Making the 15 minutes more valuable: It’s time to flip the clinic

Fifteen minutes. Give or take. That’s about how long a patient typically spends with a primary care doctor during an office visit. If you’re lucky enough to be healthy, maybe that visit comes once every year or two.  Or if you’re less healthy, maybe every few months. In either case, it’s not a lot of time. Not a lot of time to share all the relevant developments. Not a lot of time to determine what to make of them. Not a lot of time to set a course going forward. And not a lot of time to absorb it all. It stands to reason that we should figure out how to make the most of this precious 15 minutes.

When Sal Khan — whom many think is revolutionizing education — talks about Khan Academy, he talks about “flipping the classroom.” He does this in several ways, but the fundamental flip is that he moved the delivery of information (i.e., the lecture) outside of the classroom so that class time (and the teacher’s and students’ time together) could be used for problem solving, assisting and assessing. This flip was enabled by YouTube — and that’s key. Technology made it possible to envision a different way.

The “Flip the Clinic” initiative my colleagues at the Robert Wood Johnson Foundation are leading takes the spirit of Khan’s flip and brings it to the clinic. It seeks to stimulate experiments about how to make the most of the office visit. If you think about it, much of the office visit is focused on information exchange — there’s history taking, diagnostic questions and problem and symptom descriptions. There are also measurements — weight, blood pressure, heart rate and others. Now much of this information exchange really needs to happen face to face. Clinicians are trained to observe body language and tone of voice in order to pick up nuances. There are often reasons to touch, to move a joint, to listen to the sounds of the lungs or the heart. But, in an increasingly digitized and connected world, some of this information exchange can undoubtedly be done outside of the visit, so that the visit — the precious 15 minutes — can be focused on sensemaking, problem solving, and collaborating on direction and next steps.

Over the past several years, I’ve worked on two RWJF-supported initiatives that have explored opportunities to do just that, that have “flipped” the clinical encounter. The first, Project HealthDesign, sought to answer the question of whether self-tracking data — data collected by patients on a regular basis — could inform and improve the clinical treatment of people living with chronic conditions. In each of the small studies in Project HealthDesign, the researchers found clear examples of value, ranging from medication use data and spirometry data from patients with asthma leading to medication adjustments and even diagnosis changes, to declining performance on routine household tasks by seniors revealing an increase in cognitive impairment, to data on pain, sleep, exercise and medication use leading to new insights and adjusted medications for patients with Crohn’s disease. So instead of the doctor-patient conversation being an attempt to gather data, these studies demonstrated the conversation can be about the interpretation of data.

A common frustration with a doctor’s visit is the challenge of making sure that as a patient, you understand and retain all that the doctor says. We’ve all probably jotted down notes on the back of a gas station receipt or frantically tapped our smartphones trying the capture the important points. And then wondered, as we read those notes later, what they meant. The OpenNotes initiative addresses this challenge very simply — by making the clinician’s notes of the encounter available to the patient through a web-based portal.  It’s akin to have the teacher’s lecture available on YouTube. You can go through the notes again and again until you understand them. You can forward them to your cousin the nurse. You can look up the words you don’t understand. The open notes idea has been tested on a large scale. In a  trial with three health care institutions, over 100 doctors and approximately 20,000 patients, majorities of patients reported that they understood their conditions better, that they felt more in control of their health and that they took their medications more reliably. Since the study came out in late 2012, a growing number of leading health care systems are adopting the practice.

Opening up physician notes and using self-tracking data to inform the visit are two “flips” that can be tried.  What’s exciting about the Flip the Clinic initiative is crowdsourcing the new flips and getting a community of people who are dedicated to experimenting with ways to make those 15 minutes more valuable.

Steve Downs is chief technology and information officer, Robert Wood Johnson Foundation.

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  • Patient Kit

    As a patient who already tries to go to each doctor appointment very prepared and aiming to make the most of a sliver of time, both of these initiatives sound very interesting and promising to me.

  • Lisa

    I especially like the idea of open notes. I always get copies of imaging reports, surgical notes, lab reports and pathology reports. My doctors have no problems giving me copies of these reports, but I have had trouble getting copies of imaging reports even though I should have access to them. Seeing my doctors notes would help complete the picture.

    • Michael Painter

      Lisa-I agree with you.

  • medicontheedge

    This is one of the driving factors behind the reason why people over utilize the ED… There is no appointment, and you will get as much time as you need with all your complaints.

  • SarahJ89

    I have to go in once a year in order to get my levothyroxin scrip renewed. I have 15 minutes. The last visit I had four short items on my list, which we took care of.

    I then realized I’d been motor mouthing a mile a minute to squeeze all this stuff in. My NP was running late that day so I didn’t want to take up too much time. I apologized for what actually felt like rude, but necessary behaviour.

    We got our work done, but I wish there was some time to actually establish something resembling a relationship. That used to be possible, but not any more.

    • LeoHolmMD

      Unfortunately, no one is concerned with this aspect of healthcare…except doctors and patients. But they are not setting the agenda.

