David Nelson Hand Surgery Greenbrae Marin hand specialist surgery of the hand orthopedics San Francisco



MDs Improve Patient Care While Saving Time

This is an article that was published in the Bulletin of the American Academy of Orthopedic Surgery, August, 2003. It describes how I and other surgeons use the web to help improve patient care. - Dr. Nelson

MDs improve patient care while saving time:
Insights on using the Internet in orthopaedic practice

By Nancy Fehr

All physicians have patients who seek health and medical information online, and the number is increasing every year, according to the Pew Foundation. Patients are pleased when their doctors provide readable and trustworthy educational articles about their diagnosis and treatment.

The Academy's free "Rx for patient education" notepads, are printed with the Your Orthopaedic Connection Web site address (www.orthoinfo.org) and space for doctors to write recommendations to patients. Since debuting at the 2002 annual meeting, the "Rx" notepads have soared in popularity. More than 9,000 of the 25-page notepads have been distributed to more than 4,000 orthopaedists throughout the United States and abroad. This means doctors have given patients nearly one-quarter million "prescriptions for patient education."

Now the idea is beginning to catch on with other medical groups; recently the National Library of Medicine and American College of Physicians introduced a similar prescription pad program.

Innovative AAOS orthopaedists who pioneered the idea of patient information prescriptions say that Internet-based education tools improve care and compliance while saving time and money.

Improving the quality of patient care

Orthopaedist David L. Nelson, MD, of Greenbrae, Calif., developed "Rx Information Therapy" forms, a tool directing patients to his office Web site, to improve the quality of patient care. "Our patients demand medical information, and they are going to the Internet to find it. If we do not give it to them, they will get it from less reliable sources. We have a practical and moral obligation to put good, readable, well-illustrated medical material on the Internet for our patients," Dr. Nelson says.

Offering patient information online "saves me time, increases quality of care, explains ideas in text and graphic form that patients can read at their convenience, and allows patients to share information with others helping them make their medical decisions (children of my elderly patients, for example) or with friends having similar problems," he notes.

A member of the AAOS Internet Communications Committee, Dr. Nelson advises, "The key to using a Web site is to incorporate it completely into your practice. Your yellow pages ad needs to have the Web address– this is how new patients find you. All your letterhead, envelopes and business cards need it. Have your appointments secretary direct every new patient to the Web site for new patient intake forms as well as pre-office visit education.

"For example, if Dr. Smith is referring the patient for carpal tunnel syndrome, the time for the patient to start learning about their condition is prior to the first visit. It is not unusual now for a patient to say, ‘Dr. Smith said I had carpal tunnel and sent me to you. Your secretary told me to check your Web site. I did, and I think I do have carpal tunnel. I already read about it. I tried the ergonomic reconfiguration and activity modification, and they helped, but I still have it. I agree that pills and therapy don't work; I had an injection once but it came back. I read about surgery, and I know the risks and alternatives. Can I just sign up for the surgery now?’

"Think how I provided a better quality service (patients remember about 10 percent of what you tell them, but can learn more than 90 percent of what you write) and made better use of my time, reviewing the material rather than teaching it for the first time. How often can you save time and money, and get a better result? Can't beat it."

Improving ER teaching, pre-op instructions

"I use my Web site to improve the quality of the teaching I do in the emergency room (ER)," notes Dr. Nelson. "Again, if patients only remember 10 percent of what you tell them in the office when they don't hurt and aren't scared, they probably don’t remember anything you tell them in the ER. I have a page for fractures and another for general ER diagnoses. My patients know how to take care of their cast, splint, laceration, etc. between their ER visit and their first office visit. Think how quality has improved. Think how patients are comforted about their diagnosis and their terror is decreased.

"Same goes for pre-op instructions. Patients forget almost everything you say once you tell them they need surgery. Put the information on the Net so they can read it as often as they need to understand it, and share it with family members, caregivers, etc. I also hand them a synopsis in print form. Think of the increase in quality of patient education. Now it can happen in each and every case, and it does not take an extra second."

Doctor recommendations welcome

Orthopaedists using the Academy's free "Rx for patient education" notepads say patients welcome their recommendations. "Patients are usually very happy to receive a script with the Web site listed," observes Ann Babbitt, MD, of South Portland, Maine. "Every patient has come back with a positive response, which always helps understanding and outcome, and saves time and money."

