punch a hole in antiquated terminology that is a barrier for change to the healthcare delivery system. Now is the time to retire the phrase physician order and replace with a new phrase that is patient friendly and truly reflective of the physician role. Physician recommendation is quite acceptable in a healthcare model of collaboration and equality.

Copyright secured by Digiprove © 2011 Heather McKenzie

Virtual care: It’s not for everyone.

In my previous post, I talked about how virtual care is a clinical practice approach that allows healthcare service delivery to occur anywhere at any time. As technologies have emerged it has become increasingly easier to support virtual care, which was once limited to house phones, answering services and pagers. What remains unchanged as technology evolves to wireless, Web and social media, are the characteristics and skills required by both the healthcare provider and the patient for effective, efficient and safe virtual care. That is why virtual care is not for everyone. I know this flies in the face of the latest technology news that is touting technology as the cure for all of our healthcare woes, however it’s not the end all – be all solution for every clinical practice issue and patient care problem.

Even as innovative technologies emerge and become increasingly sophisticated, healthcare will always require face to face human interaction to recognize facial and body cues not obvious during virtual care episodes. In addition face to face encounters (whether they occur in the patients home or in a healthcare provider office) strengthens the trust and sustainability of the relationship, while supporting care interventions.

Virtual care is both a clinical practice model and model of patient care approach. It is an advanced level of practice, incorporated when a strong relationship exists where both the healthcare provider and patient agree to participatory care. What this means is that the healthcare provider acknowledges the patient as an equal partner and recognizes the value of the contributions the patient provides. This type of interaction allows true collaboration between the patient and the healthcare provider. The patient can spend time researching and delving deep to learn about their condition and impact on their own lifestyle while the healthcare provider can provide a range of treatment options for the patient to evaluate.

For patients this means they have reached a point in their health status where they have become engaged and empowered to self-manage. The patient has developed a level of health literacy that allows them to seek and access health information, ability to comprehend health information and ability to monitor health status data associated to chronic conditions. This type of patient is willing and able or has a caregiver that can participate in timely interactive communication with the healthcare practitioner and make adjustments to home treatment protocols when medical condition changes. The profile of a virtual care patient includes:

• High self-efficacy
• Problem solving skills
• Health literacy
• Decision making capacity
• Motivated and ready for change

For healthcare providers to support virtual care practice they have reached a point in their career where they have become comfortable with the aspect of patient’s helping themselves and utilizing the healthcare providers in a consultative capacity as opposed to directive and paternalistic interaction. This type of healthcare provider has strong communication/dialogue skills, is willing and able to support nontraditional clinical practice hours utilizing an interdisciplinary team and technology that enables 24/7 access to expert advice and health information when needed. The profile of a virtual care healthcare provider:

• Patient centric
• Flexible and adaptable
• Excellent communication skills
• Strong evidence based practice
• Committed to lifelong learning
• Knowledge of comparative effectiveness
• Willingness to support care anywhere at anytime
• Motivated and ready for change

In order for virtual care to work both the patient and the provider need to match the profiles as listed above. If only one person in the patient-provider relationship has profile characteristics it is not enough to move forward with the virtual care approach. Doing so will only cause frustration, exacerbate poor communications skills, jeopardize the trust within the relationship and may affect the overall health and safety of the patient. Virtual care could be the next best thing or your worst nightmare. Virtual care is not for everyone, however if you are patient centric, providing evidence based care, you will know when it is the right thing to do.

Copyright secured by Digiprove © 2011 Heather McKenzie

What is virtual care?

Virtual care is a clinical practice delivery approach utilizing technology. The technology enables healthcare professionals to offer service in an unconventional way, outside the confines of traditional care settings like healthcare facilities or physician offices. However virtual care is not about the technology, in fact it has very little to do with the technology and is about how healthcare professionals utilize tools to provide service anywhere at any time as a matter of economics, convenience and/or performance.

Therefore virtual care can either do one of two things, it can 1. Enhance the healthcare professional’s practice or 2. Exacerbate poor clinical and communication skills. Because of this, healthcare professionals need fundamental practice elements in place before implementing any type of virtual care approaches like telephone consultations, email dialogue, social media interactions and Web/Video conferencing to name just a few examples.  The key components to any virtual care program include understanding and adherence to professional practice standards both local and national, documented models of care and patient characteristics which successfully support virtual care, identification of technologies role in clinician practice and model of care and the measures framework to evaluate virtual care approach contributions to clinical practice process and patient care outcomes.

When healthcare professionals plan in this manner before providing virtual care, the healthcare professional will evolve and improve virtual care practice regardless of technology innovations.  That is why virtual care is not a novel idea; for decades healthcare professionals have provided remote consultation, evaluation and education services through telephone and fax.

Those that have been most successful are clinicians that have been able to use the existing technologies to its fullest capacity. What is different now is the widespread availability of technology tools by both the healthcare professional and patient, it is no longer considered a premium service but rather a core need by both the provider and patient. Eventually virtual care will no longer be considered non-conventional/non-conforming care and will become an acceptable standard form of clinical practice. Until that time, we will need to develop the standards for general acceptance.

Copyright secured by Digiprove © 2011 Heather McKenzie