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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