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Improving utilization of mammography screening in the physician's office practice
Improving Utilization of Mammography Screening in the Physician's Office Practice Charles E. Payton, MD Santa Monica Medical Center Santa Monica, California
hY is this paper focused on a group of professionals whose impact on the problems has been judged to date as ineffective? First of all, physicians are a source of accurate information. In spite of the lack of uniform access to care, physicians are a potential information source for most of the American public; they are considered to be at the top of the list. Another reason to focus on physicians is the stimulus and motivation they can provide. Numerous studies have shown that patients look to their physicians for direction with respect to health decisions. Physicians also provide an interpretive function; they translate and explain the results of screening and diagnostic procedures. Personal physicians extol the value of "normal" mammograms and assist patients whose exam was abnormal with the cognitive and emotional steps toward successful resolution. This paper is, therefore, directed to family physicians, internists, obstetricians, and gynecologists. And, to the extent that they influence patient attitude and behavior, the audience must also include pediatricians and surgeons. Which patients? The only answer can be all women, on all visits. The U.S. Preventive Services Task Force noted that "those who need preventive services the most, are the ones who seek it least".1 Preventive care must be considered on every encounter with every patient.
w
SPECIFIC ACTIONS The physician's efforts can be broken down into at least three categories: education, motivation, and enabling instructions and feedback.
The Educational Component The waiting room is an excellent site to initiate education. The ideal materials for this location include displays of educational handouts, alerting and informative posters, and commercially prepared video materials. Video disk players with wide-screen monitors may be placed in the waiting room, programmed to play on a set schedule. The use of materials in the exam room may be patient initiated or done 90
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
© 1991 by The Jacobs institute of Women's Health 1049-3867/91/$3.50 WHI Vol. 1, No. 2 Winter 1991
with the assistance of the nursing staff. This is the location of choice for posters that display more sensitive material such as breast self-examination techniques. All educational brochures, whether in the waiting area or exam room, should contain the invitation "for questions or additional information, ask your doctor." Some physicians have chosen to dedicate special rooms or areas for patient education so that they may assemble written and audiovisual materials in this single location. Although this may be beyond the resources of many private practitioners, there may be certain patient populations for whom the impact of such a resource would be cost effective. What should the focus of this educational effort be? It must go beyond the issue of mammography. If its scope is comprehensive, it is possible to create an environment that reinforces the expectation that the patient is involved in her own care. Women need to know about the risks for breast disease and how to judge each woman's susceptibility. They need information about self care. Nutrition is a major theme for patient education. It's an area under the patient's control, and the way it's dealt with can reinforce the message that the patient-physician relationship is a partnership. The manner in which educational material is presented, as well as the content, must be culturally appropriate. Many practices serve multiethnic, multflingual populations. Materials should be available in the patient's language(s). The topics that are presented should reflect a sensitivity to the standards of the various cultures being served.
Providing Motivation A number of aspects about office operation influence patient motivation. Printed materials should be colorful and "upbeat." They should, at the same time, demonstrate professionalism, accuracy, and positive attitude. The behavior of the entire ancillary staff, nursing and front office, is important. Encouraging comments have a lot to do with many patients' selection of physician and the compliance they exhibit. Physicians must make use of the fact that direct advice is a motivating force for most patients. This lesson has been demonstrated repeatedly with respect to the way patients view physicians' directives regarding breast cancer screening. Physician failure to recommend mammography has been cited as a primary reason why many women have not had the appropriate screening procedures. Another motivational step physicians can take is through the use of congratulatory feedback. When a patient has taken the recommended preventive care actions, she should be congratulated. She should know how positive her physician feels about that and be encouraged to develop similar attitudes about her behavior. At the same time, plans for annual screening can be established with the expectation of receiving further compliments.
Enabling Instructions and Feedback The enabler role starts with the motivational efforts made by the physician. The process of explaining the procedure and anticipating discomfort and anxiety demonstrates an empathy that establishes the sincerity of the physician's exhortations. The process of converting the patient's consent into specific plans involves writing the test requisition, describing the procedure, discussing safety and efficacy, and giving directions to the mammography facility. When multiple mammography sites are available, the choice of location should be made based on the patient's convenience. Conducting this open explanation will prepare the patient in a cognitive domain. At the same time, the physician's acknowledgment of the discomfort associated with mammary compression and the resulting anxiety begins the psychological preparation. All of this information, including a description of the procedure, should also WHI Vol. 1, No. 2 Winter 1991
PAYTON: IMPROVING UTILIZATION OF M A M M O G R A P H Y SCREENING
91
be provided in writing. This not only anticipates the questions that the patient remembers after arriving home, it provides the opportunity for enlisting the spouse's support through understanding and encouragement.
