Provider perspective on barriers to improved patient engagement

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I was thankfully able to catch the MEQAPI1 chat today, and I ran across the same problem that I typically do in these improving healthcare and patient involvement chats. Healthcare is a nasty and complicated business. It’s largely run by internal policies and bureaucracy that providers need to contend with. So often I see patients want good and important changes to healthcare, though missing some of the road blocks direct providers face in implementing that change. Direct providers also often take some heat that is undeserved due to a lack of understanding of how internal healthcare policy impacts patient care. We often aren’t allowed by our institutions to do the things you want, even though we badly want to.

Healthcare institution executives, quality improvement staff, and medical records staff aren’t often medically trained. As a provider I dread them, and am constantly bending rules to work around them. Their role is mostly to protect the institution and not improve patient care. The lack of medical practice experience in these departments often lead to nonsense policy that impedes the provision of good care. All direct practice providers have training, though there is a lack of mandates to keep it up to date, on continuum of care and patient interaction.

Providers tend to be bound by multiple contradictory things:

  • State law regarding license to practice
  • Federal laws regarding healthcare
  • ICD-10 guidelines in regards to diagnostics
  • Internal institutional rules and guidelines
  • Code of Ethics for the medical field
  • Health insurance authorization requirements
  • Medical training and education

The importance of continuity of care

Continuity care is what allows me to communicate with other providers who are providing treatment to my clients, and to some degree dictates my communication with my clients. HIPAA is mostly pro continuity of care2, though state law and institutional application and policy on sharing information tends to be archaic. Providers are also very pro continuity of care, often our practice guidelines rely on having objective information from other providers. We often can’t make treatment decisions without this information. Also, we care about good practice and the more information the better.

The impact of institutional practice and policy

Many institutions have some provisions for clinicians to be able to release and exchange information with other providers when the patient is actively in treatment. So when I have a client in the Emergency Room, the ER and I can communicate. I can provide history, get information on the client’s current status, and be involved in the treatment plan. Outpatient offices tend to be a little be more strict about this, however, when the same type of direct provider are able to be in contact this often goes smoothly. I can usually have good exchange with other social workers, the nurse on my team and psychiatrist on my team often have the same luck.

To release actual clinical notes and paper records tends to be more strict within institutions. Usually this involves the dreaded medical records departments and internal policies. Most providers are allowed to send the most recent notes, lab and medication information without having to involve medical records. Medical records is a nightmare usually they’re employed by mean, poorly trained people. I’d be mean too though if I had to work out of a windowless basement, almost every medical records department is in a dark basement.

Medical records policies tend to not follow HIPAA as they are more restrictive than the law, and take a VERY long time. If I request the discharge summary for one of my clients from the social worker upon discharge I have it immediately, if I wait it goes to medical records and it can take WEEKS. The same goes for my agency, if a provider wants the full record for one of my clients it can take up to a month.

Internal policy also impacts continuity of care when it comes to contact with patients. Internal policy dictates what Electronic Health Record is being used, if there is any at all. As well as the level of security required for electronic communication with patients. Not to mention what information can be discussed over the phone. Oh, and limitations in regards to treatment guidelines. Such as being limited in acting on clinical impressions, the weight of patient input, etc, etc.

Most institutions are restricted when it comes to the release of information and communication between providers and patients via e-mail. This is an iffy issue in HIPAA as well since the actual privacy of e-mail accounts is questionable and not well regulated. So patients are often limited to whatever messaging system is included in the Electronic Health Record system, if there is one at all.

The impact of state licensure law

All providers have to be state licensed for their area of practice. What’s tricky is that the rules not only vary for a specific type of provider from state to state, they vary widely when it comes to different provider types. As an example social workers in my state can never ever have any kind of nonprofessional relationship with someone under our care. Doctors can have sex with patients.

I’m bound by my license to follow strict self disclosure and dual relationship guidelines in regards to my practice. If you want to read all the crap I have to adhere to HAVE FUN3!

Dual relationship means that I cannot have contact with a client outside the bounds our professional relationship. This can get sketchy with patient engagement issues.

If my institution was mandating improved patient engagement then I could talk nonstop about it with my clients and potentially be able to extend my contact with clients. If for instance my agency had a mandate to improve patient engagement and it was a part of my job to be involved in focus groups or attend conferences with clients this would be totally fine. However, if I were to do this own my own accord I can end up out of bounds with the laws of my license.

The impact of training and education

Most medical professions require ongoing education and degrees from accredited institutions. However, there are few mandates on the types of training that medical professionals are required to receive. My license states I need 20 hours of in person training that involves the direct practice of social work and 3 hours of ethics training every 2 years. The requirement is 40 hours every 2 years, but 20 of those hours don’t have to be practice related.

I’m not required to stay up to date on the types of therapy I provide to clients, I wasn’t even required to get training on the DSM V, I can also take any ethics course I want. I work in adult outpatient mental health, though I could take an ethics class in social work and dialysis if I so pleased.

Institutions also have a huge impact when it comes to ongoing education, they set the rules in terms of what courses they will pay for. Larger institutions like hospitals tend to have their own in house ongoing education programs. Many institutions have budget limitations on what ongoing education courses they will pay for.

The end result is that up to date training on all the issues that impact patient engagement and continuity of care is almost a matter of luck.

The impact on providers in small or private practices

Providers in small and/or private practices tend to have more freedom in regards to communication and disclosure since there is less bureaucracy to contend with. However, the onus is often on the provider to stay up to date in regards to practice guidelines and often will come at their own expense. Good quality continuing education training costs more $$$.

Access to resources such as Electronic Health Records and having the staffing to promote good care is also an issue. Electronic medical records systems are expensive, and it tends to be the more expensive systems like Epic4 that are interfaced with other providers. Smaller offices have a lot of barriers and extra foot work to do when it comes to providing good continuity of care.

The art of information sharing in medical practice

I’m in a continual dance when it comes to information sharing in my clinical practice. In the end it is up to my clinical judgment what I can say and do when. Certain situations can trump institutional guidelines. If I can justify a gray area in terms of how my agency regards disclosure then I can fall back on state guidelines for example. It’s a constant game. Not only is each professional guideline different, each institution is different, and each situation is different.

In conclusion . .

Healthcare is a horrible nasty mess. Things are not as simple or as common sense as they may appear on the surface. This is only the tip of the iceberg in regards to ways that providers are limited to increasing patient engagement and empowerment in their care. The more patients understand how healthcare works the easier it will be to implement change.

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