Physician-initiated follow-up contact improves patient satisfaction, provides opportunities to improve care
HIPAA-compliant e-mail tool provides an efficient way to reach out to patients following discharge
It is entirely understandable for emergency providers to question any new task or responsibility handed down by regulators or administrators. Busy providers are already stressed with burgeoning patient volumes and all the pressures associated with handling acute care crises. Consequently, it is no surprise that when Kaiser Permanente’s Northern California region rolled out an initiative aimed at getting emergency providers to initiate post-ED visit contact with patients, it was a tough sell, at least initially.
However, three years into the initiative, ED directors report that not only is the practice improving patient satisfaction, which was a primary goal of the effort, it is also giving physicians the opportunity to reinforce instructions that may have been missed or misunderstood in the midst of a medical emergency, and to answer critical patient follow-up questions that can have an impact on outcomes. In addition, emergency providers are receiving feedback on their performance, which they never had access to before.
Phone follow-up presents challenges
Kaiser’s decision to implement the post-ED visit callbacks followed a pilot of the practice, led by Pankaj Patel, MD, former chief of the EDs at Kaiser Sacramento and Roseville Medical Center. A few of the physicians at these facilities were already contacting patients by phone following their ED visits. Patel and some of his colleagues wanted to see if they could leverage a tool that was already in use among Kaiser’s primary care practitioners, which enables secure messaging between providers and patients via e-mail. “We thought it would be a great opportunity for ED physicians to use this tool also, even though these were not our own private patients,” says Patel. “These were potentially patients we had never seen before, but we thought the impact might be equally valuable in the ED setting.”
Kaiser’s secure messaging capability is a HIPAA- (Health Insurance Portability and Accountability Act) compliant process that patients can sign up for, explains Patel. Patients who elect to take advantage of secure messaging understand that the process will be used to exchange medical information, and they determine what the confidentiality will be in the e-mail address that they provide, he says.
The pilot, which was conducted between May 1 and June 30 of 2010, involved 42 emergency physicians who volunteered to participate by either e-mailing or telephoning patients within 72 hours of their ED visit. In an alternate month, the physicians provided no follow-up contact.1
Among all patients who received follow-up contact, 348 patients returned patient satisfaction surveys, with 87.7% reporting their experience as “very good” or “excellent.” Among all the patients who did not receive follow-up contact, there were 1002 patients who returned patient satisfaction surveys, with 79.4% who rated their experience as “very good” or “excellent.”
There was little difference between patients who received follow-up via phone and those who received e-mail contact, but Patel notes the e-mail contact was more efficient. The study showed that it takes about two minutes to send a follow-up e-mail to a patient, but reaching a patient by phone may take much longer, requiring multiple attempts.
“If you do not get a hold of the patient and leave a message, then you have to leave a phone number. And if you leave a phone number, then when the patient calls back, it may be in the middle of your shift, so it presents real challenges,” says Patel. “In the ED environment, the study shows that there is no better way to communicate at this point than via e-mail because you can do it on your time and the patients are able to reply on their time.”
Positive feedback is the norm
While patients reacted positively toward the physician contacts, investigators found that they were also contacting the physicians back, and that nine times out of 10, this feedback was positive, says Patel. “It was nice. In our day-to-day affairs, we would go days and days without getting any comments or feedback at all, or just get feedback that was bad,” he says. “This was the first time when we were getting feedback that was consistently positive from the patients that were taken care of by the physicians.”
Another finding was that in instances in which an ED visit or patient interaction didn’t go as well as the physician would have liked, the follow-up provided a second opportunity to “make a good first impression,” says Patel. “Also, it allowed us to reinforce things that we may have not had enough time to reinforce during the ED visit.”
For example, if a key instruction was for a patient to stop one medication and start on a new one, the physician could state this in the follow-up e-mail message. “It gave us that opportunity to reinforce important things,” adds Patel.
When the study was completed, the two participating EDs institutionalized the practice, and it is now a standard of care in the departments. “Out of our 85 physicians in the group, almost all of them are using the e-mail function,” says Patel. “About half of the physicians are contacting every patient who is on secure messaging, and the others are contacting various percentages.”
The physicians often want to send the follow-up messages to patients with whom they have had a good interaction, explains Patel. But they also use the opportunity to reach out to patients who may not have had a good experience in the ED. “Roughly half of the patients who are on secure messaging are being contacted through our department standards,” he says. “Even patients with lacerations or simple ankle sprains will contact us back and say that they have never, in all their visits to the ED over the years, had a doctor contact them.”
The patient feedback is often infused with praise and gratitude, says Patel. “It is a nice pat on the back for physicians, and it makes them feel better about their jobs,” he says.
One very big fear of the investigators initially was that the post-ED follow-up contacts might generate all kinds of time-consuming questions and concerns from the patients. Fortunately, this has not proven to be a problem, says Patel. “It is interesting that out of 100 patients that we e-mail, literally there is only one who makes those kinds of requests,” he explains. “Our policy is that we want to respond back at least one time again if the patient asks a question, but if it is a question that is outside the realm of the ED physician, our recommendation would be that this is something that the patient really needs to follow-up with through his or her PCP. That would end the e-mail communication.”
However, there are times when physicians will carry on the e-mail communications with patients for a week or two following an ED visit — perhaps because they have a strong interest in the case — although this does not happen very often, says Patel.
Establish goals, incentives
Since the pilot was completed in 2010, the post-ED visit contacts have been adopted in all of the other 20 EDs in Kaiser’s northern California region, but physician leaders in these settings acknowledge that it took some time to get attending physicians on board.
