Sunday, June 01, 2008

We want to listen. Are we good at it?

Although we are always listed among the "most wired" hospitals in America, with lots of clinical applications for both providers and patients, we still depend on people both inside and outside of the hospital to tell us how our information systems can be improved -- from the user's point of view.

I have mentioned how useful our PatientSite program is for patients, allowing them access to medical records, appointments, prescriptions, and the like. This is a very good system, but one of our patients sent in the following suggestion:

For the wish list: This might be a substantial change but I ask that you put it into the hopper for a someday rethink. I ask that you (BIDMC) begin to define an appointment from the patient's point of view, or at least offer us a view that serves us. For me, the "appointment" object is a trip to the hospital that may have a one-to-many relationship with several sub-objects that are of interest only to the hospital, for whom each person is a schedulable resource. Right now, I have one trip to BIDMC scheduled for Monday 6/9. To me that's one appointment, one trip, and patients would be better served if we had visibility into more appointments. To you it's appointments (resource bookings) for three separate objects (people). Bottom line, I'm appealing to the hospital to consider presenting things appropriately to the POV of the individual stakeholder. You might say that it does me very little good to offer me visibility into YOUR view of the resources, when that isn't the information that *I* need.

The reply from the tech support person:

Our programmer has checked the code again. You are correct, as just 5 appointments can be displayed on the Home page at one time. There is a finite number of appointments that will display. If you have a long list of appointments, the (later) appointment with Dr. X will display after some of the others have passed.

After this reply, the patient bumped it up to me:

This is way below your radar but I want you too to be aware of this as a thought. Here's something I just submitted to the PatientSite support team, to put onto the wish list.

And from me to the relevant Vice President, who wrote to the relevant IS folks:

Can we have patient site display more than 6 appointments at a time; i.e., longer out in the timeline? Please me know.

The reply:

I'm not sure what would be involved in changing this, but we will follow up with the team and get back to you.

A few days later, the follow-up:

I reviewed with the team, and it would be possible for us to increase the number of appointments and other events that display in MyEvents in PatientSite. I have attached a screenshot for your reference.
There are three options:
1. Raise the limit of future appointments from 5 to some higher value.
2. Show all appointments that fall within a specified date range, e.g., the next six months.
3. Show all future appointments regardless of date.
All three options are technically feasible. Approaches 2 and 3 would seem to better address the patient's request that we adopt a patient's point of view in the display.
Let me know if you would prefer one of these options over the others, and we can proceed from there.

VP replies:

I think we should do option 2 or 3. Either let patient give the time frame they want to see or all appointments. I will leave that to you , but it needs to be option 2 or 3.

IS replies:

Patients can now view all future appointments on their PatientSite Home page. If the list is longer than 6 appointments, a scroll bar will appear so they can scroll down. I have emailed the patient who originally made the enhancement request.


The good news is that we listened to this excellent idea from a patient and implemented it without a lot of fuss. The not-so-good news is that the patient felt he had to send me a note on this issue to get it done. Now, it might have made it on its own through the system, or it might not have. So, the next step for me is to find out from the VP involved how patient suggestions that are made to tech support get reported and prioritized by the IS team. In other words, this now becomes a BIDMC SPIRIT call-out from the CEO's office....


e-Patient Dave said...

1. Thanks very much to the team for the response! I appreciate it.

2. I'm glad you were able to use it as a SPIRIT exercise. I'm (honestly) honored every time I (or any patient) says something useful and BIDMC listens (and does it).

3. I didn't feel I *needed* to bring it to your attention - it's not a great big deal, even though the improvement is a real convenience. And the PatientSite support people have always been great about responding warmly, intelligently and personally.

But here's the next challenge, reflecting the (still unimplemented) shift in mindset that I did feel warranted high-level attention:

4. My starting request was that everyone stop thinking in terms of the information you need to track, and in a consumer-facing view, show the information the patient needs.

In this case, June 9 still shows me as having three different appointments, when I actually have one, with three providers.

As I said, this is an appointment that has "a one-to-many relationship with several sub-objects that are of interest only to the hospital, for whom each [staffer] is a scheduleable resource. ...[But] To me, that's one appointment."

Here's an even bigger biggie that I figured would be too big a paradigm shift! Tell me when I need to show up, not when your assets will get utilized.

PatientSite shows that my upcoming CT scan appointment is at 8:45. In YOUR view, that's when the asset (the scanner) is scheduled to be used. But that's pretty uninteresting to me, because what *I* need to know is that I'm to show up at *7*:45, an hour earlier, to drink that delightful goop you peddle to make my insides more photogenic. :)

In my unhumble opinion, the consumer view ought to show what the consumer needs to know: when to arrive.