OPERATIONAL CONSIDERATIONS
Office Systems Creating office systems that support preventive care goals reduces the likelihood of important actions being omitted when patients present only for acute episodic care, when the office operates at an overburdened pace, or when the physicians (in a group practice setting) are not equally committed to the style of practice. If the practice operates on the basis of obtaining recommended studies before scheduling periodic health maintenance visits, reminders or recall notices should be used to get patients appointed for routine mammograms. These can either take the form of a postcard reminder or a phone call from the office staff. The simplest certainly is to have the patient put her name and address on a postcard that is filed in a tickler file according to the month and date when the patient is to be recalled. The appointment system must provide opportunities for the extended visits required for preventive care. It is important that the appointment book extend at least 12 months into the future. The medical record must be appropriately designed for preventive care plans and results. It must also make available essential demographic information. More and more physicians' offices are relying on computers to assist them with all modes of operation. Computers can be counted on to facilitate what has historically relied on paper and pencil "technology." Charge tickets bearing all of the data to be computerized following a patient visit should contain a recall "trigger," which will print lists at established intervals telling the office staff who needs to have a phone call and who needs to be sent a follow-up card.
Medical Records The design of the medical record greatly influences the physician's ability to address preventive care needs. The first problem on every patient's problem list should be preventive care services. In addition to the use of a problem focus, the medical record should include an age- and sex-specific preventive care protocol. The body of the record must also have a place for narrative findings. There must be a place to easily store test results and to retrieve data from serial events. The concept of information systems has come to imply computerization. In reality, many essential information functions could be accomplished with paper-and-pencil systems but with much greater personnel costs. A major benefit from office automation is the demographic data that become readily available. Whether these data describe the population that has associated itself by coming to the office for service, or a population identified through a managed-care panel, it is equally valuable in assisting the physician in delivering care to patients "in the practice." These demographic data may be used for establishing outreach activities. Breast cancer screening is one such activity. Patients in the age group for clinical breast exam or mammographic screening could be identified and contacted. The computer can provide a list of patients by the last day of service. If a patient hasn't been seen within the established interval of 6 or 12 months, a postcard or letter is sent. Although 92
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
WHI Vol. 1, No. 2 Winter 1991
practices should find this an excellent marketing tool, it also identifies the physician as concerned about patients' well-being. As noted, each medical record should contain a problem list. Frequently, computer systems will record the active problems that physicians enter for billing purposes. These may then be displayed on the "encounter form" generated for subsequent visits as a physician reminder. If, as proposed earlier, preventive care is always problem (diagnosis) number one, the physician will be continually reminded to address needs such as screening mammography. If the visit is for an urgent problem, the last 30 seconds may be used to review a preventive care protocol that should be prominently included in each chart. An automated information system also makes it possible to log referrals. When a physician sends out a laboratory or imaging requisition, truant reports will be overlooked without some form of log. Mammograms are of little value if their results are unknown. Subspecialty consultation (eg, for surgery or oncology) requests can be tracked through the same log.
Preventive Care Protocol A preventive care protocol lists all of the interventions that are appropriate for primary prevention in a given age and sex cohort. Many group women from 16-45 (the childbearing years) in one category. The next age set typically extends from 46-65. The eldest is usually 66 and beyond. The form should list a baseline set of recommendations (such as presented in the US Preventive Services Task Force Report) for a normal risk population. The bulk of the form provides a flow sheet that covers the number of years listed in the ranges described above. The protocol should describe the documentation system to be used for recording the following information on the form. First, the physician should review the patient's data base and develop a preventive care plan for the ensuing 3 - 5 years. This plan is then displayed by placing a circle around those interventions that are planned for the individual patient. Second, the physician will present the recommendations to the patient and obtain an informed consent for the appropriate procedures. If the patient declines a particular study or procedure, a notation is made on the protocol. In the system developed by this author, an R is used to indicate "refused." The description of the informed consent is then given in the text of the chart. Finally, the completion of a recommended preventive care action is noted by darkening in the circle that was entered during the planning step. Variations on this system provide for ways to indicate when tests or procedures were performed elsewhere but the results are available only "as reported by the patient." There's a lot more to such a form than just procedures and studies. It includes anticipatory guidance and reminders to instruct patients in self care. By creating the preventive care plan for each patient based on personal and family history, the protocol becomes highly personalized. By employing a set of protocols designed to display each patient's information in the same relative location, the physician can become so familiar with the form that its use is very time efficient. At the same time, it reflects the risk assessment for the individual patient.
