Doctors discover simpler way to chart outcomes
Why ask 36 questions when 6 will do?
Imagine a short survey that could tell you, within minutes, whether you are meeting your patients’ needs. Are their symptoms improving? How about their mental and physical functioning? Did your treatment match their expectations?
Answering those questions is the mission of the Dartmouth COOP Clinical Improvement System, which is based on a series of simple charts that gauge physical exertion, pain, depression, and other issues. The charts were developed by the Dartmouth Primary Care Cooperative Research Network, a network of independent clinicians based in Hanover, NH, and are available for adolescent, adult, and geriatric patients.
Above all, the charts are designed to be simple to complete and "actionable," says John Wasson, MD, professor and director of the Center for Aging at Dartmouth Medical School who developed the charts. With COOP software, physicians receive flow sheets that allow them to track preventive care and patient problems.
"If you’ve got a problem, has your doctor talked to you about it?" says Wasson, noting that such questions get to the heart of patient-physician communication.
The COOP charts are attracting interest as an alternative to other outcomes measures, such as the SF-36 health status survey, developed by the Health Institute at the New England Medical Center in Boston. The SF-36 has been incorporated into health plan assessments through the Health of Seniors measure in the Health Plan Employer Data Information Set (HEDIS) of the National Committee for Quality Assurance.
But Wasson contends, "Why ask 36 questions when you can do it with six?"
In fact, the COOP charts correlate to scores on the SF-36. "You lose precision from a researcher point of view [with fewer questions], but for clinical improvement you don’t lose anything," he says. "You gain by having a single item" to evaluate function rather than blending the answers to several related questions.
At the Jean Snyder Medical Center in Baltimore, the COOP system alerted medical director Marguerite Moran, MD, to some problems of her patients that hadn’t been successfully treated.
In a three-month pilot, 127 mostly elderly patients at three community health centers answered the surveys on a computer kiosk. One-third of the patients said they suffered from a significant amount of pain, and about the same number said they had significant difficulty with physical activity. One-third of patients said they were using walkers or canes.
"No one was aware that patients were having that degree of bodily pain," says Moran, whose center is a part of Baltimore Medical Systems. The COOP program provided personalized letters for patients as well as informational material from health encyclopedias. Physicians also targeted problem areas noted on the surveys and discussed other treatment options with patients, she says.
In other areas, the COOP system highlighted a gap between patient complaints and treatment or services. For example, 12% reported problems with feelings or emotional problems, but only 3% said they had seen a mental health professional. Some 17% complained of hearing problems, but only 9% used hearing aids.
Questions on the COOP charts cover four areas:
1. function;
2. clinical issues;
3. patient satisfaction compared to expectations;
4. cost.
When patients respond in the "poor" range on functional or clinical assessments, they also answer follow-up questions about whether or not they feel their doctors know about their problems and have adequately treated them.
Practices also can add up to five customized questions at the end of the survey. For example, Moran asked patients whether they had recently suffered a fall and whether they live alone indicators of frailty and poor social support.
Eventually, Moran would like to screen all her patients at least every year or two. "The real goal is to get to the most vulnerable patients," she says.
Computer or paper surveys?
But first, Moran needs to overcome some logistical issues. The computer kiosk included headphones, which allowed patients to hear questions read to them. Still, some groups, such as the elderly and those with lower educational backgrounds, feel uncomfortable with the computer. For some centers, scannable pencil-and-paper questionnaires are more feasible, she says. (See editor’s note for information about software and costs.)
Although the questionnaire is short, Moran says it adds about 20 minutes to the patient’s visit. Unless patients arrive early or have to wait, they may need to complete the questionnaire after the visit which delays the physician’s ability to respond to problem areas. The physician may later call the patient or discuss issues at an upcoming visit, Moran says.
"It’s a good technology," she says. "In a busy practice, we’re still trying to fit it in."
In his own practice, Wasson says patients used a plastic reusable questionnaire and wax pencil. It took only minutes to scan the results and receive a report. "It didn’t cost me time," he says. "In fact it saved me time" because it immediately identified problems patients were having. (See a sample of the questionnaire, inserted in this issue.)
The COOP system may be particularly useful for patients with high health care needs. For example, John Sadler, MD, president of Independent Dialysis Foundation in Baltimore, recently began using the questionnaires with patients in his chain of seven dialysis centers.
Sadler plans to repeat the questionnaires quarterly with his patients, who come in for dialysis three times a week. "We’re trying to see if we can create a trend in scores that will help us anticipate problems and prevent them," he says.
So far, patients have been receptive to the questionnaire, he says. "The patients have been very willing to fill it out," he says. "They seem to respond to the feedback they get in a positive way."
[Editor’s note: The Dartmouth COOP Clinical Improvement System is available in scannable, reusable questionnaires. The software costs $199 (plus $12 for shipping and handling). Responses can be scanned with a bar code wand ($125). The "Quick Start" program ($89) provides 50 machine readable forms that are processed by the FNX Corp., which distributes the system. For more information, contact the FNX Corp., 1 Dorset Lane, Lebanon, NH 03766. Telephone: (603) 448-2224. Internet: www.fnxnet.com. The paper forms alone can be purchased from the Dartmouth COOP for $20. Contact Deborah Johnson, executive director. Telephone: (603) 650-1220.]
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