I mean really: if you sat down and asked patients what they'd like it to show, would they say "I don't care when I need to show up - just show me when the machine will get used"?

p.s. Presuming there's a PatientSite wishlist, why not publish it in a consumer-accessible feedback forum? The usual groundrule would apply: discussion is welcome but not everything will get added.

Your loyal gadfly, EPD (*loving* that you guys listen and respond. That's the spirit!)

Ileana said...

Hi Paul,

This is such a common problem. Over the last year or so I am sending comments on things that do not work and improvement suggestions on healthcare-related web sites. Whenever I actually get an answer, it is a canned version of this is how you need to do it. I even requested that my email was sent to an IT person, but I got the same answer, only more annoyed.

I think that the issue is that these support emails are seen as a maintenance function when they should be a marketing function. You need to learn from each of them and prioritize future versions to make it better suited for your users. You need a smart marketing person answer the support calls and making sense of them.

But, of course you are already doing this with SPIRIT :)

Anonymous said...

I think Ileana's suggestion of a marketing person is an excellent one; but rather than pay a marketing person in each of your departments, the real conundrum is how to permanently instill a marketing (e.g., patient centric) mentality in the staff of each department. This may involve food for thought regarding additions to your training for SPIRIT and new employee orientation .
This issue also makes me wonder if PatientSite shouldn't be proactively reviewed in totality with the patient's perspective in mind, going beyond just how appointments are displayed. Perhaps a group of longtime patient-users would be willing to assist.

Way to go, epatient Dave! Keep on truckin'!

nonlocal MD

Larry said...

Thanks to Paul for calling this out, and to the folks who have commented. How patient suggestions get evaluated, prioritized and reported back are all great questions.

Over the years, our patients have helped to design and enhance PatientSite with their suggestions. We try very hard to listen to our patients, and all requests submitted to our support team are documented and reviewed.

The first step in the review is an internal review involving the PatientSite support and development staff. In this case, the limit on the number of MyEvents (appointment items) had been put in place years ago to prevent the list from taking up too much space on screen. The requested change had a clear benefit from the patient's perspective and was straightforward to implement from a technical perspective. If it were more complex, it would have been reviewed next by an advisory group. However, the PatientSite team is empowered to simply implement this kind of straightforward usability improvement - even without intervention from the CEO! Had the patient not written to Paul at about the same time the request was submitted, I believe we would have had the same outcome, that is, that we would have made the same change to PatientSite.

I think adding more transparency to this process via a publicly accessible list of customer suggestions with status updates is a great idea. We are currently in the process of preparing for the September launch of a new external BIDMC web site. My suggestion would be to bring this to the steering committee that oversees the new site once it is live. The new site is based on a commercial content management system and will have new features we may be able to leverage. In the meantime, we will be launching a request tracking site in a few weeks for webOMR, BIDMC's web Online Medical Record. The site will be available to all BIDMC users over our intranet, and we can apply lessons learned from that experience to PatientSite tracking.

Larry Markson
BIDMC Clinical Information Systems

Anonymous said...

Paul, with all due respect, no, I don't think you listened to the patient at all. It sounds like did fix a bug in your system in which you could only display 5 appointments, which is good, but was that at all the issue the patient reported?

Paul Levy said...

It was one of the issues. Others are in progress, as Dave mentions.

e-Patient Dave said...

My experience was that they did hear me. (Paul didn't post the entire email exchange, most of which was behind the walls of PatientSite's confidential (bank-like) email system.)

This all arose out of a support email I sent them because I couldn't see a subsequent appointment that I knew was in the system. And they nailed that one on the first try. :)

Anonymous said...

Sometimes being the most wired is not a good thing. I recently had a first appointment with a BIDMC physician. At that appointment he told me that he had no slots for a follow up appointment and he would let me know the results of my test through email. I was distracted by what was taking place and only said, "I wish I knew that when I made the initial appointment because I would not have come to see you." I should have just left. Indeed, this physician never picked up the phone to talk with me and only communicated via email. Your patient site made it much too easy for him to forget the importance of patient communication.

Paul Levy said...

A good point, which I will share with folks.

Paul Levy said...

Was this a primary care MD? If not, what specialty, please?

Anonymous said...

it was in Neurology...and the doctor was a fellow. I actually never followed up with him because I was so put off by the "communication style". Luckily it is not a dire issue.....thank you for your attention to this.

Mika said...