Office Environment The decor, the layout, and the staffing are all factors that contribute to patient comfort and confidence. The atmosphere of the office needs to be informative. This is engendered by the use of posters, brochures, and audiovisual educational tools that were mentioned earlier. The patient should also view it
WHI Vol. 1, No. 2 Winter 1991
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
93
as a supportive environment. All of the systems that are used should encourage a preventive care orientation. The atmosphere should not be distracting. Patients should have an opportunity to focus on the educational materials.
Confidentiality When used to describe the physician relationship, the word that is used is trust. Trust is not possible unless the entire practice environment conveys a message of confidentiality. This is a quality that is determined by staff behavior as well as the physical environment. If a patient goes into an exam room and can hear the discussions in the adjacent room, it's unlikely personal issues of importance will be shared with the physician.
Staff Qualities The staff must share in the value placed on preventive care. Their support for this goal must be demonstrated in the responses they make to patient comments. Properly educated staff can be informative as well as encouraging. The nursing staff may be a particularly important component if they are to be looked to for patient education. The nurses must then be prepared to implem e n t the physician's plans t h r o u g h one or more contacts lasting several minutes and focusing on specific knowledge or skill development. In summary, the staff presentation must always be caring and professional.
REFERENCE 1. Fisher M, ed. Guide to clinical preventive services. Baltimore: Williams & Wilkins, 1989:xxiii.
94
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
WHI Vol. 1, No. 2 Winter 1991
hY is this paper focused on a group of professionals whose impact on the problems has been judged to date as ineffective? First of all, physicians are a source of accurate information. In spite of the lack of uniform access to care, physicians are a potential information source for most of the American public; they are considered to be at the top of the list. Another reason to focus on physicians is the stimulus and motivation they can provide. Numerous studies have shown that patients look to their physicians for direction with respect to health decisions. Physicians also provide an interpretive function; they translate and explain the results of screening and diagnostic procedures. Personal physicians extol the value of "normal" mammograms and assist patients whose exam was abnormal with the cognitive and emotional steps toward successful resolution. This paper is, therefore, directed to family physicians, internists, obstetricians, and gynecologists. And, to the extent that they influence patient attitude and behavior, the audience must also include pediatricians and surgeons. Which patients? The only answer can be all women, on all visits. The U.S. Preventive Services Task Force noted that "those who need preventive services the most, are the ones who seek it least".1 Preventive care must be considered on every encounter with every patient.
w
SPECIFIC ACTIONS The physician's efforts can be broken down into at least three categories: education, motivation, and enabling instructions and feedback.
The Educational Component The waiting room is an excellent site to initiate education. The ideal materials for this location include displays of educational handouts, alerting and informative posters, and commercially prepared video materials. Video disk players with wide-screen monitors may be placed in the waiting room, programmed to play on a set schedule. The use of materials in the exam room may be patient initiated or done 90
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
© 1991 by The Jacobs institute of Women's Health 1049-3867/91/$3.50 WHI Vol. 1, No. 2 Winter 1991
with the assistance of the nursing staff. This is the location of choice for posters that display more sensitive material such as breast self-examination techniques. All educational brochures, whether in the waiting area or exam room, should contain the invitation "for questions or additional information, ask your doctor." Some physicians have chosen to dedicate special rooms or areas for patient education so that they may assemble written and audiovisual materials in this single location. Although this may be beyond the resources of many private practitioners, there may be certain patient populations for whom the impact of such a resource would be cost effective. What should the focus of this educational effort be? It must go beyond the issue of mammography. If its scope is comprehensive, it is possible to create an environment that reinforces the expectation that the patient is involved in her own care. Women need to know about the risks for breast disease and how to judge each woman's susceptibility. They need information about self care. Nutrition is a major theme for patient education. It's an area under the patient's control, and the way it's dealt with can reinforce the message that the patient-physician relationship is a partnership. The manner in which educational material is presented, as well as the content, must be culturally appropriate. Many practices serve multiethnic, multflingual populations. Materials should be available in the patient's language(s). The topics that are presented should reflect a sensitivity to the standards of the various cultures being served.
