It’s flu season again. Visits to ERs will increase, and the waiting rooms of primary care practices will be visited by the walking dead. From my first job out of residency until I began consulting, flu season always held an aura of dread. Since flu symptoms are often confused with upper respiratory ailments, during flu season colds that would normally be ignored turn into doctor visits.
I am not unsympathetic to flu suffers. The only time I can recall having the flu was the year after finishing residency. I was at death’s door for three days and very weak for a week. My hair hurt (yes, my hair). After that, every year, I was the first in line for a flu shot. Of course, flu shots don’t protect against URIs. As a result, every flu season I caught colds from patients who could have stayed home and been fine in a few days.
After being in practice for a while, I came up with a plan to stop unnecessary visits. First, I wanted a way to cut down on the number of patients who might get the flu and did the obvious thing, which was trying to get all of my patients to get a flu shot. Since flu shots vary in effectiveness, this helped somewhat. Even with increasing flu shot compliance, I still had the problem of patients with colds coming in thinking they had the flu, which was what I really dreaded. Finally, it dawned on me to try managing patients at a distance.
This was in the mid-90s, so phone calls were the main way to interact with patients. Initially, I asked patients to call before coming to see me. After a brief history, unless something significant popped out, patients were advised to rest and drink fluids. This approach cut down visits slightly. Unfortunately, patients who were not better within the next 36 hours or so usually skipped the call and came in (I always kept walk-in hours available).
Real success only happened when I added more feedback to assure patients I was continually aware of how they were doing. Here is what I eventually settled on:
- Advise all patients to get a flu shot. For those who refused, I would describe in detail the most common flu symptoms and finish with my flu war story.
- Next, everyone was instructed to call me if flu symptoms (or any URI symptoms) appeared.
- When someone with URI or flu symptoms called, I would have him/her write down the things to look for that would warrant a visit to me or the ER. I kept it simple: Fever over 101 for more than 24 hours. Vomiting or diarrhea for more than 24 hours.
All of the above helped. The visit rate dropped, and patients liked the increased level interaction. It also worked well clinically–a couple of times I had to admit patients with severe diarrhea or vomiting. A few patients would simply show up, but even during flu season, the number of visits only went up slightly.
What proved to be the final missing piece in managing flu season was, as might be expected, more interaction with me. I began to keep a “to-call” list, which consisted of patients who had called about flu or URI symptoms. Depending on the symptoms, I would check on patients within 24 to 48 hours after their initial call. Most of the time they knew to expect the call. However, often I would call (in the evening) without having arranged a specific time. Anyone I was worried about would get a call within 24 hours. I always made symptom-related calls personally (same with abnormal labs).
Though I started doing this during flu season, I began to notice a change in how patients behaved that lasted past the yearly bug season. At one point, I noticed that patients who had been through my mini-protocol would call me before coming for things other than routine visits. For example, patients would call about minor cuts or burns, which they were unsure about and get an opinion before deciding what to do. After a while, I noticed that other aspects of my practice were affected as well.
Compliance with treatment plans improved—even smoking cessation. When a medication caused side effects, patients would call instead of waiting until the next visit to tell me they had stopped taking it. Questions about instructions would come immediately. Frequently, elderly patients who had to come for visits alone would have me call in the evening to explain what happened at the visit to a spouse or one of their children.
While this may seem like a lot more work, over time it actually made my life easier. There were fewer missed appointments, more weight loss, and patients showed a greater willingness to talk about whatever was bothering them. I even had one patient who, while on vacation, became ill and after visiting a local ER, called to make sure she had been given proper medications.
In-person visits are the metric by which care quality is mainly measured. EHR systems are designed with in-person visits in mind. Reimbursement, likewise, is based on office visits, though that is changing. Patient engagement must be handled in a way that does not feel like a transaction—like going to a bank. I got a new primary care doctor last year because I like speaking to my doctor, not getting messages through surrogates where every question requires another 48-hour turnaround. Being able to get answers to simple questions should be easy. I had labs ordered by a specialist in December 2015. After multiple calls and messages, I still have never received the results (I gave up in February).
From a technology perspective, 2016 offers better ways to manage flu season than were available 16 years ago. Instead of using a spreadsheet to keep a “to-call” list, today I would use a workflow-based reminder system to keep track of each patient’s status (see Managing Patient Communications with Workflow Technology). Usually, only five to eight patients were on the list, but keeping track of whom I had spoken to and what I planned to do next would have been much easier using workflow tech instead of Excel. Even with workflow support, however, I still would have made the calls myself–they helped me as much as they helped my patients.