Abstract

Keywords: Physician-patient communication, patient-physician communication, patient engagement, participatory medicine, health data, health IT.
Citation: Greene A. Practical followup. J Participat Med. 2012 Aug 29; 4:e18.
Published: August 29, 2012.
Competing Interests: The author has declared that no competing interests exist.
 

With my father’s recent cardiac surgery and hospitalization, I experienced the deep followup disconnect that can happen even with outstanding individuals in our current health care system. Busy doctors more easily focus on the patients physically in front of them. Treated patients may get a followup phone call or two, and perhaps a visit, but they are left to navigate most of the weeks of recovery alone.

The four to six weeks after hospital discharge are a critical window when many like my father are at the highest risk for poor outcomes.[1] Questions and concerns arise with the attempted return to activities of daily living. It’s often not clear which activities to push through and which to avoid. New diets can be hard to manage in practice. Emotional struggles are common. And the cascade of small changes in how one feels as the weeks go by create a stream of concerns about whether recovery is proceeding on track. After surgery, postoperative pain might be part of normal recovery, or a critical sign of a surgical complication. Similarly, temperature elevation may be fine, or the harbinger of an infection. How high is too high? How long before it should return to normal? When is a trip to the ED recommended? Which symptoms, on which days, are signals of trouble, and which are to be expected?

Up to 80% of elders report unmet information needs in just the first week following discharge.[2] But I saw firsthand that a recovering patient may not feel comfortable reaching out to the health care team, even with many pressing questions.

Meanwhile, physicians don’t know whether patients at home are following discharge plans of medications, physical therapy, meals, activities, or other treatments. We don’t know whether patients are recovering as expected unless a big problem arises. We don’t have the time or resources for close, ongoing contact.

A quick phone call from the doctor can feel like a lifeline to the patient and be reassuring to the physician — but a Cochrane Review of health professional initiated telephone followup was unable to demonstrate that this is enough to improve outcomes (beyond patients valuing the call).[3]

Is there a practical way to decrease the barriers to efficient, ongoing followup communication?

During my father’s recovery, I learned that one of my practice colleagues, Dr. Jordan Shlain, had developed one such way: a platform of electronic followup protocols called HealthLoop. Each automated, situation-specific “Loop” communicates with patients to monitor their signs and symptoms, provide timely information for that day of recovery, and track the patient’s progress against an expected timeline for that situation. This is achieved through a series of emails tied to a HIPAA compliant SaaS platform (see Figure 1). These emails both teach patients and invite them to report any symptoms they are experiencing — prompting them with questions about key symptoms of concern.

Figure 1: A series of screenshots showing brief feedback interchanges between a physician and patient using HealthLoop.

From what I see, these patients feel more engaged, more connected, and better monitored every day of their recovery. Physicians can see at a glance a dashboard of the status of their patients recovering at home. Early signs of treatment failure or complications prompt alerts to the physician, in an effort to improve outcomes, improve satisfaction, and reduce hospital readmissions.

This example gives me hope that emerging technologies will turn followup from a weakness to a strength of our health care system, and make the period after surgery, hospitalization, or even an office visit a time of efficient, rich engagement and communication — perhaps starting when parents first bring a new child into their home.

References

1. Naylor MD, McCauley KM. The effects of a discharge planning and home follow-up intervention on elders hospitalized with common medical and surgical cardiac conditions. Journal of Cardiovascular Nursing 1999;14(1):44–54. ↩
2. Bull MJ. Discharge planning for older people: a review of current research. British Journal of Community Nursing 2000;5(2):70–4. ↩
3. Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database of Systematic Reviews 2006, Issue 4. ↩

Copyright: © 2012 Alan Greene. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.