“On the surface, it seemed like a superfluous responsibility added to an already long list of duties. It was an abstract concept that sending an e-mail to a patient after you had seen him or her in the ED added any value for the provider or the patient,” explains David Roth, MD, chief of the ED at Kaiser’s Walnut Creek Medical Center in Walnut Creek, CA, a facility that treats 54,000 patients a year. “It was difficult to explain or prove the value in secure messaging initially, and we used alternative measures to increase adoption of this practice.”
For example, ED administrators established an attainable goal that each physician would follow-up with 30% of his or her patients via secure messaging, and then the leadership began to publish each physician’s messaging rate. “It evoked a heightened awareness that this was important to the group and the organization,” says Roth. “I am sure it also fostered some healthy competition [among the physicians] to avoid being the laggard.”
Once the physicians started adopting the practice at higher rates, the benefits of the practice became more tangible and personal. “I and the others in the department now consider secure messaging as one of the more gratifying parts of our practice,” says Roth. “Unlike our MPS (member patient satisfaction) scores, which give aggregate data, we now get personal messages from patients and parents which are overwhelmingly complimentary and thankful for the care they received during their visit.”
Roth says he uses the opportunity to answer questions the patients have or to remind them of follow-up appointments. “It is a fantastic way of communicating and reinforcing our integrated model of care within Kaiser,” he observes. “The patients seem to enjoy having this level of access with their treating physicians, and this has driven even more consistent use of secure messaging by our physicians.”
While patient satisfaction has been gradually increasing in the ED at Walnut Creek, Roth acknowledges that this is probably a result of many factors. “I am convinced that secure messaging has played a large part in our record MPS scores,” he says.
To continually reinforce the importance of the practice, Roth regularly asks his physicians to send him accumulated patient secure message responses without any identifying information so he can share them with the entire department. “This reminds our physicians and staff how important their work is in the lives of our patients and their families,” adds Roth.
The ED at Kaiser Hospital in Santa Rosa, CA, a facility that treats about 49,000 patients per year, was among the first in northern California to adopt the secure messaging practice three years ago, explains Hilary Bartels, MD, the chief of Emergency Medicine. However, she experienced many of the same challenges with physician buy-in that Roth confronted at Walnut Creek.
To facilitate physician adoption of the practice, administrators began including the percentage of patients who received a secure message as one of the metrics that is tied to bonuses and salary. “It is transparent, and it is shared with all the other physicians,” explains Bartels. “It needs to become part of the culture for physician behavior.”
As with the other EDs that have adopted the practice, Bartels notes that physicians have come to realize that the practice is a nice way to keep in touch with patients. “Also, physicians have the incentive to send the secure message because it allows them to catch any overlooked follow-up items, and because it is on our publicly shared physician dashboard,” adds Bartels.
Consider legal aspects
Adoption of the post-ED contacts was a very low-cost intervention for the Kaiser EDs because they already had access to Kaiser’s secure messaging system, explains Patel. “If I didn’t have a system to e-mail patients in my ED, I would probably have to go through med-legal and make sure that I have some type of HIPAA-compliant feature that allows me to do e-mail,” he advises.
Another task that is critical to the successful adoption of the practice is having mechanisms in place to verify patient phone numbers and e-mail addresses. “We make it a point with our reception staff that if we don’t have accurate phone numbers, then following up with patients is going to be very difficult. For EDs that want to do this type of post-visit contact, this practice would need to apply to checking e-mail addresses also,” says Patel. He advises ED managers who are interested in adopting this practice to make sure that the reception desk gets an accurate e-mail address on record for every patient who comes in.
One nice thing about written communications is that they can be easily uploaded onto a patient’s electronic medical record. Kaiser now does this automatically with all secure messages that are both sent and received. “If you call a patient by phone, you then also have to enter notes in the chart to make the communication part of the medical documentation,” says Patel. With e-mail messages, such documentation is a much simpler matter, he says.
The time commitment involved for carrying out post-ED visit e-mail messages has turned out to be relatively small, says Patel. “If a physician is seeing 15 patients in a shift, roughly half of whom [have elected to take advantage of Kaiser’s secure messaging feature], the time commitment is 15 to 20 minutes per day,” he says.
Roth advises ED leaders to set attainable milestones of performance and to publish transparent data on the rates of compliance by each physician. “Physicians are, by nature, competitive and want to validate themselves to their colleagues,” he says.
Roth also recommends that administrators take the time to share patient comments with the physicians and staff, particularly in the initial stages of the intervention. This should help to increase buy-in among physicians and a willingness to give the approach a try. “After the initial adoption of this practice, I think the benefit and importance of this quick and easy communication tool will become self-evident,” he says.
1. Patel P, Vinson D. Physician e-mail and telephone contact after emergency department visit improves patient satisfaction: A crossover trial. Ann Emerg Med. 2013 Feb. 25. [Epub ahead of print]
• Hilary Bartels, MD, Chief, Emergency Department, Kaiser Hospital, Santa Rosa, CA. E-mail: firstname.lastname@example.org.
• Pankaj Patel, MD, Former Chief, Emergency Department, Kaiser Sacramento (CA) and Roseville Medical Center in Roseville, CA. E-mail: email@example.com.
• David Roth, MD, Chief, Emergency Department, Walnut Creek Kaiser Permanente, Walnut Creek, CA. E-mail: firstname.lastname@example.org.