When Marty Gagliardi, MD, of Sevierville, Tenn., refers patients to the AAOS Web site, "I discuss their diagnosis and treatment regime, and give them access to helpful hints to control their pain and further explanations to help them understand their problem. I emphasize that it is written in simple language they will understand."

H. Jay Boulas, MD, of Dallas, Tex. believes using Internet-based educational materials may help patients feel their doctor is more involved in their care. He uses the "Rx" notepads when patients have ongoing questions or want more insight. "If they seemed overwhelmed at the office, directing them to a site to review what we talked about can be helpful," Dr. Boulas notes. Patients return with directed questions, and those who better understand their problem may be more compliant with treatment.

"Patients enjoy the opportunity to pursue more information independently," says Matthew Nadaud, MD, of Knoxville, Tenn. "By referring my patients to the Web site, I feel they have been better informed."

Peter Bentivegna, MD, FACS, of Hyannis, Mass., has referred patients to Your Orthopaedic Connection for general and specific orthopaedic information while they wait two to three weeks for an elective appointment. He uses the Internet prescription pad "from time to time with select patients." Says Dr. Bentivegna, "It saves enormous time in repeat explanations to patients that never have enough information."

Patients of all ages are Internet ready and able. Says Dr. Nelson, "You would be surprised how many 80 year olds have an Internet connection. A patient asked me, ‘How do you think I get pictures of my grandkids? By e-mail!’" And retirees who are online "tend to more thoroughly investigate their diagnoses," according to Lawrence Robinson, MD, of Rockledge, Fla.

The heart of patient care

"Patient education is the heart of patient care," according to J. David Thompson, MD, of St. Louis, Mo., who uses the notepads "because my families want access to useful information, and I want them to have quality information." According to Stephen Samelson, MD, of Montgomery, Ala., the notepads are "a great way to educate our patients and keep musculoskeletal health issues at their fingertips."

Susanne Zimmermann, MD, of Nashua, N.H., calls the Web site "a valuable tool in educating patients about their condition and reinforcing what I tell them. I often feel that seeing something in print makes the diagnosis more ‘believable’ to the patient and thereby helps them to be compliant with treatment."

"Rx for patient education" notepads were so popular at the University of Washington School of Medicine in Seattle that "patients snatched our entire supply rather quickly," according to Kevin L. Smith, MD. "The access to the material is beneficial, to say nothing of the customer satisfaction that comes with it."

Improving office interactions

Richmond, Ind.-based orthopaedist John Cherf, MD, MPH, MBA, says referring patients to the AAOS Web site also helps with patient expectation management and supplementation for patient informed consent. "This provides consistent information, reinforces the office visit interaction and serves as a vehicle for preoperative information about treatment outcomes. It is a reliable source of information that patients warmly receive."

Use of the Web site has been one of the most significant innovations in his practice in several years, Dr. Cherf continues. "Not only does it decompress my time schedule, it has the same effect for patients, many of whom take time from work for their office visits. They are frequently pressed to get back to work and this can be a distraction for patient comprehension. By visiting our Web site, patients can revisit topics discussed in our clinic at their own convenience."

Observes Dr. Gagliardi, "The usual bottom line (overhead) can be helped. Some companies other than AAOS charge fairly expensive prices for patient information booklets. If 30 percent of your patient population (or more) has Internet access, then, theoretically, you can save 30 percent (or more) on the money you spend buying patient information booklets and brochures."

Helping patients take active roles

Information on Your Orthopaedic Connection "... allays patient fears that they don’t know enough about their health problem," Dr. Boulas believes. Says Dr. Gagliardi, "I tell them to write down any questions they might have after reading the information for further elaboration on the next visit." He recalls recommending Your Orthopaedic Connection information on total joint replacement: "One patient who had reservations about the operation decided to proceed with surgery after she read the articles."

Dr. Babbitt relates another success story: "A patient who was rather scared and confrontational about an arthroscopy came back after assessing the Web site with a completely new and open attitude, had the surgery and did very well."

"Those who wish to be well-educated about their health always appreciate more information," observes Crystel Knierim, MD, of Floirssant, Mo. "Unfortunately, we do not always have the time to explain all the details. Having a notepad makes it possible to write a few words for the patient to look up or expand upon, and the patient is always very appreciative of this," says Dr. Knierim, "The notepads hold a spot right next to my prescription pad!"
"Showing patients you genuinely want to educate them shows that you are interested in their problems and want to assist them in getting better," says Dr. Gagliardi. Concludes John W. Blute, MD, of Concord, Mass., "A better informed patient is a better patient."