The conversation about accountability for care is well underway, and there is no turning back now.  The road ahead for dedicated people in the clinic includes real uncertainty regarding how to deliver on this new promise of accountability from care coordination to capitated payments.  But that road also represents the path of building the legacy of the clinic from the reputation in the community to the entity value if it were to change ownership.

It’s why being social as a clinic with a fully engaged staff is so important in the culture of care.  Because the reputation does hinge on the physicians, but it is also influenced by everyone else on staff as well.  For many in the clinic this idea of being social is just as much of a challenge between clinical and clerical staff as it is between those same people and patients.  Too often the patient experience is defined by the need to fix a problem.  So the interaction from scheduling the appointment to checking out following the examination is this routinized series of fragmented sound bite conversations.

The accountability for care does include being social and it must include a personalized dialogue between each patient and the clinic staff.  It’s a big step from the “pay-for-the-transaction-to-address-my-latest-problem” experience that we’ve all become familiar with through generations of families.  It is this unfortunate culture that has many in the clinic doing what a wise statistician once expressed to me as “checking your brain at the door.”  What he meant was that too often people are so focused on the data that they fail to recognize the influence of human factors and individual differences of people.

Take the example of the receptionist who views each person as an appointment, insurance plan and a copayment.  That information represents the data that she is too focused on as she overlooks the opportunity of the personal interaction with each patient.  It can also carry through to the exam area where the physician views the patient in terms of the History of Present Illness (HPI) and one of a certain number of patients per hour in productivity.  It’s important for everyone to reconcile the true expectations for the patient experience in the clinic in terms of appropriate interactions based upon knowledge, skills and training.

The reputation of the clinic has for so long been driven by the word of mouth reputation of patients.  It still matters today even with our new levels of online or “virtual” interactions with social media. But being social is the foundation for any of these interactions, whether in-person or online.  It matters because without the shared perspective of the importance of each interaction with every patient, it’s easy to fall into the trap of just issuing directives and broadcasting from your given role with that patient data in the clinic.  So don’t check your brain at the door, bring it with you to all of those interactions because accountability for care is much more than just the patient’s data.

The patient experience as always been a personal one.  I’ve been sharing thoughts here about my book regarding engaging patients in a clinic of any size by creating an awareness among a fully engaged staff to recognize all of those people who pass through and reach out the clinic in some way.  It’s much more than a transaction that results in a claim for reimbursement with an insurance plan.  Each person in the clinic has a different perspective on what their job means in a culture of care within the clinic, although it may be more based in assumptions with the absence of medical training. The continuing evolution of electronic Personal Health Information (ePHI) and the expanding use of Health Information Technology (HIT) continues to drive the transparency of information among physicians and patients and the entire staff in the clinic as a team.

There is another level of transparency in the patient experience that extends well beyond health information – invisible illness.  This is very personal experience for someone because it’s not something that others can see even when its happening right before their eyes.  I’ve learned so much from some incredible people in online communities about what this experience has been for them over the course of years and day-by-day.  I’ve been learning about another experience with a family member who was very recently diagnosed with vascular cognitive impairment.  It’s certainly invisible, but its a very real experience.  This is an experience that only she knows, and I do more listening that talking when we share time together.  What we also do is make the most of each day.  I help her by being present in the moment and recognizing what I can do to help in the way that she needs help.  It means making sure that we keep traditions like going to the mall to shop for a new Christmas sweater or even for a walk in the park in the afternoon as a top priority everyday.  The symptoms of this illness are real, and so is the experience of life shared with family and friends.  More to come soon, it’s a journey for all of us.

We all understand how important gut feelings can be, so here’s a scenario from both sides of the physician-patient encounter where they contradict.  The patient is actually a child, whose mother has a gut feeling that the child has the flu and would like a flu test performed on the child to confirm.  The physician has a different gut feeling that the child does not have the flu, that the appropriate course of action is to let the illness just run its course and states there is no medical necessity for the flu test.

This is obviously more than a discussion of medical necessity.  There is no question that from patient education materials to accessibility of electronic medical records, the informed and educated patient is a going concern.  With the evolving climate of accountable care and measurement of health outcomes in a highly coordinated healthcare process, the value of managing the patient relationship has never been more important.  This is not intended to be an inference that the customer is always right, but rather a patient/patient advocate who is willing to pay for the additional testing and more insight during the physician encounter.

Combining the nature of trust that is well-established over time between this physician and patient advocate (for the child), there is an impasse regarding these two people with regard to a ‘medical necessity’ and a ‘perceived necessity’.  Trust does matter in this relationship, and so do those gut feelings.  But even with this trust, gut feelings may be enough of a motivator for a patient/patient advocate to seek that ‘perceived necessary’ test from another physician in the community for the benefit of the patient.

The question is:  What would you do about the perceived necessity and the value of this relationship?