Hi Paul,

About 3 or so years ago, I came to BIDMC primarily because of your Patient Site program. On day 1, I think it was truly revolutionary.

However, I have been frustrated that BIDMC does not regularly add features and capabilities to the Patient Site web services. Whenever I write to support, I get what I would call a typical polite corporate canned response saying basically "thanks for your suggestions."

Here are some of the features that I would really expect to have in approximate order of importance:

1. Real Time Appointment Scheduling:
Right now when a patient either makes, changes, or cancels an appointment, PS handles it as an email to the office staff. Then the office staff completes the transaction I'm assuming in Care Web, and then emails the patient with regard to the transaction they completed. Instead, the patient should be able to directly add or cancel an appointment in real time based on the providers schedule availability which is already in the system. I would think this would free up the office staff to do more interesting work, and this would save all involved a lot of administrative steps. A nice to have feature in this regard would also be SMS text message reminders or a way to cancel (or advise running late) an appointment by SMS text message say if something comes up on the day of;

2. Access To Clinical Notes In Medical Record:
The patient should be able to access the clinical notes in his or her medical record with in Patient Site. Right now, a patient can access that information in many cases by requesting a copy of the medical record from the hospital or provider, so this information should be available on-line. this would also be useful if a patient needs to forward records to another provider or specialistt. This would save the hospital paper, and a bunch of administrative steps and make the data instantly available to the patient either at their home or at another providers office even in say London. If you must have forms completed, these could be electronically done on-line;

3. Request Provider CallBack:
Right now if a patient wants to talk by phone to his/her provider, usually they have to call in to the office. Then my understanding is that a CSR types that information in, and sends it to the providers BIDMC email and possibly their pager. You should be able to request such a callback with in Patient Site and the system should be able to route the request in much the same way a CSR does. You should probably have the patient pick a priority when they submit the provider callback request over the web so the providers can more easily triage these requests based on priority or urgency. A nice to have feature in this regard might be Skype or other VOIP intigration perhaps with a device that a patient could have at home to at least send say blood pressure, pulse, oxygen level, and other vitals to the provider. Skype and VOIP also facilitate video calling;

4. Review Pending Activities:
There should be a screen where a patient can review all open referrals, ordered tests, or other pending activity. Right now, for instance if I want to find a referral# that a BIDMC PCP created, I would have to search through emails as opposed to just looking at a single screen with my open referrals and expiration dates for such referrals. I also don't know right now that there is a screen where one can browse pending tests that have been ordered;

5. Better Referral Intigration For BIDMC Specialty Appointments:
Right now even if a patient books a specialty appointment with in BIDMC, they must manually create a referral request form in Patient Site. If a patient is seeing a specialist and has a BIDMC appointment that is already in Care Web/Patient Site, there should be a single transaction that prepopulates a referral form with much of the information from the visit. Like the date/time, provider name, address, tel#, etc.

6. Specialty Screening Paperwork:
Right now, very often if you visit a specialist even at BIDMC, you must complete screening forms in paper which such a specialist department uses. Such forms are often filled out by patients in the waiting room for specialist offices. Instead, these forms should be completed on the web and then electronically transmitted to the provider office. Besides being a good solution consistent with universal design, such a solution would also better facilitate people who are blind or visually impaired being able to privately complete these forms;

7. Provider Appointment Data Not Accessible To Screen Reader Users:
Currently Patient Site has a capability where you can view the times a provider is in and avaialble for appointments. This information is presented only by color, and is not accessible to people who are blind using screen readers. I pointed this out to tech support some time ago, and got the usual "thanks for your suggestion," response but they didn't fix the issue of course, and I don't even know if it got logged as a to do with the development department. Some other tables may also need to be reviewed for accessibility. A commonly used screen reader is:
This also speaks to the need for bugs or enhancement requests to be better logged, perhaps even publically.

I would personally disagree somewhat with earlier comments that Patient Site should have more consumer oriented screens. I hate if things are watered down for the consumer or shown differently. As an example, if I were to look at my credit report I'd prefer to see the version (with all the jargon etc.) that a mortgage loan officer sees, rather than some kind of watered down version made for the consumer. I don't mind if I have to learn their jargon. Incidentally if someone is a frequent customer in any type of industry, I think they are better off if they learn that industries jargon as well as official and unofficial practices and customs in that industry. To me, Patient Site should be more a part of Care Web rather than a separate system. I think right now the providers have to jump in between Care Web, Patient Site, and their regular BIDMC email accounts. That is probably too many systems.