      • Michael Painter

        Sarah and Leo–EXACTLY. You are both making the point for the Flip the Clinic effort. It’s time for doctors, nurses and other health professionals and their patients–who care most about the time they spend together–and know what is and isn’t working–to think about ways to make that time better. Flip the Clinic is an invitation to well-meaning, passionate people like that who want to make things better.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Why are assuming that the 15 minutes visit is some sort of immutable law of physics? Why are we not trying to solve the real problem, instead of the problems created by the real problem?

  • PCPMD

    During what hours do you see this additional communication occuring, besides the 8 that the physician spends addressing matters that require face-to-face time? Remember, the complaint isn’t that face to face time is un-needed (which seems to be your suggestion), its that there isn’t enough face to face time to address all of the things that both the physician, and the patient, would like to address.

    • Steve Downs

      PCPMD,

      Thanks for your comment. I have to believe that some of the time spent in the visits is on transactions that could be handled more efficiently through other means and that some visits might be unnecessary (we’re seeing, for example, anecdotes from OpenNotes where patients, having reviewed the note from the last visit, email their physician and suggest canceling the upcoming visit). But if I hear you right, any efficiencies gained would be offset by more face-to-face time to handle things currently not addressed. So what would you suggest?

      • guest

        As others in this conversation have mentioned, we suggest that doctors and patients should be given more real time together.

        Suggestions for using “technology” to squeeze more “efficiency” into an inadequate 15 minute visit don’t address the underlying problem, which is that 15 minutes with your doctor is not enough time in many cases, no matter how energetically we “leverage” technological solutions.

        Also, if you look at the actual study on Open Notes, it does not appear to me that the findings in any way support your conclusion that Open Notes can save a doctor time:

        “3% to 36% of doctors reported changing documentation content; and 0% to 21% reported taking more time writing notes. Looking ahead, 59% to 62% of patients believed that they should be able to add comments to a doctor’s note. One out of 3 patients believed that they should be able to approve the notes’ contents, but 85% to 96% of doctors did not agree. At the end of the experimental period, 99% of patients wanted open notes to continue and no doctor elected to stop.”

        • Michael Painter

          Guest–I personally don’t think it’s about anybody giving health professionals and patients more real time–I think it’s about doctors, nurses and others working with their patients finding ways to make the relationship better. That might mean better technology–it might mean less. It might mean more time for some–it might mean less for others–it depends. And the health professionals and patients know what might work for them and might not. Flip the Clinic is just an invitation for passionate folks interested in making that time better–to come together, propose ideas or flips to make the time better and then try them.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    ere is what I don’t quite understand, Steve:
    If we replace some of
    the in-person time with email or Skype or something more sophisticated,
    all we are saving is patient travel time and waiting time, and perhaps
    some staff time at the clinic, but we are not saving is doctor time,
    assuming that all these remote or even asynchronous interactions are
    with a physician.

    I can see how a few minutes of doctor time can
    be saved by having someone else input basic information, but not as much
    as we think, if the doctor is going to actually review the information.
    If she isn’t, then why do we need to input it at all?

    I guess my biggest issue is the preoccupation we all seem to have with infinitesimal units of time in this context.
    How
    about a leisurely conversation, where both sides have plenty of time to
    think, remember, understand, forget and be reminded again, and just get
    to explore each other’s humanity… When did we allow this to become a
    luxury, and why? (please don’t say physician shortage or productivity :-)

  • PrimaryCareDoc

    I can tell more from a 2 second face-to-face glance at a patient than I can from reams of “data” such as blood pressure logs, finger stick logs, and emails.

    You people (and by “people” I am talking to consultants, techies, CEOs, “quality initiative” nurses…) who are not actual primary care providers need to step back and realize that all this crap that you’re proposing is rearranging the deck chairs on the Titanic.

    Primary care medicine is about the RELATIONSHIP. It’s about knowing your patient well, so that when you see them you know when they’re sick and when they’re well. When they’re stressed. When they’re depressed. When they’re scared. That is what makes the primary care doc/patient relationship special.

    So you can take your Project Health Design and your Patient Centered Medical Homes and your “care teams” and, quite frankly, shove them you-know-where. Stop trying to further destroy a noble profession and relationship.

    • Michael Painter

      PrimaryCareDoc–please see my prior comment. You are making the point for the Flip the Clinic initiative–it’s way past time to ask you the doctors how to make the time you spend with your patients better. You’re describing the pain point pretty accurately: lots of well-meaning efforts to try to get docs to change–without asking them what they want to change–and how they would do it. The sad result of all these efforts to push change–the patients aren’t happy either. Thanks for your awesome comment.

      • PrimaryCareDoc

        So why is it that out of the 10 people involved in this initiative (per your website) there is exactly ONE practicing physician? You have social media consultants and designers and marketers and freelance writers, but only ONE physician.

