Self-Care Seen Key In Visits to Doctor

Hanover — Medicaid expansion. Health exchanges. Accountable care.

A lot is happening to reform the nation’s health care system. But one aspect that’s not getting as much attention is the patient’s role in managing their own health.

In order for someone to take responsibility , however, they need to be confident in their abilities to do so. Health experts say patient confidence is crucial to controlling health spending in the U.S. and needs to be a part of the national conversation.

“We focus a lot on the big picture and the cost of health care,” said Adam Schwarz, a physician at the Hanover Continuity Clinic. “And people who are highly confident in self-care don’t seek as much health care.”

Schwarz is among the doctors who have given the idea of patient confidence a lot of thought in his own primary care practice, looking at how to measure it and help individuals manage their health issues. Engaging patients has been talked about for years, but often it has been in the context of “20th century” notions of care, where doctors lead the discussion and pass down medical advice to patients, said John Wasson, professor of community and family medicine at Geisel School of Medicine at Dartmouth College.

What needs to occur is a bottom-up approach, Wasson said, where patients feel confident to make decisions outside of the doctor’s office, talking about their health and consulting with each other. New technology allows this change to start happening.

“If you start looking at it from the bottom up, and you start looking at crowd-sourcing and new technologies, what works for you may not work for me,” Wasson said. “And so the goal of health confidence as a population strategy and using Internet and other technologies is to enable you to look for people like you who have solved problems like yours in a way that suits your needs.”

Wasson has been developing a suite of tools to help patients think daily about their own health and take ownership of their care. They include visual aids, such as posters and wallet-sized cards that pose questions for patients to consider, to a website used by Schwarz and others called Through the website, patients spend several minutes answering a series of questions about their health (e.g. “During the past 4 weeks, how much have you been bothered by emotional problems such as feeling anxious, depressed, irritable, sad or downhearted and blue?”) and then are provided information they can use at home to improve how they manage it and also in communicating with nurses and doctors.

Patients can send the survey results to their doctor, who uses the feedback to figure out where they need to help their patients’ confidence improve.

When he gets results from patients, Schwarz said the information usually matches up with what he already knows about the person. But one in 20 yields something surprising that he flags for a follow up. He might learn about a domestic situation affecting their health, for example, but which his patient was reluctant bring up in a face-to-face conversation.

“It removes the (doctor-patient) relationship issue,” Schwarz said. “It gives a little bit of that triangulation in that relationship.”

Mark Nunlist, of White River Family Practice, also encourages patients to use the website and said “it’s been a rare patient who’s complained that it’s not helpful.”

Some of Wasson’s work around patient confidence has highlighted issues that need to be addressed on the provider side of care, too, Nunlist said. One of them is in how different institutions coordinate.

Nunlist’s practice has made greater use of electronic medical records to evaluate and keep track of patients. One challenge with these systems, however, has been getting different software systems to “talk” to each other at separate institutions.

Wasson’s work with patient confidence has shown is that when providers are better at coordinating with each other, patients are less confused about what they need to be doing and, therefore, require fewer visits to their doctor.

“I think what (Wasson’s) work is showing is that much of what happens to patients doesn’t need to happen if we did a better job at inter-provider communication,” he said.

Wasson’s work is going beyond online technology, though. He’s developed cards that ask patients to rate their confidence on three questions: Are they receiving the best health care they need? How good is the information they’ve received from their doctor? And how confident are they to control and manage their health problems?

These are essential questions that everyone needs to be asking themselves on a regular basis, Wasson said. He envisions these cards being posted not only in doctors offices, but in places throughout the community to keep them in the public consciousness. It’s not enough to have health conversations only when a person visits the doctor. And online technology allows patients to have informed discussions with other people dealing with the same issues, not just with medical experts.

There will be a day when patients rely more on their iPhones to answer questions about their care than a doctor, Wasson said. When that day comes, those patients will need to have the confidence to know what they are doing.

“Who owns your medical record right now?” Wasson said, pointing out that hospitals control that information. “Well you should have it on your own iPhone. You should control it, it shouldn’t be controlled by a health care system. If you start thinking that way about the future of health care, then health confidence rightfully part and parcel of your language, your existence, your way of doing things and you’ll share a lot with others.

“It’s going to be a very different world.”

Chris Fleisher can be reached at 603-727-3229.