Also for routine communication, I don't mind using regular email. If I write to my PCP that I have a cold or back pain, I don't think I need to communicate in some walled garden like Patient Site. I can see keeping test results in a walled garden, but I don't think evry basic conversation between a patient and a provider needs to be in some sort of special walled off garden. Also as I said it creates additional overhead if both the provider and patient have to communicate not using their existing email accounts that they are in all the time. Maybe I should be more paranoid about privacy etc. :)? I can access my regular email on my computer and cell phone, but getting to the PS email system is more of a chore especially if on the go.

Its good you have the walled garden available I suppose, but then again also its kind of creepy that evry conversation is going to get recorded in your medical record if you do use the walled garden. I think that fact, that all conversations become part of some formal record, probably makes it so that both providers and patients can't speak as openly and honestly as they might otherwise if the conversations were not recorded in such a formal way. Do people speak as freely on the phone if its a recorded line? Perhaps this speaks to medicine becoming too stuffy, bureaucratic, rushed, and formal as opposed to say the old small town family doctor and friend.

I'm surprised that in Boston of all places concierge medicine has not picked up more steam to try to fill some of these voids in the traditional health care system.

I'm glad you brought this up in your blog. When I first read about Spirit, I was curious if patients could submit problems via Spirit. And over the years, I've wondered how I would go about submitting feedback like this. I had thought of trying to find the CIO's email address, etc. but had not gotten around to it.

In conclusion Patient Site should strive to introduce new features at least about evry quarter, and an email should be sent to Patient Site users explaining the new features, what is on the horizon, or why it is taking you so long to do certain things. There should also be a better path for people to report bugs, request enhancements, or ask real questions in a forum where we can get real answers. This could be done both electronically and/or via in person user groups with the product managers and developers.

Larry said...

Thanks very much to Mika for the thoughtful and detailed suggestions. I am sure this input will be valuable to our PatientSite Steering Committee, and I will forward all these suggestions to them.

Some of Mika's ideas have been raised before by the patients and providers who use PatientSite. For example, real time appointment scheduling is a great suggestion and we certainly hope to get there soon. The challenge of this and some of the other suggested changes is that they require both technical changes to achieve the desired integration and organizational changes in the way scheduling and other activities are handled. For example, our provider schedules are templated to allow (or not allow) certain activities (visit types) within specific blocks of time and for specific lengths of time. Our experience has been that when we map appointment requests to the proper visit types, we improve the ability of our clinicians to see patients in an efficient and timely manner. Our scheduling staff currently map appointment requests to visit types, and we will need to develop a new model for performing this function in order to open appointment booking directly to patients.

On the provider side, I think the suggestion to reduce the number of systems our clinical staff must use is exactly right. We already provide some integration between webOMR, our electronic medical record, and PatientSite. We are in the process of reviewing ways to redesign the technical components of PatientSite to allow even tighter integration. Our long term goal is to enable clinicians to do all PatientSite functions from within webOMR, without having to log in to a separate PatientSite application.

e-Patient Dave said...


I'm guessing that I'm the one you're referring to, re a comment about having more consumer-oriented screens.

I had said that I wanted to see the information that *I* need: when to show up, not when the scanner is booked.

Just to be clear, I'm not interested in dumbing things down, at the cost of hiding clinically useful information. To the contrary, what I see is that *me*-useful information *is* missing.

And I do advocate considering each persona when designing a site's features. What does the provider need to see? What does the patient need to see? (What does the insurer need to see? etc.)

Re showing all the technical details: As long as we're blue-skying it, I suppose the ultimate system could offer a preference setting (a knob, if you will) for how comfortable I feel with varying levels of hairiness. MS Office has a vaguely comparable setting for simple menus or (big, scary) full-featured menus. I *love* the full scary-hairy menus, but a lot of people don't.

Agreed, btw, about minimizing how many systems a provider must use. Ideally each party would have a single-sign-in system, which could interact with any other system transparently. (One gigantic mash-up. Good luck, I know.)

In fact I have to wonder why it's not all one big system, with different facades for different audiences. (I know that takes a lot of work.)

I must say that I'm very pleased to have patients openly discussing stuff like this on the CEO's blog. I'm sure Paul will be happy when we get a forum of our own. Question is, will he still listen? [wink]

Mika said...

Yes, I'd agree also it would be helpful to show patients when to arrive for an appointment or procedure. Also perhaps the procedure or appointment type would be a clickable hyperlink, and would take you to information about that procedure and any steps you might need to take to prepare for the procedure or visit type. E.g. it might instruct you not to eat after midnight for some procedures or tests.

I like the idea also of the preference setting as to the degree of technical detail that one sees.