Providing Motivation A number of aspects about office operation influence patient motivation. Printed materials should be colorful and "upbeat." They should, at the same time, demonstrate professionalism, accuracy, and positive attitude. The behavior of the entire ancillary staff, nursing and front office, is important. Encouraging comments have a lot to do with many patients' selection of physician and the compliance they exhibit. Physicians must make use of the fact that direct advice is a motivating force for most patients. This lesson has been demonstrated repeatedly with respect to the way patients view physicians' directives regarding breast cancer screening. Physician failure to recommend mammography has been cited as a primary reason why many women have not had the appropriate screening procedures. Another motivational step physicians can take is through the use of congratulatory feedback. When a patient has taken the recommended preventive care actions, she should be congratulated. She should know how positive her physician feels about that and be encouraged to develop similar attitudes about her behavior. At the same time, plans for annual screening can be established with the expectation of receiving further compliments.
Enabling Instructions and Feedback The enabler role starts with the motivational efforts made by the physician. The process of explaining the procedure and anticipating discomfort and anxiety demonstrates an empathy that establishes the sincerity of the physician's exhortations. The process of converting the patient's consent into specific plans involves writing the test requisition, describing the procedure, discussing safety and efficacy, and giving directions to the mammography facility. When multiple mammography sites are available, the choice of location should be made based on the patient's convenience. Conducting this open explanation will prepare the patient in a cognitive domain. At the same time, the physician's acknowledgment of the discomfort associated with mammary compression and the resulting anxiety begins the psychological preparation. All of this information, including a description of the procedure, should also WHI Vol. 1, No. 2 Winter 1991
PAYTON: IMPROVING UTILIZATION OF M A M M O G R A P H Y SCREENING
91
be provided in writing. This not only anticipates the questions that the patient remembers after arriving home, it provides the opportunity for enlisting the spouse's support through understanding and encouragement.
OPERATIONAL CONSIDERATIONS
Office Systems Creating office systems that support preventive care goals reduces the likelihood of important actions being omitted when patients present only for acute episodic care, when the office operates at an overburdened pace, or when the physicians (in a group practice setting) are not equally committed to the style of practice. If the practice operates on the basis of obtaining recommended studies before scheduling periodic health maintenance visits, reminders or recall notices should be used to get patients appointed for routine mammograms. These can either take the form of a postcard reminder or a phone call from the office staff. The simplest certainly is to have the patient put her name and address on a postcard that is filed in a tickler file according to the month and date when the patient is to be recalled. The appointment system must provide opportunities for the extended visits required for preventive care. It is important that the appointment book extend at least 12 months into the future. The medical record must be appropriately designed for preventive care plans and results. It must also make available essential demographic information. More and more physicians' offices are relying on computers to assist them with all modes of operation. Computers can be counted on to facilitate what has historically relied on paper and pencil "technology." Charge tickets bearing all of the data to be computerized following a patient visit should contain a recall "trigger," which will print lists at established intervals telling the office staff who needs to have a phone call and who needs to be sent a follow-up card.