        • Michael Painter

          PrimaryCareDoc–Hi, Flip the Clinic a work-in-progress. If you or other docs and nurses you know are interested in making the time you spend with your patients better, PLEASE join Flip the Clinic. And if you know of others who are interested–please pass along the invitation. We need your brain and help–it won’t work if it’s just as you say, designers and consultants. (though incidentally the designer folks are in the camp of folks saying, “Invite and ask the professionals and patients what they want.”)

  • Michael Painter

    Great post and conversation, Steve.

    In fact, this very conversation is also nicely making the point for the opportunity–the friction point–for Flip the Clinic. The point is that neither health professionals nor patients are satisfied with the time they spend together–no matter how long or short it might be. Flip the Clinic is not the usual program pushing this or that neat fix–it’s not really a program at all. Instead it’s an invitation to patients and health professionals who are interested in working together to think about and try ways to improve that healing relationship. Ideally, as patients and health professionals try these various ideas the time would become better for both. But it’s not about being patient- or professional-centered–it’s about the relationship.

    A key goal of Flip the Clinic is to do something we don’t talk about that often in health care these days–increase the joy in that healing relationship. For instance, I’m going to bet that the health professionals in this exchange did not go into health care to be frustrated and unhappy. Instead they became doctors or nurses or other care professionals to help people become healthy–to heal–and to realize the deep satisfaction and joy that comes from helping other human beings.

    Let’s not get stuck on some random allotment of time (by the way, who exactly came up with 15 minutes anyway? It wasn’t the health professionals or the patients–they need what they need to promote healing)-let’s focus on talking about ways to make the time better.

  • Steve Downs

    Thanks all for jumping in and sharing your thoughts. I hear quite clearly the message from Margalit, PCPMD, southerndoc1, guest, and PrimaryCareDoc that the pressures on a physician’s time are so severe that it’s hard to muster enthusiasm for possible changes that don’t address that pain point. And I think the comments about the importance of the relationship are really crucial. Mike Painter’s comments about the spirit and the approach of Flip the Clinic are valuable here as they give context to this discussion — the key is to engage both physicians and patients in thinking through how to make things better. So that there are fewer experiences like the one SarahJ89 describes.

    I do want to respond to a few of the points raised about the programs with which I’ve been directly involved. I want to be clear that I’m not suggesting that OpenNotes saves physician time. The data show that, depending on the physician, the practice can lead to a small but noticeable increase in time as more care is taken in writing the note, but anticipated increases in emails or other interactions did not result. The point of OpenNotes in the Flip the Clinic context is that it can make the visit more valuable — instead of forgetting 60% of the conversation, a patient can refer to the notes as often as she wants. And vast majority of patients report being more understanding of their conditions, in better control of their health and that they’re taking their meds better.

    As for the value of patient-generated data, it’s early days and there’s much to learn. I don’t want to suggest for a minute that face-to-face time isn’t valuable — of course it is — or underestimate in any way the observational and diagnostic powers of a trained physician. What we did find in the Project HealthDesign experiments were examples of where patient-generated data made a difference. Where spirometry and medication usage data led to change in diagnosis from asthma to COPD. Where med usage data showed that an asthma patient had reversed her controller and rescue meds. Where data on the performance of household tasks revealed an accelerating cognitive decline. Where data on pain, energy level, med use and exercise for Crohn’s patients led to medication adjustments. The point is not whether these data are better or worse than face-to-face interactions. The point is that they can be combined to create a fuller picture. I should also add that in Project HealthDesign the initial reviewers of the data were often not physicians. The project with asthma patients used nurses to screen the data and then alert physicians as needed based on a predetermined protocol.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I get this feeling that we are talking in parallel tracks….

      Is more pertinent data better? Yes. Does more pertinent data take more physician time to analyze and act on? Yes.
      Is pertinent data collected without physician involvement more conducive to better outcomes that information collected through face-to-face unhurried interactions? No.
      Why are we suggesting that Flipping things is a good idea? Because in lieu of ample time to care for patients, collecting data by other means may lessen the damage inflicted by the artificial limitations placed on patient-doctor time and relationships.

      Limiting patient-doctor time is a bad idea. It cannot be fully mitigated by flipping technology (what does flipping even mean?). Why are we looking for a second best option when we all know what the absolute best option is?

      That is in no way to say that technology cannot be very useful in improving the best option to be even better….

  • Michael Painter

    Great discussion. Obviously, opportunities to work with others to improve the relationship between health professionals and patients are precious things. Taking the time to work with others to improve that relationship-will, well, take time–that part is certainly true. Again, though, most folks voicing frustration with the visit in this string and elsewhere are actually just making the case for Flip the Clinic. The friction point–the opportunity for innovation–is the recognition that the current clinic visit isn’t working well. So then what? Criticize opportunities to make it better like Flip the Clinic? That probably doesn’t make a great deal of sense. Again, Flip the Clinic is simply a place for people interested in exploring ways to improve the encounter (both before, during and after the face-to-face visit using any number of tools, approaches and technology) to propose and try out new or novel approaches. But, let’s also be clear: Flip the Clinic is not for everybody and that’s absolutely fine too.