Medical Records The design of the medical record greatly influences the physician's ability to address preventive care needs. The first problem on every patient's problem list should be preventive care services. In addition to the use of a problem focus, the medical record should include an age- and sex-specific preventive care protocol. The body of the record must also have a place for narrative findings. There must be a place to easily store test results and to retrieve data from serial events. The concept of information systems has come to imply computerization. In reality, many essential information functions could be accomplished with paper-and-pencil systems but with much greater personnel costs. A major benefit from office automation is the demographic data that become readily available. Whether these data describe the population that has associated itself by coming to the office for service, or a population identified through a managed-care panel, it is equally valuable in assisting the physician in delivering care to patients "in the practice." These demographic data may be used for establishing outreach activities. Breast cancer screening is one such activity. Patients in the age group for clinical breast exam or mammographic screening could be identified and contacted. The computer can provide a list of patients by the last day of service. If a patient hasn't been seen within the established interval of 6 or 12 months, a postcard or letter is sent. Although 92
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
WHI Vol. 1, No. 2 Winter 1991
practices should find this an excellent marketing tool, it also identifies the physician as concerned about patients' well-being. As noted, each medical record should contain a problem list. Frequently, computer systems will record the active problems that physicians enter for billing purposes. These may then be displayed on the "encounter form" generated for subsequent visits as a physician reminder. If, as proposed earlier, preventive care is always problem (diagnosis) number one, the physician will be continually reminded to address needs such as screening mammography. If the visit is for an urgent problem, the last 30 seconds may be used to review a preventive care protocol that should be prominently included in each chart. An automated information system also makes it possible to log referrals. When a physician sends out a laboratory or imaging requisition, truant reports will be overlooked without some form of log. Mammograms are of little value if their results are unknown. Subspecialty consultation (eg, for surgery or oncology) requests can be tracked through the same log.
Preventive Care Protocol A preventive care protocol lists all of the interventions that are appropriate for primary prevention in a given age and sex cohort. Many group women from 16-45 (the childbearing years) in one category. The next age set typically extends from 46-65. The eldest is usually 66 and beyond. The form should list a baseline set of recommendations (such as presented in the US Preventive Services Task Force Report) for a normal risk population. The bulk of the form provides a flow sheet that covers the number of years listed in the ranges described above. The protocol should describe the documentation system to be used for recording the following information on the form. First, the physician should review the patient's data base and develop a preventive care plan for the ensuing 3 - 5 years. This plan is then displayed by placing a circle around those interventions that are planned for the individual patient. Second, the physician will present the recommendations to the patient and obtain an informed consent for the appropriate procedures. If the patient declines a particular study or procedure, a notation is made on the protocol. In the system developed by this author, an R is used to indicate "refused." The description of the informed consent is then given in the text of the chart. Finally, the completion of a recommended preventive care action is noted by darkening in the circle that was entered during the planning step. Variations on this system provide for ways to indicate when tests or procedures were performed elsewhere but the results are available only "as reported by the patient." There's a lot more to such a form than just procedures and studies. It includes anticipatory guidance and reminders to instruct patients in self care. By creating the preventive care plan for each patient based on personal and family history, the protocol becomes highly personalized. By employing a set of protocols designed to display each patient's information in the same relative location, the physician can become so familiar with the form that its use is very time efficient. At the same time, it reflects the risk assessment for the individual patient.
Office Environment The decor, the layout, and the staffing are all factors that contribute to patient comfort and confidence. The atmosphere of the office needs to be informative. This is engendered by the use of posters, brochures, and audiovisual educational tools that were mentioned earlier. The patient should also view it
WHI Vol. 1, No. 2 Winter 1991
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
93
as a supportive environment. All of the systems that are used should encourage a preventive care orientation. The atmosphere should not be distracting. Patients should have an opportunity to focus on the educational materials.
Confidentiality When used to describe the physician relationship, the word that is used is trust. Trust is not possible unless the entire practice environment conveys a message of confidentiality. This is a quality that is determined by staff behavior as well as the physical environment. If a patient goes into an exam room and can hear the discussions in the adjacent room, it's unlikely personal issues of importance will be shared with the physician.
Staff Qualities The staff must share in the value placed on preventive care. Their support for this goal must be demonstrated in the responses they make to patient comments. Properly educated staff can be informative as well as encouraging. The nursing staff may be a particularly important component if they are to be looked to for patient education. The nurses must then be prepared to implem e n t the physician's plans t h r o u g h one or more contacts lasting several minutes and focusing on specific knowledge or skill development. In summary, the staff presentation must always be caring and professional.
REFERENCE 1. Fisher M, ed. Guide to clinical preventive services. Baltimore: Williams & Wilkins, 1989:xxiii.
94
PAYTON: IMPROVING UTILIZATION OF MAMMOGRAPHY SCREENING
WHI Vol. 1, No. 2 Winter 1991